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Background Percutaneous left atrial appendage exclusion (LAAE) has evolved as an alternative strategy for stroke prevention in atrial fibrillation (AF). Recent observational data have suggested that epicardial LAAE can have substantial impact on arrhythmia burden and hemodynamic profile. Objectives The authors aimed to study the impact of epicardial versus endocardial LAAE on systemic blood pressure in hypertensive AF patients. Methods This was a prospective, nonrandomized study comparing 247 patients who underwent epicardial LAAE with 124 patients with endocardial exclusion. Clinical outcomes were measured at 3 months and 1 year. Primary outcome was improvement in systolic blood pressure (SBP) between both groups compared with baseline. Secondary outcome included changes in diastolic pressures (DBP), serum electrolytes, and creatinine. Results There was no significant difference in baseline SBP between epicardial and endocardial groups. SBP was significantly lower in the epicardial group both at 3 months (122 ± 11.8 mm Hg vs. 129.7 ± 8.2 mm Hg; p Conclusions In hypertensive AF patients, epicardial LAAE significantly decreases SBP both at 3 and 12 months compared with endocardial exclusion.

Objectives The present study describes the use of octreotide (OCT) in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC) who have gastrointestinal (GI) bleeding related to arteriovenous malformations (AVMs), as well as its effect on OAC tolerance and subsequent rebleeding. Background AVMs cause significant GI bleeding, especially in patients with AF who are receiving OAC for stroke prevention. OCT has been shown to minimize recurrent GI bleeds related to AVMs. Methods In a multicenter, observational study, 38 AF patients with contraindications to OAC because of AVM-related GI bleeding were started on 100 μg of subcutaneous OCT twice daily. OAC was resumed in all patients within 48 h. Incidence of recurrent GI bleeds was calculated, and hemoglobin levels were recorded at enrollment and at 3 and 6 months’ follow-up. Results After a median follow-up of 8 months, 36 patients (mean age 69 ± 8.0 years; mean CHA2DS2-VASc score 3 ± 1 and mean HAS-BLED score 3 ± 1) were available for analysis. All were able to successfully resume OAC, and 28 of 36 (78%) remained on OAC at the conclusion of the study, whereas 8 underwent left atrial appendage closure with subsequent OAC discontinuation. No systemic thromboembolic events occurred in follow-up. Of the 28 patients who continued receiving OAC, 19 (68%) were free of recurrent GI bleed, 4 had minor GI bleeds, 4 required transfusion, and 1 required colectomy for GI bleeding. Mean hemoglobin levels in all patients receiving OAC were significantly higher at 3- and 6-month follow-up than at baseline (p Conclusions Subcutaneous OCT therapy is an attractive option in AF patients receiving OAC who have AVM-related GI bleeds. It allows successful reinitiation of OAC as a bridge to left atrial appendage exclusion or short-term relief from bleeding.

Background Single-chamber leadless pacemakers (LPs) have been shown to be an effective alternative to conventional transvenous pacemakers (CTPs), but their benefit in the context of cardioinhibitory vasovagal syncope (CI-VVS) is unknown. Objective The purpose of this study was to evaluate the safety and efficacy of LP compared with dual-chamber CTP for CI-VVS. Methods We conducted a multicenter, retrospective study comparing patients who received LP or dual-chamber CTP for drug-refractory CI-VVS. CI-VVS was diagnosed clinically and supported by cardiac monitoring and head-up tilt table testing. The primary efficacy endpoint was freedom from syncope during follow-up. Secondary endpoints included device efficacy and safety estimated by device-related major and minor adverse events (AEs). Results Seventy-two patients (24 LP, 48 CTP; age 32 ± 5.5 years; 90% female; syncope frequency 7.6 ± 3.4 per year) were included. At 1 year, 91% of patients (22/24) in the LP group and 94% of patients (43/48) in the CTP group met the primary efficacy endpoint (P = .7). Device efficacy endpoint was met in 92% of the LP group and 98% of the CTP group (P = .2). Early major AEs occurred in 2 of 24 in the LP group and 3 of 48 in the CTP group (P = .4). Late major AEs occurred in 0 of 24 in the LP group and 2 of 48 in the CTP group (P = 1). Conclusion In patients with CI-VVS, single-chamber LP demonstrated equivalent efficacy in reducing syncopal events compared to dual-chamber CTP, with a similar safety profile.

Background: Premature ventricular contractions are a common clinical presentation that drives further diagnostic workup. We hypothesize the presence of underlying inflammation is often unrecognized in these patients with a potential for continued disease progression if not diagnosed and treated early in the disease course. Methods: This is a single-center, prospective study including 107 patients with frequent symptomatic premature ventricular contractions (>5000/24 h) and no known ischemic heart disease. Patients underwent a combination of laboratory testing, 18F-fluorodeoxyglucose positron emission tomography scan, cardiac magnetic resonance imaging, and biopsy. Patients were diagnosed with myocarditis based on a multidisciplinary approach and treated with immunosuppressive therapy. Results: The mean age of the cohort was 57±15 years, 41% were males, and left ventricular ejection fraction was 47±11.8%. Positive positron emission tomography scan was seen in 51% (55/107), of which 51% (28/55) had preserved left ventricle function. Based on clinical profile, 18F-fluorodeoxyglucose—positron emission tomography imaging, cardiac magnetic resonance, and histological data 58% patients (32/55) received immunosuppressive therapy alone and 25.4% (14/55) received immunosuppressive therapy and catheter ablation. Optimal response was seen in 67% (31/46) over a mean follow-up of 6±3 months. In patients with left ventricle systolic dysfunction, 37% (10/27) showed an improvement in mean left ventricular ejection fraction of 13±6%. Conclusions: Approximately 51% of patients presenting with frequent premature ventricular contractions have underlying myocardial inflammation in this cohort. 18F-fluorodeoxyglucose—positron emission tomography scan can be a useful modality for early diagnosis and treatment with immunosuppressive therapy in selected patients can improve clinical outcomes.

Warfarin is deemed safe compared to bridging with heparin in the peri-procedure setting while implanting cardiac devices. The timing of discontinuation and re-initiation of direct anticoagulant agents (DOACs) such as dabigatran, apixaban, and rivaroxaban in the peri-procedural setting in comparison to warfarin is not well studied. We wanted to compare three DOAC agents with warfarin during cardiac device implantation. Consecutive patients on treatment with dabigatran, rivaroxaban, or apixaban (group A) undergoing a cardiac device generator change, upgrade, or new implantation procedure were compared to those on warfarin (group B). Incidence of hematoma, infection, effusion, stroke, and other complications were noted at 1 day, 1 week, and 3 months. A total of 311 patients in group A underwent the above procedures with 73 patients on dabigatran, 153 on rivaroxaban, and 85 on apixaban. There were 467 patients on warfarin in group B. Mean age of the total population was 68 ± 12 years with 67% males and > 80% Caucasians. The last dose of the DOAC was the night prior to the procedure and resumed the night of the procedure (single dose interruption for apixaban and dabigatran and no un-interruption for rivaroxaban). There was no difference noted in the incidence of minor or major hematoma (9% vs 8.5%, p = 0.7). No stroke occurred in either group. Use of DOAC agents with transient interruption of one dose is as safe as warfarin in the peri-procedural setting during implantation of cardiac devices.

