Prior studies have demonstrated the safety of same day discharge in appropriately selected patients undergoing CIED implantation though a limitation is the requirement for prolonged post-operative observation. There is limited data on whether expedited discharge pathways, which can reduce post-operative resource utilization, can offer comparably safe outcomes.

Epicardial ablation is less common but often critical approach for suppression of ventricular arrhythmias (VA), particularly in patients with arrhythmogenic cardiomyopathies. The use of irrigated ablation catheters in this space requires manual aspiration of fluid to prevent tamponade, creating frequent interruptions that prolong procedure time.

Activation and pace mapping are common strategies for PVC localization. Sinus rhythm electrogram (EGM) characteristics have also been associated with PVC site of origin. Describe the correlation of sinus rhythm late potentials (LPs) identified with high density mapping with the site of PVC origin. Patients undergoing PVC ablation between 1/1/20-12/31/20 using the Ensite Precision system (Abbott) at a single center were included. Sinus rhythm EGMs at the site of successful ablation obtained with a high-density multipolar catheter (Advisor HD Grid, Abbott) and bipolar ablation catheter (TactiCath SE, Abbott) were evaluated. PVC location was categorized as outflow tract (OT) and non-outflow tract (non-OT). The presence of a sinus rhythm LP, defined as single or multicomponent EGM after the end of the surface QRS complex, was recorded. 23 patients (25 PVC foci) were included. Mean patient age and LVEF were 50.4 years old (19-70 years old) and 49.2% (20-60%). 21/25 PVC foci were successfully ablated. LPs were identified at 12 sites of successful ablation (57%) with the multipolar catheter; of these, 5/12 were observed with a bipolar ablation catheter. LPs were seen in 8/10 LVOT sites, 3/4 RVOT sites, and 1/7 non-OT sites. LPs were more frequently observed in OT PVCs vs non-OT PVCs (79% vs 14%, p = 0.0158). In the 4 unsuccessfully ablated PVCs, no LPs were observed. Sinus rhythm LPs may be correlated to site of successful ablation in patients with PVCs, particularly in the outflow tracts. Further investigation is warranted to characterize the frequency of this finding, potential mechanisms, and utility for guiding catheter ablation.

BACKGROUND Pacing lead-related tricuspid regurgitation (TR), a recognized complication of ventricular pacing lead implantation, may be affected by lead position or diameter. OBJECTIVE This study sought to determine the effect of ventricular pacing lead position and diameter on pacing lead-related TR. METHODS A randomized prospective trial compared pacing leads in the right ventricular apex (RVA), right ventricular septum (RVS), or left ventricle via the coronary sinus (LV-CS) in a 1:1:1 fashion. Patients undergoing implantable cardioverter-defibrillator lead implantation in the RVA (RVA-ICD) were enrolled in a comparison group. Patients with preexisting moderate or greater TR were excluded. Prospective clinical evaluation, transthoracic echocardiograms, and device interrogation occurred 24 hours and 12 months after device implantation. RESULTS Sixty-three patients undergoing pacemaker implantation were randomized to RVA, RVS, or LV-CS pacing, and 48 RVA-ICD patients were enrolled as a comparison group. At 12 months, 6 patients (6.4%) developed moderate or greater TR. Moderate or greater TR was not significantly different between groups if analyzed by intention to treat (RVA 5.9%, RVS 10.0%, LV-CS 6.7%, and RVA-ICD 4.8%) or if analyzed by final lead location (RVA 4.8%, RVS 10.5%, LV-CS 8.3%, and RVA-ICD 5.1%). Ventricular lead-related complications occurred in 3 patients with right ventricular leads (3.2%) and 2 patients with LV-CS leads (11.1%) (P = .184). CONCLUSION Neither pacing lead position nor diameter appears to affect TR development significantly. LV-CS leads failed to achieve a statistically significant reduction in TR as compared with right ventricular leads.

