INTRODUCTION:A leadless pacemaker (LLPM) was recommended for a patient with intermittent complete heart block and near-syncope. METHODS AND RESULTS:Delivery of LLPM is through a large sheath that has limited deflection and steerability. This report describes the successful deployment of a ventricular LLPM in a patient with prior surgical correction of AV septal defect with subsequent significant right atrial enlargement. The LLPM could not traverse the tricuspid valve. A snare was advanced to the right atrium and used to create greater tip deflection of the delivery sheath. Importantly, once the delivery sheath crosses the tricuspid valve, the snare is loosened to allow directing the sheath to the right ventricular septum rather than the initial direction that was toward the right ventricular apex. The ventricular LLPM was successfully fixated. CONCLUSION:In the presence of complex anatomy, deployment of a LLPM delivery sheath can be facilitated with use of a snare to assist with increased deflection then subsequent guidance to the preferred right ventricular location of the septum.

Background: Stereotactic body radiation therapy (SBRT) is an emerging modality for the treatment of ventricular tachycardia (VT). The workflow for delineation of the SBRT target is evolving. Objective: This project describes the procedural workflow and outcomes of SBRT for VT. Methods: The primary indication for SBRT was recurrent VT despite maximal contemporary treatment. Target delineation for SBRT involved combining imaging and electrophysiological data. VT burden, defined as the number of sustained VT episodes per month, was compared as the primary outcome. Secondary outcomes assessed included reduction of antitachycardia pacing and defibrillator shock episodes and reduction in the number of antiarrhythmic drugs per patient during follow-up. Results: Workup for VT target delineation and radiation delivery was conducted in 25 patients receiving 27 SBRT procedures. VT management prior to SBRT consideration included ≥2 catheter ablations in 22 (88%) and surgical sympathectomy in 7 patients (28%). Of the 27 performed cases, SBRT target delineation incorporated electrocardiogram of clinical VT in 16 (59%), at least 2 noninvasive imaging modalities to assess scar in 24 (89%), and invasive electroanatomic mapping in 25 (93%). Among 16 patients with a complete 6-month follow-up, the reduction of VT burden per month was 81% (P < .05). Reduction in antitachycardia pacing and defibrillator shocks per month was 86% and 98%, respectively (P < .05). The number of patients on ≥2 antiarrhythmic drugs decreased from 69% to 0% (P < .01). One patient developed diaphragmatic paralysis after SBRT. Conclusion: In patients with recurrent VT despite maximal contemporary antiarrhythmic therapies, SBRT offers a safe alternative once the target is adequately delineated by combining imaging and electrophysiological data.

Marshall bundle ablation via retrograde ethanol infusion into the vein of Marshall (VoM) is one of the few adjunctive approaches complementary to the success of pulmonary vein (PV) isolation during catheter ablation for persistent atrial fibrillation (AF). VoM ablation also increases the success and durability of mitral isthmus block for the management of peri-mitral flutter. Despite its promise, the adoption of VoM ablation is limited due to anatomical variations that result in a steep learning curve. Successful Marshall bundle ablation requires accurate identification and successful cannulation of the VoM with an appropriate-size balloon to achieve adequate occlusion, followed by non-traumatic ethanol infusion. VoM ablation is often performed before wide-area circumferential ablation of the left-sided PVs. Mitral isthmus ablation to achieve mitral annular block is always recommended after VoM ablation to minimize the risk of peri-mitral flutter. This paper discusses a step-by-step approach for successful Marshall bundle ablation with tips and tricks for difficult cases based upon the performance of over 500 cases performed at the Ohio State University Medical Center.

BACKGROUND:Peridevice leak (PDL) after left atrial appendage closure (LAAC) portends adverse outcomes. OBJECTIVE:The purpose of this study was to assess the incidence, predictors, clinical implications, and temporal evolution of PDL after LAAC. METHODS:This single-center retrospective study included all patients who underwent LAAC with Watchman FLX and had no PDL detected at the time of implantation. The primary end point was the incidence of new PDL at initial imaging. The composite secondary end point included continued oral anticoagulation after initial imaging, device-related thrombus, stroke or transient ischemic attack, major bleeding, and need for PDL closure at longest follow-up. Temporal evolution of PDL was assessed in patients with available surveillance imaging. RESULTS:Of the 355 patients who completed imaging at 47 days (interquartile range [IQR] 44-50 days), 139 (39%) had new PDL with a mean leak size of 3.2 ± 1.4 mm (median 3.0 mm; IQR 2.0-4.0 mm; range 1.0-9.0 mm). Multiple deployment attempts and larger device size were positive predictors of PDL, while increased contrast volume administration was a negative predictor of PDL. The composite secondary end point occurred in 42 (30%) patients with PDL and 33 (15%) patients without PDL (P < .001). Of the 139 patients with PDL, 43 (31%) had surveillance imaging where the leak size regressed from 3.7 ± 1.8 mm at 46 days (IQR 44-51 days) to 1.7 ± 2.0 mm at 189 days (IQR 158-285 days) (P < .001). The leak size regressed in 33 (77%), remained stable in 4 (9%), and progressed in 6 (14%) cases. CONCLUSION:Despite design improvements, LAAC with Watchman FLX demonstrates a significant incidence of PDL with meaningful clinical implications. Regardless of initial size, most leaks regressed over time.