Background There have been an increasing number of atrial fibrillation (AF) patients with Watchman® left atrial appendage occlusion (LAAO) device, requiring catheter ablation (CA) for maintenance of normal sinus rhythm. In this study, we describe our experience with the feasibility and safety of CA in patients with a preexisting Watchman LAAO device. Methods This was a retrospective multicenter AF registry of 60 patients with Watchman® LAAO device who underwent CA for AF. Baseline clinical and procedural characteristics of the included subjects were retrieved from review of medical records and were analyzed. Results The mean age was 72.7±4.9 years and the mean CHADS2 score was 2.3±0.6. All patients had successful pulmonary vein isolation (PVI). The left atrial appendage (LAA) was electrically active in 34 (56%) while reentrant tachycardia and AF triggers were seen in 17 (28%) patients. Electrical isolation was attempted in these 17 patients with only 10 achieving complete LAA isolation. Repeat imaging showed new peri-device leaks in 30% (12/40) patients, while new significant peri-device leaks (≥5 mm) were noted in 10% (10/40) of patients after RFA, respectively, requiring continuation of oral anticoagulation. There were a higher proportion of patients with severe peri-device leaks (≥5 mm) after LAA isolation. However, >50% of those leaks sealed off on follow-up TEE. Conclusion AF ablation is a feasible and safe in patients with preexisting Watchman LAAO device. Electrical isolation of the LAA could be difficult and when attempted can result in increased risk of short-term peri device leak and recurrence of AT/AF in almost all patients. This article is protected by copyright. All rights reserved

Background There is limited data regarding effect of prolonged radiation exposure during electrophysiological (EP) procedures on direct DNA damage. Comet test has shown to assess DNA damage following radiation exposure. Methods We performed a single-center prospective observational study assessing direct DNA damage using the quantitative comet assay in patients undergoing cardiac resynchronization (CRT) and atrial fibrillation (AF) catheter ablation procedures. Venous comet assay was performed pre, immediately post procedure and at 3-month duration in twenty-two (N=22) patients who underwent catheter ablation for symptomatic AF and fourteen (N=14) patients who underwent CRT implantation. Results The median [interquartile range (IQR)] fluoroscopy time, radiation dose and dose area product (DAP) were 34.3 (27.97 - 45.48) minutes, 853.07 (611.36 - 1334.76) mGy and 16,994.10 (9,023.65 - 58,845.00) UGym2 in the ablation group and 30.05 (18.75 - 37.33) minutes, 345.00 (165.09 - 924.79) mGy and 11,837.20 [7182.67 - 35567.75] UGym2 in the CRT group. When compared with pre-procedure, there was a statistically significant increase in median (IQR) DNA migration on comet assay in the ablation group immediately post procedure [+6.55 µm (0.78, 10.25, p=0.02)] that subsequently decreased at 3 months [-1.00 µm (-2.20, 0.78), p=0.03] but not in the CRT group. Conclusion There was a significant increase in DNA damage as detected by comet assay immediately post procedure that normalized at 3 months in patients undergoing AF ablation. Further large prospective studies are warranted to evaluate the impact of this prolonged radiation exposure and DNA damage on long-term follow up.

Introduction Limited data is available regarding the novel Reveal LinQ™ (LinQ) which is a new generation implantable loop recorders (ILRs). Methods We performed a prospective, observational study of all consecutive patients undergoing conventional (Reveal XT™; XT) and LinQ devices at our institution between January 2012 and December 2014. Results A total of 217 patients underwent ILR implantation. XT was implanted in 105 and LinQ in 112 patients. There were no significant differences in baseline characteristics between the two groups. LinQ implantation using the manufacturer's technique termed, "manufacturer's method" group had significantly higher incidence of pocket infection compared to XT (6/50, 12% vs 3/105, 3%, p=0.032). With modifications to the LinQ implantation technique (using a conventional scalpel and placing a suture when needed to the incision) termed "modified method" group, the rate of infection has decreased significantly compared to "manufacturer's method group" (0/62, 0% vs 6/50, 12%, p=0.004) (Table 3). In multivariate regression analysis, the only independent predictors of infection were younger age (OR 0.95; p=0.04), insertion of LinQ device (OR 30.02; p=0.006) and procedure time (OR 1.07; p=0.03). Conclusion In our single-center, prospective, observational study we found that with the current implantable techniques, the novel insertable LinQ device is associated with increased risk of complications.

Background Watchman and Lariat left atrial appendage (LAA) occlusion devices are associated with LAA leaks postdeployment. Objective The purpose of this study was to compare the incidence, characteristics, and clinical significance of these leaks. Methods We performed a multicenter prospective observational study of all patients who underwent LAA closure. Baseline, procedural, and imaging variables along with LAA occlusion rates at 30–90 days and 1-year postprocedure were compared. Results A total of 478 patients (219 with the Watchman device and 259 with the Lariat device) with successful implants were included. Patients in the Lariat group had a higher CHADS 2 (congestive heart failure, hypertension, age >74 years, diabetes, stroke) score and a larger left atrium and LAA. A total of 79 patients (17%) had a detectable leak at 1 year. More patients in the Watchman group had a leak compared with those in the Lariat group (46 [21%] vs 33 [14%]; P = .019). All the leaks were eccentric (edge effect) in the Watchman group and concentric (gunny sack effect) in the Lariat group. The size of the leak was larger in the Watchman group than in the Lariat group (3.10 ± 1.5 mm vs 2.15 ± 1.3 mm; P = .001). The Watchman group had 1 device embolization requiring surgery and 2 pericardial effusions requiring pericardiocentesis. In the Lariat group, 4 patients had cardiac tamponade requiring urgent surgical repair. Three patients in each group had a cerebrovascular accident and were not associated with device leaks. Conclusion The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Objectives This study was intended to evaluate the impact of adding the left atrial appendage (LAA) closure system (LARIAT) procedure to conventional atrial fibrillation (AF) ablation in patients with persistent AF. Background Percutaneous endoepicardial LARIAT may result in both mechanical and electrical exclusion of the LAA and aid in improving the outcomes of catheter ablation by eradicating the LAA triggers and altering the substrate. Methods We performed a prospective observational study of patients with persistent AF referred for AF ablation. Patients underwent LAA ligation with LARIAT procedure before undergoing AF ablation (LARIAT group). Age- and sex-matched persistent AF patients undergoing AF ablation during the same time frame were included in the control group (ablation-only group). Results A total of 138 patients were included in the study, with 69 patients in the LARIAT group. The mean age of the population was 67 ± 10 years, with 96 (70%) men. Left atrial (LA) size, CHADS 2 , CHADSVasc, and HAS-BLED scores were higher in the LARIAT group when compared with the ablation-only group. There were no differences in the type of lesions during AF ablation between the groups. The primary outcome of freedom from AF at 1 year off antiarrhythmic therapy after 1 ablation procedure was higher in the LARIAT group (45 [65%] vs. 27 [39%]; p = 0.002). More patients in the ablation-only group underwent repeat ablation because of AF recurrence (11 [16%] vs. 23 [33%]; p = 0.018). Conclusions In patients with persistent AF, addition of LAA ligation with the LARIAT device to conventional ablation appears to improve the success rate of AF ablation.