ICD Characteristics and Survival in Young PatientsIntroductionIndications for implantable cardioverter defibrillators (ICDs) in young patients have expanded and differ from those in older adults. We sought to provide descriptive characteristics and data regarding ICD therapy and outcomes among younger and older ICD recipients.Methods and ResultsDemographics, device type and programming, remotely transmitted data, shock events, and survival were compared among younger (≤30 years) and older (>30 years) cohorts with ICDs from a single manufacturer followed on a remote network. The younger cohort included 904 patients (1.6% of all implants). This group had more females (46% vs. 25%; P < 0.01), single‐coil leads (21% vs. 4%; P < 0.01), and single‐chamber devices (46% vs. 34%; P < 0.01). Shock incidence was higher (40% younger vs. 32% older at 4 years; P < 0.01) and survival was better over comparable follow‐up (88% vs. 72%; P < 0.01). Remote monitoring was associated with improved survival in both groups (93% vs. 86% ≤ 30 years, P < 0.01; 73% vs. 66% > 30 years, P < 0.01). Shock for polymorphic ventricular tachycardia/fibrillation (VT/VF) was more frequent in younger patients (12% vs. 5%; P < 0.01); 39% of all shocks were inappropriate. A 10‐fold increased risk of mortality was seen among young patients with shocks for atrial fibrillation/flutter (AF/AFL).ConclusionsDifferences in survival, shock incidence, and prognostic significance of VT/VF and AF/AFL exist between younger and older ICD recipients. These suggest distinct differences in myocardial substrates and diseases that ultimately impact ICD management.

Although rare, Chiari networks are elaborate embryological remnants that can pose distinct challenges for catheter and pacing lead manipulation within the right atrium. Device entrapment may require open thoracotomy for removal, with significant morbidity. We report an unusual case of pacing lead entanglement within this structure, followed by prompt intracardiac echocardiographic identification and laser sheath removal.

Background. Surgical left atrial appendage (LAA) closure is often incomplete, with patients frequently requiring direct current cardioversion (DCCV) for atrial arrhythmias. Transesophageal echocardiography (TEE) is often performed before DCCV to exclude LAA thrombus. The impact of incomplete surgical LAA closure on patients referred for postoperative DCCV is unknown.Methods. We retrospectively reviewed patients undergoing TEE-guided DCCV within 30 days of cardiac surgery and surgical LAA closure. All pre-DCCV TEEs were reviewed to assess LAA patency and the presence of thrombus.Results. Ninety-three patients (mean age 68 years; 61 men [66%]) had a median time from surgery to DCCV of 6 days. Duration of atrial fibrillation was 48 hours or more in 85% (n = 79). On pre-DCCV TEE, a residual communication from the LAA was noted in 37% (n = 34). The rate of LAA patency was higher after suture closure than after surgical excision or staple closure. Thrombus was present in 26 of the 93 patients (28%), including 16 of 34 patients (47%) with incomplete closure of LAA. The strongest risk factor for thrombus was a patent, partially closed LAA (odds ratio 4.36, p = 0.003). Systemically accessible thrombus was present in 19 of the 93 patients (20%), and cardioversion was cancelled owing to thrombus in 15 (16%).Conclusions. Surgical closure of the LAA is often incomplete. Interrogation of the residual LAA after surgical LAA intervention with TEE before DCCV frequently detects thrombus and alters clinical management. Patients undergoing DCCV after surgical LAA intervention require evaluation with TEE for LAA patency and thrombus. (C) 2016 by The Society of Thoracic Surgeons

Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia that leads to hospitalizations for complications and adverse events each year. Despite significant improvement in our therapeutic approaches in the past decade, management of AF remains a difficult task. Novel therapies have failed to terminate AF and prevent its recurrence, and patients with AF continue to have thromboembolic complications. With the increasingly aging population and associated conditions, the prevalence of AF is expected to progressively increase, becoming a public health problem. Most patients with AF have multiple comorbidities and are of advanced age, making long-term anticoagulation challenging. This article provides an overview of the current pharmacological therapies for the management of AF, with particular emphasis on the emerging agents.