BACKGROUND Injury to the esophagus has been reported ina high percentage of patients undergoing ablation of atrial fibrillation (AF). OBJECTIVES This study assessed the incidence of esophageal injury in patients undergoing ablation of AF with and without an esophageal deviating device. METHODS This prospective, randomized, multicenter, double -blinded, controlled Food and Drug Administration investigational device exemption trial compared the incidence of ablation-related esophageal lesions, as assessed by endoscopy, in patients undergoing AF ablation assigned to a control group (luminal esophageal temperature [LET] monitoring alone) compared with patients randomized to a deviation group (esophagus deviation device thorn LET). This novel deviating device uses vacuum suction and mechanical deflection to deviate a segment of the esophagus, including the trailing edge. RESULTS The data safety and monitoring board recommended stopping the study early after randomizing 120 patients due to deviating device efficacy. The primary study endpoint, ablation injury to the esophageal mucosa, was significantly less in the deviation group (5.7%) in comparison to the control group (35.4%; P < 0.0001). Control patients had a significantly higher severity and greater number of ablation lesions per patient. There was no adverse event assigned to the device. By multivariable analysis, the only feature associated with reduced esophageal lesions was randomization to deviating device (OR: 0.13; 95% CI: 0.04-0.46; P = 0.001). Among control subjects, there was no difference in esophageal lesions with high power/short duration (31.8%) vs other radiofrequency techniques (37.2%; P = 0.79). CONCLUSIONS The use of an esophageal deviating device resulted in a significant reduction in ablation-related esophageal lesions without any adverse events. (J Am Coll Cardiol EP 2024;10:68-78) (c) 2024 by the American College of Cardiology Foundation.

BACKGROUND:There is a paucity of data regarding the optimal timing of left atrial appendage closure (LAAC) and whether scheduling delays increase the risk for adverse outcomes. OBJECTIVES:This study sought to assess the incidence and predictors of adverse events among patients awaiting LAAC. METHODS:This single-center retrospective study assessed all patients who underwent LAAC from January 2017 to March 2020. The primary study endpoints were the rate and characteristics of adverse events occurring from the time of initial shared decision to pursue LAAC until the time of LAAC. Adverse events were defined as clinically significant bleeding or anemia, thromboembolic complications, or death. Patients were censored after successful closure or the first adverse event. RESULTS:Two hundred and sixty-five patients underwent LAAC with demographics notable for age 73.5 ± 8.1 years, 98 (37%) females, left ventricular ejection fraction 52.3% ± 10.4%, CHA2DS2-VASc 4.8 ± 1.4, and HAS-BLED 3.2 ± 1.2. Median time from shared decision to insurance approval and insurance approval to LAAC were 18 (IQR 28) and 44 (IQR 40) days, respectively. Seventeen (6%) patients suffered an adverse event, including 15 (88%) cases of bleeding or anemia and 2 (12%) cases of thromboembolism. Multivariate analysis demonstrated that increased time to LAAC (odds ratio [OR] 1.31, 95% confidence interval [CI] [1.15, 1.50], p < 0.001) and higher HAS-BLED score (OR 1.67, CI [1.11, 2.59], p = 0.017) were associated with significantly increased risk for adverse events. CONCLUSION:Prolonged time to LAAC and higher HAS-BLED score portend an increased risk for adverse events while awaiting LAAC. Expedited closure is warranted in high-risk patients.

Preoperative imaging for left atrial appendage closure (LAAC) is essential for LAA sizing and thrombus assessment. Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) have been utilized to date for this purpose. During the recent global iodine contrast shortage, cardiac magnetic resonance imaging (CMR) was utilized as an alternative imaging modality.