The left atrial appendage (LAA) is a well-known source of atrial natriuretic peptide (ANP) and therefore plays an important role in homeostasis. The neurohormonal impact of epicardial exclusion of the LAA with the LARIAT procedure is unknown. In this proof-of-concept study, we postulated that LAA exclusion would impact homeostasis as evidenced by changes in electrolytes and blood pressure (BP). A total of 76 patients who underwent successful LAA exclusion were enrolled in this retrospective observational study utilizing a prospective registry. Electrolytes, BP, and heart rate (HR) were monitored before LARIAT and post-LARIAT (24 and 72 h and 6 months). There was a significant reduction of systolic BP (mmHg) at 24 h (113.3 ± 16.0; p

Background The fibrous capsule around cardiac implantable device generators is known to promote bacterial colonization and latent infection. Removal of the capsule during device replacement procedures may reduce infection rates but may increase hemorrhagic complications. Objective The purpose of this study was to evaluate the effect of pocket capsule decortication procedure on infection and bleeding rates in patients undergoing device replacement procedures. Methods In a prospective randomized single-blind control study, patients undergoing device replacement, upgrade, or lead extraction were randomized to Group A "with pocket revision" (n = 131) and group B "without pocket revision" (n = 127). Deep and superficial infection rates, bleeding, and prolonged serous drainage were assessed during 12 months of follow-up. Data were analyzed according to intention-to-treat principle. Results A total of 258 patients were enrolled in the study. Rates of generator change, upgrade, and lead extraction/replacement were similar between both groups. There was no incidence of deep infection in either group at 12-month follow-up. There was no significant difference in the incidence of superficial infection between groups (1.5% vs 4.7%, P = .13) during 12-month follow-up. There was a significant increase in acute hematoma formation in group A compared to group B (6.1% vs 0.8%, P = .03). Two patients in group A had to undergo hematoma evacuation. Conclusion There was increased incidence of hematoma formation in group A with no effect on infection rates. Our study suggests that there is no benefit to performing empiric pocket revision.

Pleural Effusions After the Lariat Procedure Background The Lariat procedure is increasingly used for the exclusion of the left atrial appendage (LAA) in atrial fibrillation (AF) patients. There are anecdotal reports of pleural effusions after the Lariat procedure. However, the incidence, demographics, and pathophysiology of these effusions are largely unknown. Objective Characterization of pleural effusions in patients who underwent LAA exclusion using the Lariat procedure. Methods We report the incidence, demographics, and clinical and laboratory characteristics of patients from a multicenter prospective registry who underwent the Lariat procedure and subsequently developed pleural effusions. Results A total of 10 out of 310 (3.2%) patients developed significant pleural effusions after the Lariat procedure. The mean age of these patients was 67 ± 9, ranging from 52 to 78 years and included 5 (50%) males. Nine patients had persistent AF with median CHADS2 score of 2.7 ± 1.2. The LAA was successfully ligated in all these patients. Post-Lariat procedure, 6 patients developed bilateral and 4 patients developed left-sided pleural effusions. Pleural tap revealed transudative in 2 and exudative in 6 patients. The remaining 2 patients responded to active diuresis and behaved clinically like transudative effusions. There is a statistically significant difference between the onset of pleural effusion after the Lariat procedure between tPLE versus ePLE groups (14 ± 1.2 vs. 6 ± 6, P = 0.05). Conclusion Incidence of clinically significant pleural effusion is uncommon after the Lariat procedure and can be either exudative or transudative in nature depending on the underlying mechanisms. More prospective studies are needed to study the pathophysiologic basis of development of pleural effusions after the Lariat procedure.

Neurocardiogenic syncope (NCS) is a common clinical condition characterized by abrupt cardiovascular autonomic changes resulting in syncope. This is a recurring condition with mixed results from current strategies of treatment. Subjects with a diagnosis of NCS were screened and enrolled. All the participants were given a DVD containing yoga videos and were instructed to practice yoga therapy for 60 min, three times a week for 3 consecutive months. Syncope functional status questionnaire score (SFSQS) was administered at the beginning and the end of the study. The subjects were followed for 3 months and underwent repeat tilt table testing at the end of the study. Of the 60 patients screened, 44 subjects were enrolled, 21 in the intervention group and 23 in the control group. Most of the participants were females, and the mean age was 21 ± 3 years. In the intervention group, who finished the yoga regimen, there was a statistically significant improvement from control phase to the intervention phase, in number of episodes of syncope (4 ± 1 vs 1.3 ± 0.7, p

Background Left atrial (LA) strain (e) and e rate (SR) analysis by 2-dimensional speckle tracking echocardiography is a novel method for functional assessment of the LA. Objective The purpose of this study was to determine the impact of left atrial appendage (LAA) exclusion by Lariat epicardial ligation on mechanical function of the LA by performing e and SR analysis before and after the procedure. Methods A total of 66 patients who underwent successful LAA exclusion were included in the study. Of these 66 patients, 32 had adequate paired data for e and SR analysis. SR during ventricular systole (LA-SRs) represents LA reservoir function, and SR during early ventricular diastole (LA-SRe) represents LA conduit function. e and SR were determined from apical 4- and 2-chamber views using the electrocardiographic QRS as a reference point. LA volume index as surrogate for LA remodeling was measured from apical views. Results Mean patient age was 70 ± 9.2 years. LAA ligation resulted in improved reservoir function (LA-SRs: pre 0.72, confidence interval [CI] 0.63–0.83 vs post 0.81, CI 0.73–0.98; P = .043) and conduit function (LA-SRe: pre 0.74, CI 0.67–0.99 vs post 0.89, CI 0.82–1.07; P = .025). LA volume index improved significantly with the Lariat (pre 35.4, CI 29.4–37.2 vs post 29.2, CI 28.2–35.9; P Conclusion LAA exclusion seems to improve mechanical function of the LA and results in reverse LA remodeling.