OBJECTIVE:To investigate a potential relationship between implantable cardioverter defibrillator (ICD) therapies and daily geomagnetic activity (GMA) recorded in a large database. PATIENTS AND METHODS:The ALTITUDE database, derived from the Boston Scientific LATITUDE remote monitoring system, was retrospectively analyzed for the frequency of ICD therapies. Daily GMA was expressed as the planetary K-index and the integrated A-index and was graded as levels I (quiet), II (unsettled), III (active), and IV (storm). RESULTS:A daily mean ± SD of 59,468±11,397 patients were monitored between January 1, 2009, and May 15, 2012. The distribution of days according to GMA was as follows: level I, 924/1231 (75%); level II, 226/1231 (18%); level III, 60/1231 (5%); and level IV, 21/1231 (2%). The daily mean ± SD numbers of ICD shocks received per 1000 active patients in the database were 1.29±0.47, 1.17±0.46, 1.03±0.37, and 0.94±0.29 on level I, II, III, and IV days, respectively; the daily mean ± SD sums of shocks and antitachycardia pacing therapies were 9.29±2.86, 8.46±2.45, 7.92±1.80, and 7.83±2.28 on quiet, unsettled, active, and storm days, respectively. A significant inverse relationship between GMA and frequency of ICD therapies was identified, with the most pronounced difference between level I and level IV days (P<.001 for shocks; P=.008 for shocks + antitachycardia pacing). CONCLUSION:In a large-scale cohort analysis, ICD therapies were delivered less frequently on days of higher GMA, confirming the previous pilot data and suggesting that higher GMA does not pose an increased risk of arrhythmias using ICD therapies as a surrogate marker. Further studies are needed to gain an in-depth understanding of the underlying mechanisms.

Atrial fibrillation and flutter (AF) are common and can have adverse effects in patients with left ventricular dysfunction. The present study assessed the long-term implications of AF on shock incidence and survival in patients with implantable cardiac resynchronization devices followed on a remote monitoring network. Patients implanted with cardiac resynchronization therapy defibrillators (CRT-D) manufactured by Boston Scientific, who regularly communicated information over a secure network, were eligible for enrollment in this study. Atrial fibrillation burden was calculated using atrial sense histograms. Shock episode electrograms were adjudicated by a panel of electrophysiologists. Both univariate and multivariate logistic regression models adjusting for age, gender, and device type were used to analyze the effects of AF on overall survival and the incidence of ICD therapies. A total of 63,866 patients were included in this analysis and 2,173 first shock episodes were adjudicated. Three hundred and eighty-eight first shock episodes (18%) were classed as due to AF with a rapid ventricular response. The overall incidence of AF was 47.1%. Regardless of shock occurrence, any AF burden was associated with decreased survival compared with no AF (AF burden .0.01%, p,0.001). Conclusions: In an unselected population of patients with implantable resynchronization cardiac devices, remotely followed via a secure network, atrial fibrillation is extremely prevalent, and even low burdens of AF are associated with worsened outcome.

Cardiac resynchronization therapy (CRT) improves outcomes in patients with heart failure, yet response rates are variable. We sought to determine whether physician-specified CRT programming was associated with improved outcomes.

The stiff left atrial (LA) syndrome is defined as pulmonary hypertension (PH) secondary to reduced LA compliance and has recently been shown to be one cause of PH after atrial fibrillation (AF) ablation. We aimed to determine the incidence of an increase in pulmonary arterial (PA) pressure post-ablation and examine the clinical and echocardiographic associations.

BACKGROUND:Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to repeat TEE to exclude left atrial or left atrial appendage thrombus before direct current cardioversion (DCCV) in patients with a recent intraoperative TEE showing no thrombus is unclear. We sought to determine the incidence of and risk factors for new thrombus in patients undergoing TEE-guided DCCV after cardiac operations. METHODS:We reviewed 817 patients referred for TEE-guided DCCV within 30 days of a cardiac operation and an intraoperative TEE. Patients were excluded if the intraoperative TEE showed thrombus or a surgical left atrial appendage intervention was performed. Univariate logistic regression identified risk factors for thrombus. RESULTS:The study included 362 patients (71% male) with a mean age of 69 years. Median time from the operation to DCCV was 6 days. Thrombus was present in 13 patients (3.6%) on TEE before cardioversion; DCCV was cancelled in these patients. Heart failure was associated with a significantly higher risk of new thrombus formation (7% vs 2%; odds ratio, 3.26; 95% confidence interval, 1.07 to 9.95). Preoperative atrial arrhythmias, duration of perioperative arrhythmias, level of anticoagulation, and time from operation to DCCV were not significantly associated with thrombus. Thrombus was not associated with 30-day mortality. CONCLUSIONS:Development of new thrombus in patients with atrial arrhythmias early after cardiac operations is not uncommon, especially in patients with heart failure. Patients at high risk for thromboembolic events should undergo TEE before DCCV, even if a recent intraoperative TEE showed no thrombus.

