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Patients with left ventricular assist devices (LVAD) often tolerate ventricular arrhythmias (VA). We aim to assess the frequency and outcomes of ICD therapies averted by ultraconservative ICD programming (UCP) in LVAD patients.This single center, retrospective cohort study included patients with LVADs and ICDs implanted from 2015 to 2019 that had UCP. The aim for UCP was to maximally delay VA treatments and maximize anti-tachycardia pacing (ATP) prior to ICD shocks. VA events were reviewed after UCP and evaluated under prior conservative programming to assess for potentially averted events (that would have resulted in either ATP or defibrillation with prior programming).Fifty patients were included in the study with follow-up of median 16 ± 10.2 months after UCP. The median time from LVAD implantation to reprogramming was 7 days (IQR 5-9 days). Fourteen patients (28%) had potentially averted VA events that would have been treated with their prior ICD programming (82 total events, median two events per patient, IQR 1-10 events). Treated VA events occurred in 15 patients (30%). Eleven of the 14 patients with potentially averted VAs had treated events as well. Only one patient reported definitive symptoms of self-limited "dizziness" during a potentially averted event that did not result in hospitalization. No patients died of complications from or needed emergent care/hospitalization due a potentially averted VA.UCP in LVAD patients likely prevented unnecessary VA treatments in many patients with minimal reported symptoms during these potentially averted events. Prospective studies are necessary to confirm these findings.

Introduction Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter-defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD-related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs. Methods Single-center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal-to-noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events. Results Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months [2.3, 11.4 months]. LVAD subtypes included: HeartWare (n=22, 55%), Heartmate II (n=10, 25%), and Heartmate III (n=8, 20%). Over a follow-up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n=2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow-up. The SNR was similar between IB and DB sensing (50 [29-67] and 57 [41-69], p=0.89). Conclusion ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R-wave SNR with IB versus DB ICD leads. This article is protected by copyright. All rights reserved.

The subcutaneous ICD (S-ICD) is a viable alternative to transvenous ICD and avoids intravascular complications in patients without a pacing indication. The outcomes of S-ICD implantation are uncertain in patients with prior sternotomy.We aim to compare the implant techniques and outcomes with S-ICD implantation in patients with and without prior sternotomy.Multicenter retrospective cohort study including adult patients with an S-ICD implanted between January 2014 and June 2020. Outcomes were compared between patients with and without prior sternotomy.Among the 212 patients (49 ± 15 years old, 43% women, BMI 30 ± 8 kg/mImplantation of an S-ICD in patients with prior sternotomy is safe with a similar risk of 30-day complications and inappropriate ICD shocks as patients without prior sternotomy.

Many techniques exist for venous access (VA) during cardiac implantable electronic device (CIED) implantation.We sought to evaluate the learning curve with ultrasound (US) guided axillary vein access (USAA).Single-center prospective randomized controlled trial of patients undergoing CIED implantation. Patients were randomized in a 2:1 fashion to USAA versus conventional VA techniques. The primary outcomes were the success rates, VA times and 30-day complication rates.The study included 100 patients (age 68 ± 14 years, BMI 27 ± 4 kg/mAlthough the success rate with USAA was high, there was a significant learning curve. Once experienced with the USAA technique, there is the potential for reduced complications without adding to the procedure duration.

Left atrial appendage closure (LAAC) is a promising site-directed therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF) who are ineligible or contraindicated for long-term oral anticoagulation. A variety of LAAC modalities are available, including percutaneous endocardial occluder devices such as WATCHMAN TM (Boston Scientific Corp., Marlborough, MA, USA), and an ever-increasing body of evidence is helping to define the optimal use of each technique. Similarly increased experience with LAAC has revealed challenges such as device-related thrombi and peri-device leaks for which the long-term significance and appropriate management are areas of active investigation. We review the evolution and long-term outcomes with the WATCHMAN TM device with particular emphasis on the nuances of its use and its role in the broader landscape of appendageology.

Introduction: Management of voluminous data from implantable cardiac devices is resource intensive. False positive events can be especially problematic with implantable loop recorders (ILRs). We sought to describe our early experience with a novel ILR. Hypothesis: Sensitivity adjustment to Methods: A single center retrospective study was performed in patients with the Abbott Confirm RX ILR. Tachycardia, atrial fibrillation (AF), bradycardia, and pause events were reviewed to determine whether they were true or false positives. Results: The study included 13 patients (age 67 ±15.8 years, 62% men). The reasons for implant included: AF (n=7, 54%), syncope(n=3, 23%), palpitations (n=2, 15%), and stroke (n=1, 8%). The median follow-up duration was 3.1 months (IQR 1.3-4.4 months). There was no change in serial R waves during mean follow-up of 0.58 months (pre 0.62±0.22 mV, post 0.63±0.22 mV, p=0.52). Tachycardia detection occurred in 6 patients (46%), with only 1 patient having a false positive episode. AF detection occurred in 8 patients (62%), with only 2 patients having true AF episodes. Pause/bradycardia episodes were detected in 5 patients (39%), with false positive episodes in 4 patients. There was no difference in R waves at implant among patients with and without false positive bradycardia/pauses episodes (0.66 ±0.27 vs. 0.44 ± 0.28 mV, p=0.21). The max sensitivity was higher among patients with than without false positive bradycardia/pause episodes (0.14 ±0.01, 0.07 ±0.02 mV, p Conclusion: Programming the novel ILR to a sensitivity of

