We previously introduced the Inverse Solution Guidance Algorithm (ISGA) methodology using a Single Equivalent Moving Dipole model of cardiac electrical activity to localize both the exit site of a re-entrant circuit and the tip of a radiofrequency (RF) ablation catheter. The purpose of this study was to investigate the use of ISGA for ablation catheter guidance in an animal model. Ventricular tachycardia (VT) was simulated by rapid ventricular pacing at a target site in eleven Yorkshire swine. The ablation target was established using three different techniques: a pacing lead placed into the ventricular wall at the mid-myocardial level (Type-1), an intracardiac mapping catheter (Type-2), and an RF ablation catheter placed at a random position on the endocardial surface (Type-3). In each experiment, one operator placed the catheter/pacing lead at the target location, while another used the ISGA system to manipulate the RF ablation catheter starting from a random ventricular location to locate the target. The average localization error of the RF ablation catheter tip was 0.31 ± 0.08 cm. After analyzing ~35 cardiac cycles of simulated VT, the ISGA system’s accuracy in locating the target was 0.4 cm after 4 catheter movements in the Type-1 experiment, 0.48 cm after 6 movements in the Type-2 experiment, and 0.67 cm after 7 movements in the Type-3 experiment. We demonstrated the feasibility of using the ISGA method to guide an ablation catheter to the origin of a VT focus by analyzing a few beats of body surface potentials without electro-anatomic mapping.

Background There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction. Objective To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE). Methods Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23). Results During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed. Conclusion Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Introduction: Atrial fibrillation (AF) is common in patients with chronic kidney disease (CKD) and is associated with higher rates of hospitalization compared to those without AF. Whether routine electrocardiographic parameters are predictive of future hospitalizations with AF is not clear. Methods: The present study is an analysis of a prospective cohort of 2,759 patients without baseline AF from the Chronic Renal Insufficiency Cohort, a large prospective multicenter study of patients with nondialysis-dependent CKD. Unadjusted and adjusted Cox regression models were fit to examine the association of baseline categories of QTc, QRS, and PR intervals with time to first hospitalization with AF. Restricted cubic splines were used to display nonlinear associ­ations. Results: The mean age of subjects at baseline was 58 ± 11 years, 55% were male, and 44% were Black. The mean follow-up was 6.6 years during which 224 participants experienced a hospitalization with AF. The association of baseline QTc interval with risk of AF hospitalization was nonlinear, such that the lowest and highest quartiles of QTc (<407 and >431 ms, respectively) had higher adjusted risk of AF hospitalization, compared with the second quartile (407–416 ms) (aHR Q1:Q2 1.58, 95% CI 1.03–2.41; p = 0.03; aHR Q4:Q2 1.84, 95% CI 1.22–2.78; p < 0.01). Longer QRS was associated with a higher risk of hospitalization with AF among the subgroup of patients with a history of heart failure (HF). PR interval was not associated with AF hospitalization. Discussion/Conclusion: The association of QTc with risk for hospitalization with AF among patients with CKD is nonlinear, while the association of longer QRS with AF hospitalization is restricted to patients with baseline HF. Electrocardiography may represent a simple and widely accessible method for risk stratification of future AF in patients with CKD.

There have been nearly 70 million cases of COVID-19 worldwide, with over 1.5 million deaths at the time of this publication. This global pandemic has mandated dramatic changes in healthcare delivery with a particular focus on social distancing in order to reduce viral transmission. Heart failure patients are among the highest utilizers of health care and are at increased risk for COVID-related vulnerabilities. Effectively managing this complex and resource-intensive patient population from a distance presents new and unique challenges. Here, we review relevant data on telemedicine and remote monitoring strategies for heart failure patients and provide a framework to help providers treat this population during the COVID-19 pandemic. This includes (i) dedicated pre-visit contact and planning (i.e. confirm clinical appropriateness, presence of compatible technology, and patient comfort); (ii) utilization of virtual clinic visits (use of telehealth platforms, a video-assisted exam, self-reported vital signs, and weights); and (iii) use of existing remote heart failure monitoring sensors when applicable (CardioMEMS, Optivol, and HeartLogic). While telemedicine and remote monitoring strategies are not new, these technologies are emerging as an important tool for the effective management of heart failure patients during the COVID-19 pandemic. In general, these strategies appear to be safe; however, additional data will be needed to determine their effectiveness with respect to both process and outcomes measures.