Introduction: Adjudication of thousands of implantable cardioverter defibrillator (ICD)-treated arrhythmia episodes is labor intensive and, as a result, is most often left undone. The objective of this study was to evaluate an automatic classification algorithm for adjudication of ICD-treated arrhythmia episodes.Methods: The algorithm uses a machine learning algorithm and was developed using 776 arrhythmia episodes. The algorithm was validated on 131 dual-chamber ICD shock episodes from 127 patients adjudicated by seven electrophysiologists (EPs). Episodes were classified by panel consensus as ventricular tachycardia/ventricular fibrillation (VT/VF) or non-VT/VF, with the resulting classifications used as the reference. Subsequently, each episode electrogram (EGM) data was randomly assigned to three EPs without the atrial lead information, and to three EPs with the atrial lead information. Those episodes were also classified by the automatic algorithm with and without atrial information. Agreement with the reference was compared between the three EPs consensus group and the algorithm.Results: The overall agreement with the reference was similar between three-EP consensus and the algorithm for both with atrial EGM (94% vs 95%, P = 0.87) and without atrial EGM (90% vs 91%, P = 0.91). The odds of accurate adjudication, after adjusting for covariates, did not significantly differ between the algorithm and EP consensus (odds ratio 1.02, 95% confidence interval: 0.97-1.06).Conclusions: This algorithm performs at a level comparable to an EP panel in the adjudication of arrhythmia episodes treated by both dual-and single-chamber ICDs. This type of algorithm has the potential for automated analysis of clinical ICD episodes, and adjudication of EGMs for research studies and quality analyses.

Introduction: Management of early recurrence of atrial fibrillation (AF) or atrial flutter or atrial tachycardia (ERAF) post AF ablation patients is often very difficult. The aim of this study was to evaluate the outcome with dofetilide therapy in these refractory patients with ERAF after AF ablation. Methods: We reviewed 2272 patients presenting for ablation between Nov 2000 and Dec 2011. Prospectively collected data from 41 consecutive patients (65±9 years, 31 male), in whom dofetilide for ERAF post-AF ablation was used during hospitalization, was analyzed. Results: The baseline AF type was paroxysmal AF in 11 patients and persistent AF in 30 patients. Mean LVEF was 57±11%, mean LA volume index was 46±16 cc/m2. In addition to pulmonary vein isolation, 30 of 41 patients underwent additional ancillary linear or CFAE-related ablation. After ablation, the recurrent atrial arrhythmia was AF in 29 patients and atrial tachycardia in 12 patients. Dofetilide was initiated at doses of 250 mcg BID (n = 25) and of ...