Background Atrioventricular node (AVN) ablation and permanent pacing is an established strategy for rate control in the management of symptomatic atrial fibrillation (AF). Leadless pacemakers (LPs) can overcome some of the short-term and long-term limitations of conventional transvenous pacemakers (CTPs). Objectives The purpose of this study was to compare the feasibility and safety of LP with those of single-chamber CTP in patients with AF undergoing AVN ablation. Methods We conducted a multicenter observational study of patients undergoing AVN ablation and pacemaker implantation (LP vs single-chamber CTP) between February 1, 2014 and November 15, 2016. The primary efficacy end points were acceptable sensing (R wave amplitude ≥5.0 mV) and pacing thresholds (≤2.0 V at 0.4 ms) at follow-up. Safety end points included device-related major and minor (early 1 month) adverse events. Results A total of 127 patients with LP (n = 60) and CTP (n = 67) were studied. The median follow-up was 12 months (interquartile range 12–18 months). Ninety-five percent of the LP group and 97% of the CTP group met the primary efficacy end point at follow-up (57 of 60 vs 65 of 67; P = .66). There was 1 major adverse event (loss of pacing and sensing) in the LP group and 2 (lead dislodgement) in the CTP group (1 of 60 vs 2 of 67; P = 1.00). There were 6 minor adverse events (5 early and 1 late) in the LP group and 3 (early) in the CTP group (6 of 60 vs 3 of 67; P = .30). Conclusion Our results demonstrate the feasibility and safety of LP compared with CTP in patients undergoing AVN ablation for AF.

AF Ablation in Pulmonary Vein Stumps Background Pulmonary vein isolation (PVI) of the remnant pulmonary vein (PV) stumps in pneumonectomy patients has not been well characterized. Methods This is a multicenter observational study of patients with a remnant PV stump after pneumonectomy. Consecutive patients with a history of pneumonectomy and who had undergone RF ablation for drug refractory AF were identified from the AF database at the participating institutions. Results There were 15 patients in whom pneumonectomy was performed, for resection of tumors in 10, infection in 4, and bullae in 1 patient and who underwent RF ablation for AF. The mean age was 63 ± 7 years. The stumps were from the right lower PV in 5, left upper PV in 5, left lower PV in 3, and right upper PV in 2 patients. All the PV stumps were electrically active with PV potentials and 9 (60%) of them had triggered activity. PVI was performed in 14 and focal isolation in 1 patient. At 1-year follow-up, 80% were free of AF, off of antiarrhythmic medications. Conclusion PV stumps in AF patients with previous pneumonectomy are electrically active and are frequently the sites of active firing. Isolation of these PV stumps can be accomplished safely and effectively using catheter ablation with no practical concern for PV stenosis or compromising PV stump integrity.

The left atrial appendage (LAA) is a well-known source of atrial arrhythmia and atrial fibrillation (AF).The purpose of this study was to determine whether LAA exclusion using the LARIAT device would decrease AF burden.A total of 50 patients with AF and cardiac implantable electronic devices who underwent successful LAA exclusion were enrolled in this prospective observational study. AF burden before LAA exclusion (baseline) and 3 and 12 months after exclusion was assessed by device interrogation.AF burden at 3-month follow-up (42% ± 34%) was significantly lower compared to baseline (76% ± 33%, P.0001). The reduction in AF burden was sustained at 12 months (59% ± 26%, P.001). Subgroup analysis revealed that AF burden at 3-month follow-up was similarly reduced in both paroxysmal AF (n = 19) and nonparoxysmal AF (n = 31). However, there was no reduction in AF burden in patients with paroxysmal AF at 12 months. AF burden in patients with known AF triggers in the LAA (n = 9) was significantly reduced at 3 months (52% ± 35%) and 12 months (42% ± 19%) compared to respective baseline (84 ± 31%, P.0001).LAA exclusion appears to reduce AF burden. The presence of AF triggers in the LAA appears to be the strongest predictor of AF reduction. The study underscores the role of the LAA in arrhythmogenesis for AF and highlights the complementary role of LAA exclusion in restoration of normal sinus rhythm.

Background: We sought to investigate and compare the safety and efficacy of two commonly used antiarrhythmic drugs, Dofetilide (DF) and Sotalol (SL), during inpatient drug initiation in patients with symptomatic atrial fibrillation (AF). Methods: We performed a single center retrospective study of consecutive patients, admitted for initiation of either DF or SL, for AF between 2012 and 2015. Rates of successful cardioversion, QT interval prolongation, adverse events and drug discontinuations were calculated and compared. A two-tailed p value less than 0.05 was considered statistically significant. Results: Of 378 patients, 298 (78.8%) received DF and 80 (21.2%) SL, mean age was 64 ± 11 years, 90% were Caucasians and 66% were males. Among the patients who remained in AF upon admission (DF: 215/298 (72%) vs. SL: 48/80 (60%)), no significant differences were noted in pharmacological cardioversion rates (DF: 125/215(58%) vs. SL: 30/48 (62.5%); p = 0.58). Baseline QTc was similar between the groups, with higher dose dependent QTc prolongation with DF (472.25± 31.3 vs. 458± 27.03; p = 0.008). There were no significant differences in the rates of adverse events such as bradycardia (7.4% vs. 11.3%; p = 0.26), Torsades de pointes (1.3% vs. 1.2%; p = 1.00), and drug discontinuation (9.0% vs. 5.0%; p = 0.47) between the two groups. Conclusion: In our large, single center experience, we found that the use of Dofetilide resulted in significantly higher QTc without differences in the rates of successful cardioversion, adverse events, and drug intolerance when compared to Sotalol in AF patients.

Introduction: Radiofrequency catheter ablation (RFCA), an effective treatment for atrial fibrillation (AF), is rarely complicated by severe pulmonary vein stenosis (PVS) requiring intervention. We sought to evaluate the safety of repeat RFCA in AF patients with moderate PVS after index RFCA. Hypothesis: We hypothesized, in patients with moderate PVS, repeat RFCA would not result in significant progression of PVS. Methods: We performed a retrospective, observational study of all patients who developed moderate PVS (decrease in the PV cross sectional area ≥50% but Results: Of a total of 2550 AF patients who underwent RFCA from 2011-2016, 165 (6.4%) developed moderate PVS of at least one PV. Mean age was 65 ± 11 years, with 130 (79%) males and 113 (68%) with paroxysmal AF. Right superior, right inferior, left superior and left inferior PVs were involved in 31%, 29%, 41%, and 20% of patients, respectively. Of these 165 patients, 78 (47%) underwent repeat CT scan (with or without redo ablation), and 48 (29%) underwent redo RFCA in the antrum of the involved PV. Mean times between CT1-CT2 and CT2-CT3 were 6 and 11 months, respectively. On repeat CT, 6 (8%) developed severe PVS of at least one PV. There was no statistical difference in the incidence of severe PV stenosis between those who underwent repeat ablation compared to those who did not (4.2 vs. 14.3 respectively; p = 0.185) Conclusions: Repeat RFCA for AF in patients with prior moderate PV stenosis appears to be safe with an acceptable risk (4.2%) of developing severe PV stenosis.