A 39-year-old woman with cyclic vomiting syndrome and polysubstance use disorder presented to the emergency department with abdominal pain, vomiting, and odd behavior. Supraventricular tachycardia developed and was treated with adenosine. A diagnostic test was performed.

difference between male and female was noted in the Psd from PARS (male 2.260.6 vs female 2.560.6,p¼.0021), and the difference remained after ablation (male 2.160.6 vs female 2.460.7,p¼.0013).Before ablation, physical functioning, according to PARS scores, was similar in males and females, but in the follow-up boys showed greater improvement than girls (male 1.660.4vs female 2.060.6,p<.0001).There was a significant improvement of Psd in children who was on preablation antyarythmic therapy: WHOQoL-BREF (73.4615.2vs 78.2614.7;p¼0.0007);PARS (2.460.6 vs 2.360.6;p¼0.05); no improvement was noticed in children who was off medications before ablation.The type of arrythmia, frequency of episodes and time from diagnosis to ablation had no significant impact on QoL scores. Conclusions:The ablation procedure has a positive impact on general satisfaction with health condition, general satisfaction with the quality of life and QoL scores of SVT children.Regarding the QoL there are some gender differences in children with SVT, which suggest that females deal less effectively with disease related limitations and the relevant treatment.The preablation antyarythmic therapy has negative impact on psychological parameters of QoL. P389Direct ultrasound visualization in combination with micropuncture needle reduces vascular access complications in cardiac electrophysiological procedures

Aims Controversy on the optimal ablation strategy for persistent atrial fibrillation (AF) exists with limited work evaluating a strategy of pulmonary vein isolation (PVI) alone when AF terminates during PVI. Thirty-five patients had AF termination during PVI in the Modified Ablation Guided by Ibutilide Use in Chronic Atrial Fibrillation (MAGIC-AF; ClinicalTrials.gov number: NCT01014741) study. The objective of the current study is to report the 1-year outcome after PVI alone in this unique patient group. Methods and results The 1-year single procedure freedom from atrial arrhythmia off anti-arrhythmic drugs was reported for the 35 patients in the MAGIC-AF study with persistent AF termination during or upon completion of PVI. Freedom from recurrent atrial arrhythmia was achieved in 60% of patients where AF terminated during PVI. Cavotricuspid isthmus flutter was common when AF terminated to a macro re-entrant flutter during PVI, and responsible for 92% of all flutter circuits with AF termination. Conclusions Persistent AF termination during PVI may identify a subgroup of patients who experience a similar long-term clinical outcome with PVI ablation alone when compared with other more extensive persistent AF ablation strategies. Pulmonary vein isolation alone may be an appropriate tactic in this subgroup of persistent AF patients.

AIMS Complex fractionated atrial electrograms (CFAE) are targeted during persistent atrial fibrillation (AF) ablation. However, many CFAE sites are non-specific resulting in extensive ablation. Ibutilide has been shown to reduce left atrial surface area exhibiting CFAE. We hypothesized that ibutilide administration prior to CFAE ablation would identify sites critical for persistent AF maintenance allowing for improved procedural efficacy and long-term freedom from atrial arrhythmias. METHODS AND RESULTS Two hundred patients undergoing a first-ever persistent AF catheter ablation procedure were randomly assigned to receive either 0.25 mg of intravenous ibutilide or saline placebo upon completion of pulmonary vein isolation. Complex fractionated atrial electrogram sites were then targeted with ablation. The primary efficacy endpoint was the 1-year single procedure freedom from atrial arrhythmia off anti-arrhythmic drugs. Similar procedural characteristics (procedure, fluoroscopy, and ablation times) were observed with both strategies despite a greater reduction in left atrial surface area with CFAE sites (8 vs. 1%, P < 0.0001) and AF termination during CFAE ablation with ibutilide compared with placebo (75 vs. 57%, P = 0.007). The primary efficacy endpoint was achieved in 56% of patients receiving ibutilide and 49% receiving placebo (P = 0.35). No significant differences in peri-procedural complications were observed in both groups. CONCLUSION Despite a reduction in CFAE area and greater AF termination during CFAE ablation, procedural characteristics and clinical outcomes were unchanged when CFAE ablation was guided by ibutilide administration. CLINICAL TRIAL REGISTRATION INFORMATION ClinicalTrials.gov number: NCT01014741.