We read with great interest the article by Fender et al.1 Severe pulmonary vein (PV) stenosis is a major complication of catheter ablation, which can lead to significant morbidity and mortality. Its nonspecific symptoms and delayed onset from the time of ablation underscore the importance of a high index of suspicion for successful diagnosis and prompt management. The authors describe their approach to diagnosis using dedicated contrast computer tomography (CT) timed for optimal PV enhancement, noting a high concordance with ventilation-perfusion scan findings and superior spatial resolution compared with magnetic resonance imaging.2 However, given the inherent anatomic variability and lack of a standardized approach …

Background— Atrial fibrillation ablation has made tremendous progress with respect to innovation, efficacy, and safety. However, limited data exist regarding the burden and trends in adverse outcomes arising from this procedure. The aim of our study was to examine the frequency of adverse events attributable to atrial fibrillation (AF) ablation and the influence of operator and hospital volume on outcomes. Methods and Results— With the use of the Nationwide Inpatient Sample, we identified AF patients treated with catheter ablation. We investigated common complications including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, vascular access complications (hemorrhage/hematoma, vascular complications requiring surgical repair, and accidental arterial puncture), and in-hospital death described with AF ablation, and we defined these complications by using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. An estimated 93 801 AF ablations were performed from 2000 to 2010. The overall frequency of complications was 6.29% with combined cardiac complications (2.54%) being the most frequent. Cardiac complications were followed by vascular complications (1.53%), respiratory complications (1.3%), and neurological complications (1.02%). The in-hospital mortality was 0.46%. Annual operator ( Conclusions— The overall complication rate was 6.29% in patients undergoing AF ablation. There was a significant association between operator and hospital volume and adverse outcomes. This suggests a need for future research into identifying the safety measures in AF ablations and instituting appropriate interventions to improve overall AF ablation outcomes.

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.

Background: Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF and severe LA scarring/fibrosis identified by 3D mapping undergoing ablation of the pulmonary veins (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI plus ablation of the non-PV triggers. Methods: One-hundred seventy seven consecutive patients with paroxysmal atrial fibrillation and severe left atrial scarring were included in this study. LA scarring was diagnosed by 3D voltage mapping. The degree of scar was described as severe when >60% of the LA area was involved. Non-PV triggers were defined as ectopic triggers originating from sites other than pulmonary veins such as interatrial septum, superior vena cava, left atrial appendage, ligament of Marshall, crista terminalis and coronary sinus. Patients underwent ablation of the pulmonary vein antrum (PVAI) only (n=45, group 1), PVAI extended to the entire scar areas (scar homogenization [n=66, group 2]) or PVAI plus ablation of non-PV triggers (n=66, group 3). Choice of ablation strategy was determined by the operator. Patients were followed up for arrhythmia recurrence with event recorders, ECG and Holter monitoring. Results: Baseline characteristics were not different between the groups (age 63±9 vs 58±10 vs. 60±11 years, p=0.23; male 71%, vs. 72% vs. 73% p= 0.91). After a single procedure, all patients were followed-up for a minimum of two years. The long-term success rate at the end of the follow up was 19% (12 pts) in group 1, 21% (14 pts) in group 2, and 61% (40 pts) in group 3. Kaplan-Meier log-rank test indicated that the cumulative probability of AF-free survival was significantly higher in group 3 (overall log-rank p Conclusions: In patients with paroxysmal atrial fibrillation and severe left atrial scarring, PVAI plus ablation of non-PV triggers is associated with significantly better long-term outcome than PVAI alone or when PVAI is combined with scar homogenization.

Pulmonary vein (PV) isolation with catheter ablation in treating atrial fibrillation carries the risk of injury to phrenic nerve (PN). Left PN (LPN) stimulation continues to be one of the common complications of transvenous left ventricular lead placement during cardiac resynchronization therapy (CRT).In 30 formalin-fixed cadavers, spatial relationship of PNs with PV ostia, left atrial appendage (LAA), and cardiac veins was observed. Segmental location of LPN and cardiac vein crossover was also noted. Right and left PNs coursed abutting the ostium of right superior and left superior PVs in five (16.6%) and one (3.33%) cases, respectively. LPN coursed along the lateral surface of LAA in 20 (66.66%) cases and behind LAA in one (3.33%) case. Out of 18 (60%) cases having two cardiac veins draining free wall of left ventricle (LV) and suitable for CRT lead placement, both cardiac veins were crossed by LPN in two (6.66%) cases. LPN-cardiac vein crossover was located in midlateral segment in 10 (33.3%) cases; mid posterolateral segment in five (16.7%) cases; apical lateral segment and apical posterolateral segment in three (10.0%) cases each.PN is highly susceptible to either injury during catheter ablation or stimulation with LV pacing in certain critical locations. Detailed knowledge of spatial relationship of PNs with cardiac structures could help minimize inadvertent complications during these transcatheter electrophysiological procedures.