The prevalence and predictors of atrial tachyarrhythmias (ATa) in patients with pulmonary hypertension (PH) is less well understood. We performed a retrospective study including 311 patients with PH, confirmed by right heart catheterization in our center between 2007 and 2011. Baseline characteristics, clinical, echocardiographic, and hemodynamic data were collected and compared between patients with and without ATa. The mean age was 61 ± 13 years with 64 % females. The mean pulmonary artery pressure (mPAP) was 46 ± 20 mmHg, mean left ventricular ejection fraction (LVEF) was 55 ± 13 %, and mean pulmonary capillary wedge pressure (PCWP) was 19 ± 9 mmHg. Of the 311 patients with PH, 121 (39 %) patients had ATa. Patients with ATa were older (p

RF Ablation of VT in Chronic Cocaine Users Background Cocaine use is a known but rare cause of cardiac arrhythmias. Ventricular arrhythmias related to cocaine may not respond to antiarrhythmic drugs and may need treatment with radiofrequency ablation. Objectives We describe the clinical and electrophysiological characteristics of cocaine-related ventricular tachycardia (VT) from a multicenter registry. Methods Subjects presenting with VT related to cocaine use and being considered for radiofrequency ablation have been included in the study. Patients who were refractory to maximal medical therapy underwent radiofrequency ablation of the VT. Clinical, procedural variables, efficacy, and safety outcomes were assessed. Results A total of 14 subjects met study criteria (age 44 ± 13, range 18- to 68-year-old with 79% male, 71% Caucasian). MRI showed evidence of scar only in 43% of patients (6/14). The mechanism of VT was focal in 50% (n = 7) and scar related reentry in 50% (n = 7) based on 3D mapping. The mean VT cycle length was 429 ± 96 milliseconds. The site of origin was epicardial in 16% (3/18) of VTs. Most clinical VTs were hemodynamically stable (75%). Mean ejection fraction at the time of admission was 44 ± 14%. Duration of procedure was 289 ± 50 minutes. One subject developed pericardial tamponade requiring drainage. At 18 ± 11 months follow-up, freedom from arrhythmia was seen in 86% (1 case lost to follow-up and 2 died). Conclusion Radiofrequency ablation is not only feasible but also safe and effective in patients who have drug refractory VT related to chronic cocaine use. © 2014 Wiley Periodicals, Inc.

Pre- and postablation atrial fibrillation (AF) brain natriuretic peptide (BNP) levels were shown to predict increased recurrence of AF following ablation. Our objective was to assess whether elevated BNP levels merely represent the presence of AF at the time of measurement or indeed the true recurrence of AF. In a prospective study of 88 patients undergoing AF ablation, BNP levels were measured immediately before, after, 24 h, and 4–6 months postablation. BNP levels were stratified by presenting rhythm and ventricular rate at the time of measurement. Median BNP level preablation was higher in patients presenting in AF compared to sinus rhythm (SR) (54(44–79) pg/ml vs. 30(18–47) pg/ml, p

Background A significant proportion of patients treated with warfarin for atrial fibrillation (AF) become warfarin ineligible (WI) due to major bleeding events (MBE) or systemic thromboembolism (STE). We report a large multicenter real-world experience of the use of DOACs in these WI patients. Methods We report the outcomes of 263 WI patients treated with DOACs. The primary objective was to evaluate clinical outcomes of STE and MBE with DOACs. Secondary objective was to assess clinical predictors of repeat MBE and STE on DOACs. Results 63% (166/263) patients had a repeat MBE on DOACs. Repeat MBE was significantly higher in patients with prior gastrointestinal bleeding (74.5% vs 30%, p

Objectives The purpose of this study was to examine the impact of yoga on atrial fibrillation (AF) burden, quality of life (QoL), depression, and anxiety scores. Background Yoga is known to have significant benefit on cardiovascular health. The effect of yoga in reducing AF burden is unknown. Methods This single-center, pre-post study enrolled patients with symptomatic paroxysmal AF with an initial 3-month noninterventional observation period followed by twice-weekly 60-min yoga training for next 3 months. AF episodes during the control and study periods as well as SF-36, Zung self-rated anxiety, and Zung self-rated depression scores at baseline, before, and after the study phase were assessed. Results Yoga training reduced symptomatic AF episodes (3.8 ± 3 vs. 2.1 ± 2.6, p Conclusions In patients with paroxysmal AF, yoga improves symptoms, arrhythmia burden, heart rate, blood pressure, anxiety and depression scores, and several domains of QoL. (Yoga on Arrhythmia Burden and Quality of Life in Paroxysmal Atrial Fibrillation; NCT00798356 )

Introduction: Restoration of normal sinus rhythm by radiofrequency ablation (RFA) in atrial fibrillation (AF) patients can result in a reduction of left atrial (LA) volume and pulmonary vein (PV) dimensions. It is not clear if this PV size reduction represents a secondary effect of overall LA volume reduction or true PV stenosis. We assessed the relationship between LA volume reduction and PV orifice area pre- and post-RFA. Methods: A retrospective cohort study was conducted at a tertiary care academic hospital. Pre- and post-RFA cardiac computed tomography (CT) studies of 100 consecutive AF patients were reviewed. Studies identifying obvious segmental PV narrowing were excluded. Left atrial volumes and PV orifice cross-sectional areas (PVOCA) were measured using proprietary software from the CT scanner vendor (GE Healthcare, Waukesha, WI). Results: The cohort had a mean age of 60 ± 8 years, 73% were male, and 90% were Caucasian. Non-paroxysmal AF was present in 76% of patients with a mean duration from diagnosis to RFA of 55 ± 54 months. Mean procedural time was 244 ± 70 min. AF recurred in 27% at 3 month follow-up. Pre-RFA LA volumes were 132 ± 60 ml and mean PVOCA was 2.89 ± 2.32 cm2. In patients with successful ablation, mean LA volume decreased by 10% and PVOCA decreased by 21%. PVOCA was significantly reduced in patients with successful RFA compared to those who had recurrence (2.18 ± 1.12 vs. 2.8 ± 1.9 cm2, p = 0.04) but reduction in LA volume between groups was not significant (118 ± 42 vs. 133 ± 54 ml, p=0.15). Conclusions: The study demonstrates that both PV orifice dimensions and LA volume are reduced after successful AF ablation. These data warrant a reassessment of criteria for diagnosing PV stenosis based on changes in PV caliber alone, ideally incorporating LA volume changes.