Gender and Persistent AF Introduction Atrial fibrillation (AF) ablation is less frequently performed in women when compared to men. There are conflicting data on the safety and efficacy of AF ablation in women. The objective of this study was to compare the clinical characteristics and outcomes in a contemporary cohort of men and women undergoing persistent AF ablation procedures. Methods and Results A total of 182 men and 53 women undergoing a first‐ever persistent AF catheter ablation procedure in The Modified Ablation Guided by Ibutilide Use in Chronic Atrial Fibrillation (MAGIC‐AF) trial were evaluated. Clinical and procedural characteristics were compared between each gender. The primary efficacy endpoint was the 1‐year single procedure freedom from atrial arrhythmia off anti‐arrhythmic drugs. Women undergoing catheter ablation procedures were older than men (P < 0.001). The duration of AF and associated co‐morbidities were similar between both genders. Single procedure drug‐free atrial arrhythmia recurrence occurred in 53% of the cohort with no difference based on gender (men = 54%, women = 53%; P = 1.0). Procedural (P = 0.04), fluoroscopic (P = 0.02), and ablation times (P = 0.003) were shorter in women compared to men. Periprocedural complications and postablation improvement in quality of life were similar between men and women. Conclusion Women undergoing a first‐ever persistent AF ablation procedure were older but had similar clinical outcomes and complications when compared with men.

Catheter ablation has become a widely available and accepted treatment to restore sinus rhythm in atrial fibrillation patients who fail antiarrhythmic drug therapy. Although generally safe, the procedure carries a non-negligible risk of complications, including periprocedural cerebral insults. Uninterrupted anticoagulation, maintenance of an adequate ACT during the procedure, and measures to avoid and detect thrombus build-up on sheaths and atheters during the procedure, appears useful to reduce the risk of embolic events. This is a review of the incidence, mechanisms, impact, and methods to reduce catheter ablation related cerebral insults.

During tachycardia, atrial overdrive pacing resulted in entrainment of the tachycardia with an AVA response upon cessation of pacing. Similarly, ventricular overdrive pacing resulted in a VAV response on cessation of pacing. A narrow-complex tachycardia was never observed. These findings were in keeping with orthodromic atrioventricular re-entrant tachycardia during ipsilateral bundle branch block (BBB) using a concealed left-sided accessory pathway. Thus ipsilateral BBB was necessary for induction and maintenance of the SVT, which was manifested as a wide-complex tachycardia because of ipsilateral BBB.

BackgroundChronic kidney disease (CKD) severity is associated with increased morbidity and mortality in congestive heart failure. There is a paucity of data regarding renal improvement after cardiac resynchronization therapy (CRT) and its potential impact on clinical outcomes, especially in patients with severe CKD.MethodThis was a retrospective analysis of a prospectively collected cohort of 260 patients with CKD undergoing CRT at a single center. Renal function was compared before and after CRT. The primary end point was a composite of death, heart transplant, and left ventricular assist device (LVAD), assessed at 5 years.ResultsPatients with more severe CKD demonstrated increased risk of death, transplant, or LVAD following CRT (P = 0.015). Renal response (estimated glomerular filtration rate improvement ≥10 mL/min/1.73 m2) was observed in 14% of all patients and 28% of patients with stage IV CKD. Independent predictors of renal response included left ventricular ejection fraction improvement (odds ratio [OR] 1.06, confidence interval [CI] 1.01–1.10), angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker use (OR 4.31, CI 1.08–17.23), and advanced CKD stage (OR 2.19, CI 1.14–4.23). Renal response independently decreased hazard of the primary outcome (HR 0.24, CI 0.08–0.73, P = 0.01). Renal responders with stage IV CKD had 80% 5‐year event‐free survival, compared to 0% for nonrenal responders in stage IV (P = 0.03).ConclusionAlthough severity of CKD is associated with poorer outcome after CRT, improvement in renal function can occur in patients across all CKD stages. Renal responders, including those with stage IV CKD, demonstrate favorable 5‐year outcomes. Assessment of renal response may help better prognostic outcomes following CRT.