Background: Cardiac resynchronization therapy (CRT) has been shown to improve heart failure (HF) symptoms and survival. We hypothesized that a greater improvement in left-ventricular ejection fraction (LVEF) after CRT is associated with greater survival benefit.Methods and Results: In 693 patients across 2 international centers, the improvement in LVEF after CRT was determined. Patients were grouped as non-/modest-, moderate-, or super-responders to CRT, defined as an absolute change in LVEF of <= 5%, 6-15%, and >15%, respectively. Changes in New York Heart Association (NYHA) functional class and left ventricular end-diastolic dimension (LVEDD) were assessed for each group. There were 395 non-/modest-, 186 moderate-, and 112 super-responders. Super-responders were more likely to be female and to have nonischemic cardiomyopathy, lower creatinine, and lower pulmonary artery systolic pressure than non-/modest- and moderate-responders. Super-responders were also more likely to have lower LVEF than non-/modest-responders. There was no difference in NYHA functional class, mitral regurgitation grade, or tricuspid regurgitation grade between groups. Improvement in NYHA functional class (-0.9 +/- 0.9 vs -0.4 +/- 0.8 [P < .001] and -0.6 +/- 0.8 [P = .02]) and LVEDD (-8.7 +/- 9.9 mm vs -0.5 +/- 5.0 and -2.4 +/- 5.8 mm [P < .001 for both]) was greatest in super-responders. Kaplan-Meier survival analysis revealed that super-responders achieved better survival compared with non-/modest- (P < .001) and moderate-responders (P = .049).Conclusions: Improvement in HF symptoms and survival after CRT is proportionate to the degree of improvement in LV systolic function. Super-response is more likely in women, those with nonischemic substrate, and those with lower pulmonary artery systolic pressure.

BACKGROUND:Patients with preexisting mild cognitive impairment or dementia may be at increased risk for developing cardiac device complications due to an impaired ability to follow postimplant care instructions. We sought to determine whether rates of infection, lead dislodgement, or appropriate or inappropriate implantable cardioverter defibrillator (ICD) shocks are increased in this population.METHODS:Medical charts of 561 patients with mild cognitive impairment or dementia who underwent pacemaker (PM) or ICD implantation between January 2002 and October 2009 at Mayo Clinic were identified. A total of 134 patients who were diagnosed with cognitive impairment or dementia before device implantation or within 1 year of implantation were compared with 134 matched controls. Information was collected on patient characteristics, comorbid medical conditions, ejection fraction, complications, device type, device therapy, and mortality. Device information was prospectively entered into a database and retrospectively reviewed.RESULTS:Of the 134 patients with mild cognitive impairment and dementia, 99 underwent PM implantation and 35 underwent ICD implantation. Compared to controls, there was no difference in patient characteristics, ejection fraction, or comorbidities except for diabetes, which was more prevalent in the cognitively impaired and demented group (18.7% vs 30.6%, P = 0.02). There was no difference in device therapy and complications (14.4% vs 5.8%, P = 0.268). However, there was a decreased survival in patients with cognitive impairment and dementia when compared to the control group (42% vs 67% at 5 years, P = 0.007).CONCLUSION:Patients with cognitive impairment and standard device indications are not at increased risk for device complications and therapy but their survival is much lower than in matched controls. The cause of this lower survival is unknown but may be related to the underlying neurological disease. Presence of cognitive impairment should therefore be considered when contemplating implantation of a cardiac device.

Aims: We sought to determine whether atrial fibrillation (AF) patients following cardiac resynchronization therapy (CRT) benefit from atrioventricular node (AVN) ablation by mechanisms other than rate control alone. Methods and results: In this single-center retrospective cohort study we analyzed the device database registry to identify heart failure patients with AF who underwent CRT. Among 137 patients with successful CRT, 42 (31%) had persistent AF. Patients with AF were divided into two groups on basis of AVN ablation. Patients underwent AVN ablation because of rapid ventricular rates in spite of maximizing medical therapy, and were expected to have a low percent biventricular pacing. Transthoracic echocardiography and the 6-min walk test were obtained at baseline and 3 months after CRT. At 3 months, resting and peak heart rates ¡SD during the 6-min walk were similar for both groups, nine AVN ablation patients (71¡4 and 91¡9 bpm respectively) and 31 without AVN ablation (71¡9 and 92¡16 bpm respectively; p50.77). Biventricular pacing was greater with AVN ablation than no ablation (96¡7% and 87¡24%, respectively; p50.27). Heart rates during the 6-min walk did not correlate with the percent biventricular pacing. Left ventricular end-systolic volume after CRT improved by .15% in 56% of AVN ablation versus 27% without ablation (p50.12). Conclusions: AVN ablation patients had a non-statistically significant improvement in reverse remodeling compared with no ablation. Rate control does not fully account for CRT response. Regularization of the ventricular rate may contribute to increased biventricular pacing and optimize the benefits of CRT in AF patients with heart failure.