There have been an increasing number of atrial fibrillation (AF) patients with Watchman left atrial appendage occlusion (LAAO) device, requiring catheter ablation (CA) for maintenance of normal sinus rhythm. In this study, we describe our experience with the feasibility and safety of CA in patients with a preexisting Watchman LAAO device.This was a retrospective multicenter AF registry of 60 patients with Watchman LAAO device who underwent CA for AF. Baseline clinical and procedural characteristics of the included subjects were retrieved from review of medical records and were analyzed.The mean age was 72.7 ± 4.9 years and the mean CHADS2 score was 2.3 ± 0.6. All patients had successful pulmonary vein isolation (PVI). The left atrial appendage (LAA) was electrically active in 34 (56%) while reentrant tachycardia and AF triggers were seen in 17 (28%) patients. Electrical isolation was attempted in these 17 patients with only 10 achieving complete LAA isolation. Repeat imaging showed new peri-device leaks in 30% (12/40) patients, while new significant peri-device leaks (≥5 mm) were noted in 10% (10/40) of patients after RFA, respectively, requiring continuation of oral anticoagulation. There were a higher proportion of patients with severe peri-device leaks (≥5 mm) after LAA isolation. However,50% of those leaks sealed off on follow-up transesophageal echocardiogram.AF ablation is a feasible and safe in patients with preexisting Watchman LAAO device. Electrical isolation of the LAA could be difficult and when attempted can result in increased risk of short-term peri-device leak and recurrence of AT/AF in almost all patients.

The objective of this study was to examine the clinical determinants of incidence and prognosis of arrhythmias in the setting of acute brain injury. Acute brain injury is known to cause electrocardiographic abnormalities and cardiac arrhythmias. The relation between partial brain tissue oxygen (PBTO) and intracranial pressure (ICP) with arrhythmia incidence and prognosis remains unknown. Consecutive patients with acute brain injury and intracranial bleed admitted to the neurosurgical intensive care unit were enrolled in the study. Baseline characteristics [demographics, medical history, etiology of brain injury, Glasgow Coma Scale (GCS) score, blood pressure, and respiratory rate] were documented. Patient's telemetry recordings were reviewed for daily mean heart rates and arrhythmias. If arrhythmia was noted, PBTO levels at the beginning of arrhythmia, ICP, brain tissue temperature, and outcomes were recorded. A total of 106 subjects (53% men, age 39 ± 18 years, 65 traumatic and 41 nontraumatic brain injuries) were studied. Overall, 62% of subjects developed a total of 241 arrhythmia episodes. Ventricular arrhythmias were associated with significantly higher daily mean heart rates, low PBTO levels, and low GCS scores, whereas atrial arrhythmias were associated with lower daily mean heart rates, normal PBTO levels, and higher GCS and ICP. Three or more episodes of arrhythmia predicted worse outcomes, including mortality (P = 0.001). In patients with acute brain injury, poor PBTO levels are associated with higher incidence of ventricular tachyarrhythmias. In contrast, atrial tachyarrhythmias occur in patients with normal PBTO levels and higher ICP. Incidence of ventricular arrhythmia in those with poor PBTO is associated with increased mortality.

ObjectivesThis study sought to examine whether suppressing premature ventricular contractions (PVC) using radiofrequency ablation improves effectiveness of the cardiac resynchronization therapy (CRT) in nonresponders.BackgroundCRT is an effective strategy for drug refractory congestive heart failure. However, one-third of patients with CRT do not respond clinically, and the causes for nonresponse are poorly understood. Whether frequent PVC contribute to CRT nonresponse remains unknown.MethodsIn this multicenter study, CRT nonresponders with >10,000 PVC in 24 h who underwent PVC ablation were enrolled from a prospective database.ResultsSixty-five subjects (age 66.6 ± 12.4 years, 78% men, QRS duration of 155 ± 18 ms) had radiofrequency ablation of PVC from 76 foci. Acute and long-term success rates of ablation were 91% and 88% in 12 ± 4 months of follow-up. There was significant improvement in left ventricular (LV) ejection fraction (26.2 ± 5.5% to 32.7 ± 6.7 %, p < 0.001), LV end-systolic diameter (5.93 ± 0.55 cm to 5.62 ± 0.32 cm, p < 0.001), LV end-diastolic diameter (6.83 ± 0.83 cm to 6.51 ± 0.91 cm, p < 0.001), LV end-systolic volume (178 ± 72 to 145 ± 23 ml, p < 0.001), LV end-diastolic volume (242 ± 85 ml to 212 ± 63 ml, p < 0.001), and median New York Heart Association functional class (3.0 to 2.0, p < 0.001). Modeling of pre-ablation PVC burden revealed an improvement in ejection fraction when the pre-ablation PVC burden was >22% in 24 h.ConclusionsFrequent PVC is an uncommon yet significant cause of CRT nonresponse. Radiofrequency ablation of PVC foci improves LV function and New York Heart Association class and promotes reverse remodeling in CRT nonresponders. PVC ablation may be used to enhance CRT efficacy in nonresponders with significant PVC burden.

Patients with prosthetic valves have a high prevalence of atrial fibrillation (AF). We report a multicenter experience of performing pulmonary vein antral isolation (PVAI) in this challenging, high-risk cohort of patients.The purpose of this study was to assess the feasibility, safety, and efficacy of radiofrequency (RF) ablation for sinus rhythm restoration in AF patients with mitral or aortic mechanical prosthetic valves.A total of 50 patients with prosthetic valves (group I) who underwent RF ablation for AF between January 1, 2007, and April 30, 2009, were identified prospectively at four tertiary care centers. A matched group of 50 patients (group II) acted as controls.Total procedural time (199.4 ± 49 minutes vs 166.6 ± 27.5 minutes, P.001) and fluoroscopy time (60 ± 17 minutes vs 53.8 ± 6.8 minutes, P.01) were prolonged, with a higher incidence of atrial flutter at 3 months in group I (18% vs 6%, P = .1) compared to group II. At 12 months, 80% of patients in the valve group were in sinus rhythm after an average of 1.3 procedures, and 82% of controls were in sinus rhythm after an average 1.2 procedures (P = .9). There was a trend toward a higher nonfatal complication rate in the valve group than in the control group (8% vs 4%, P = .1).In patients with prosthetic valves, RF ablation for AF is feasible, safe, and efficacious, with a trend toward a higher nonfatal complication rate and an increased rate of postablation atrial flutter.

Atrial fibrillation and flutter are well known causes of stroke. Whether other atrial arrhythmias like paroxysmal supraventricular tachycardia (PSVT) is associated with stroke is not clear. We aimed to evaluate the association of PSVT with ischemic and embolic stroke and its impact on short term

Fluctuation of impedance on defibrillator leads is highly suggestive of lead failure. A drop in impedance is associated with insulation defects while high impedance is suggestive of lead fracture. In this case report, we described a patient where electromagnetic interference from radiofrequency ablation near the site of superior vena cava coil caused the sensed impedance to fluctuate without uneventful outcomes and we discussed the possible mechanism. Both electromagnetic interference and defibrillator lead insulation defect can result in low threshold and inappropriate shocks. Sometimes electromagnetic interference may result in physical damage of the implanted system and may result in subsequent fluctuations in impedance. Awareness of electromagnetic interference that can cause fluctuating impedance without structural damage can help in making appropriate diagnosis and may avoid unnecessary procedures. (PACE 2012; 35:e163–e166)

Background: Epicardial ligation of left atrial appendage (LAA) is an attractive alternative to oral anticoagulation for patients with atrial fibrillation and high risk of bleeding. Objectives: To delineate the safety of epicardial ligation of the LAA for stroke prevention in atrial fibrillation Methods: This is a retrospective, multicenter registry of consecutive patients undergoing LAA ligation with the LARIAT device at 14 U.S. sites. The primary endpoint was procedural success, defined as device success (suture deployment and Results: A total of 610 patients underwent LARIAT exclusion of LAA. The mean age of the participants was 71 (SD: ± 10) years. The mean CHADs2VASc and HASBLED score was 2.74(±1.33) and 3.87 (±1.8) respectively. Epicardial access was obtained using micro-puncture needle in 60 percent of the cases. The acute closure was achieved in 554 (91 %) patients. Cardiac perforation needing continued drainage and transfusion occurred in 12 patients (1.96 %). Perforation of epigastric artery occurred in 2 patients (0.3 %). Eight patients (1.3 %) required open heart surgery. Five patients required > 2 weeks of treatment for pericarditis. No myocardial infarction or stroke happened in the peri-procedural period. One patient died as complication of the procedure. A follow up transesophageal echocardiogram (TEE) was performed in 76 % of the patients that showed a leak of < 5 mm and thrombus in 49 (8 %) and 12 (1.96 %) patients respectively. Conclusions: In this largest multicenter experience of LAA ligation with the LARIAT device, the rate of acute closure was high with significantly fewer complications compared to limited contemporary data. The use of micro-puncture is probably safer approach to avoid cardiac injury during epicardial access. A prospective randomized trial is required to adequately define clinical efficacy, optimal post-procedure medical therapy, and the effect of operator experience on procedural safety.

Objectives: Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM.) Aggressive rhythm control is recommended for this group of patients and radiofrequency catheter ablation is emerging as a frontline strategy. This pooled analysis aims to study the efficacy and outcomes of AF ablation in HCM patients Methods: PubMed, EMBASE and Google Scholar databases were searched to identify all studies describing the outcomes of catheter ablation of AF in HCM. Data from identified studies was extracted and pooled analysis was carried out using CMA 2 software. Pooled adjusted procedure duration and incident rates of recurrence and adverse events were calculated using random effects model. Results: A total of 11 studies with 384 patients were included in this study. For the index procedure, mean procedural time, radio frequency ablation and fluoroscopy times were 207.3 minutes, 39.7 minutes and 62.4 minutes respectively. The adjusted incidence of major ablation-related complications (death, stroke, transient ischemic attack, peripheral embolism, cardiac tamponade or perforation, valvular damage, arteriovenous fistula requiring surgical intervention, and a large vascular access site hematoma resulting in a drop of hemoglobin level by 2 g/dL) was 4 per 100 procedures (95% CI 2.1 - 7.5%). The recurrence of AF after index ablation during the mean follow up period of 14.5 months occurred in 58% (95% CI 50 -66%) of the patients (Figure1). Conclusion: The results of our analysis suggest that there is a high rate of recurrence of AF in HCM patients who undergo single AF ablation. The risk of complications with AF ablation appears to be low in this group of patients. Further studies are needed to assess the impact of multiple ablations on long term outcomes in these patients.

Published studies of epicardial ligation of left atrial appendage (LAA) have reported discordant results.The purpose of this study was to delineate the safety and efficacy of LAA closure with the LARIAT device.This is a multicenter registry of 712 consecutive patients undergoing LAA ligation with LARIAT at 18 US hospitals. The primary end point was successful suture deployment, no leak by intraprocedural transesophageal echocardiography (TEE), and no major complication (death, stroke, cardiac perforation, and bleeding requiring transfusion) at discharge. A leak of 2-5 mm on follow-up TEE was the secondary end point.LARIAT was successfully deployed in 682 patients (95.5%). A complete closure was achieved in 669 patients (98%), while 13 patients (1.8%) had a trace leak (2 mm). There was 1 death related to the procedure. Ten patients (1.44%) had cardiac perforation necessitating open heart surgery, while another 14 (2.01%) did not need surgery. The risk of cardiac perforation decreased significantly after the introduction of a micropuncture (MP) needle for pericardial access. Delayed complications (pericarditis requiring2 weeks of treatment with nonsteroidal anti-inflammatory drugs/colchicine and pericardial and pleural effusion after discharge) occurred in 34 (4.78%) patients, and the risk decreased significantly with the periprocedural use of colchicine. Follow-up TEE (n = 480) showed a leak of 2-5 mm in 6.5% and a thrombus in 2.5%. One patient had a leak of5 mm.LARIAT effectively closes the LAA and has acceptable procedural risks with the evolution of the use of the micropuncture needle for pericardial access and the use of colchicine for mitigating the postinflammatory response associated with LAA ligation and pericardial access.

Atrioventricular node (AVN) ablation is an effective treatment for symptomatic patients with atrial arrhythmias who are refractory to rhythm and rate control strategies where optimal ventricular rate control is desired. There are limited data on the predictors of failure of AVN ablation. Our objective was to identify the predictors of failure of AVN ablation. This is an observational single-center study of consecutive patients who underwent AVN ablation in a large academic center. Baseline characteristics, procedural variables, and outcomes of AVN ablation were collected. AVN "ablation failure" was defined as resumption of AVN conduction resulting in recurrence of either rapid ventricular response or suboptimal biventricular pacing. A total of 247 patients drug refractory AF who underwent AVN ablation at our center with a mean age of 71 ± 12 years with 46% being males were included. Ablation failure was seen in 11 (4.5%) patients. There were no statistical differences between patients with "ablation failure" versus "ablation success" in any of the baseline clinical variables. Patients with moderate-to-severe tricuspid regurgitation (TR) were much more likely to have ablation failure than those with ablation success (8 [73%] vs 65 [27%]; p = 0.003). All 11 patients with ablation failure had a successful redo procedure, 9 with right and 2 with the left sided approach. On multivariate analysis, presence of moderate-to-severe TR was found to be the only predictor of failure of AVN ablation (odds ratio 9.1, confidence interval 1.99 to 42.22, p = 0.004). In conclusion, moderate-to-severe TR is a strong and independent predictor of failure of AVN ablation.

Patients with cardiac implantable electronic devices (CIEDs) frequently have arrhythmias warranting catheter ablation (CA). The risk of lead dislodgement with CA in patients with CIED implant within 1 year is uncertain. We retrospectively evaluated patients undergoing CA of arrhythmias at an

There is very limited data on long-term safety and efficacy of ablation procedures for Junctional ectopic tachycardia (JET) in adults. A retrospective chart analysis of all patients who underwent catheter ablation for JET between 2007 and 2016 were included in the study. A total of 12 patients are

Quadripolar (Quad) left ventricular (LV) leads have been approved for implantation in CRT devices in October of 2011 in United States. Limited data is available regarding the real world experience with these lead implantations, especially in the United States. All patients undergoing CRT

This study was intended to evaluate the impact of adding the left atrial appendage (LAA) closure system (LARIAT) procedure to conventional atrial fibrillation (AF) ablation in patients with persistent AF.Percutaneous endoepicardial LARIAT may result in both mechanical and electrical exclusion of the LAA and aid in improving the outcomes of catheter ablation by eradicating the LAA triggers and altering the substrate.We performed a prospective observational study of patients with persistent AF referred for AF ablation. Patients underwent LAA ligation with LARIAT procedure before undergoing AF ablation (LARIAT group). Age- and sex-matched persistent AF patients undergoing AF ablation during the same time frame were included in the control group (ablation-only group).A total of 138 patients were included in the study, with 69 patients in the LARIAT group. The mean age of the population was 67 ± 10 years, with 96 (70%) men. Left atrial (LA) size, CHADSIn patients with persistent AF, addition of LAA ligation with the LARIAT device to conventional ablation appears to improve the success rate of AF ablation.

Introduction: In patients who undergo cardiac device (ICD) implantation for primary prevention of sudden cardiac death (SCD), data is unclear if their generator needs to be replaced at end of life if their ejection fraction improves. Despite improvement in EF however, the underlying scar may remain the same. Methods: A retrospective study was performed at two high volume centers. Data on 280 patients who underwent ICD implantation for primary prevention of SCD was obtained after excluding patients with incomplete follow-up data. These patients were followed until November 2013 for any improvement in EF and if they underwent a generator change at device ERI. All arrhythmic events and appropriate and inappropriate shocks/ATP were all recorded. Mortality records were obtained from social security death index and chart review. Results: Thirty percent (n=86/280) of patients improved their EF to > 35% of which 41% (n=36) underwent a generator change by the study ending period for ERI/lead malfunction/infection issues with the rest not yet at ERI. Mean baseline EF in patients with and without EF improvement was 26±7% and 23±7%, p=0.2. Data for arrhythmic events was unavailable in n=25 patients in those with EF improvement and n =39 patients in those without EF improvement. Among the remaining 61 patients, appropriate events (shock+ATP) were noted in 22% of patients (n=14/61) and inappropriate shocks and ATP in 6% of (n=4/61) patients after their EF improved to > 35%. Two patients received a prior shock when their EF was low. In contrast, in patients who had no improvement in EF, 31% (n=48/155) received an appropriate event (p= Conclusions: Although patients with improvement in EF had fewer total events (ATP+shock) than those without improvement, the percentage of patients with ICD therapy post EF improvement with no prior ICD discharges is high enough (20%, n=12/59) to warrant an ICD despite EF improvement.

Introduction: Atrial fibrillation (AF) after cardiac surgery is associated with increased morbidity and mortality. Data comparing the occurrence of AF after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is unknown. Methods: We identified all studies reporting outcomes after TAVI in all available electronic databases. Meta-analysis of all the studies was performed using random effects model to a) evaluate the incidence of AF and b) compare the incidence of AF between TAVI and SAVR. Results: The incidence of AF was reported in 7 studies, 5 prospective observational studies and 2 randomized controlled studies. The cumulative event rate for new onset AF at 30 days after TAVI was 0.1 (95% CI; 0.06 -0.17). Three studies reported incidence of AF after TAVI and SAVR. The odds ratio (OR) of developing new onset AF with TAVI compared to SAVR was 0.3 (95% CI; 0.10 - 0.88) at 30 days. One year outcome of new onset AF was reported in only two studies. Although, the incidence of AF was lower in the TAVI group, this did not reach statistical significance (OR 0.7, 95% CI; 0.46 -1.07). Conclusion: The incidence of new onset AF after TAVI is 10% within the first 30 days. This risk is 70% lower in patients undergoing TAVI compared to SAVR. The impact of AF after TAVI in terms of stroke, mortality and future recurrences of AF are unknown. Further studies are therefore necessary to study these outcomes.

The Lariat procedure is increasingly used for the exclusion of the left atrial appendage (LAA) in atrial fibrillation (AF) patients. There are anecdotal reports of pleural effusions after the Lariat procedure. However, the incidence, demographics, and pathophysiology of these effusions are largely unknown.Characterization of pleural effusions in patients who underwent LAA exclusion using the Lariat procedure.We report the incidence, demographics, and clinical and laboratory characteristics of patients from a multicenter prospective registry who underwent the Lariat procedure and subsequently developed pleural effusions.A total of 10 out of 310 (3.2%) patients developed significant pleural effusions after the Lariat procedure. The mean age of these patients was 67 ± 9, ranging from 52 to 78 years and included 5 (50%) males. Nine patients had persistent AF with median CHADS2 score of 2.7 ± 1.2. The LAA was successfully ligated in all these patients. Post-Lariat procedure, 6 patients developed bilateral and 4 patients developed left-sided pleural effusions. Pleural tap revealed transudative in 2 and exudative in 6 patients. The remaining 2 patients responded to active diuresis and behaved clinically like transudative effusions. There is a statistically significant difference between the onset of pleural effusion after the Lariat procedure between tPLE versus ePLE groups (14 ± 1.2 vs. 6 ± 6, P = 0.05).Incidence of clinically significant pleural effusion is uncommon after the Lariat procedure and can be either exudative or transudative in nature depending on the underlying mechanisms. More prospective studies are needed to study the pathophysiologic basis of development of pleural effusions after the Lariat procedure.

Pulmonary vein isolation (PVI) of the remnant pulmonary vein (PV) stumps in pneumonectomy patients has not been well characterized.This is a multicenter observational study of patients with a remnant PV stump after pneumonectomy. Consecutive patients with a history of pneumonectomy and who had undergone RF ablation for drug refractory AF were identified from the AF database at the participating institutions.There were 15 patients in whom pneumonectomy was performed, for resection of tumors in 10, infection in 4, and bullae in 1 patient and who underwent RF ablation for AF. The mean age was 63 ± 7 years. The stumps were from the right lower PV in 5, left upper PV in 5, left lower PV in 3, and right upper PV in 2 patients. All the PV stumps were electrically active with PV potentials and 9 (60%) of them had triggered activity. PVI was performed in 14 and focal isolation in 1 patient. At 1-year follow-up, 80% were free of AF, off of antiarrhythmic medications.PV stumps in AF patients with previous pneumonectomy are electrically active and are frequently the sites of active firing. Isolation of these PV stumps can be accomplished safely and effectively using catheter ablation with no practical concern for PV stenosis or compromising PV stump integrity.