Concerns exist about the safety of non-anesthesiologist positive pressure ventilation with sedation/analgesia during cardiac electrophysiology (EP) procedures in high-risk patients with known or risk factors such as obstructive sleep apnea (OSA). This is magnified if the procedures are done outside of intensive care areas or outside of hospital policies and procedures rules. BACKGROUND:Noninvasive positive pressure ventilation mask ventilation (NIPPV including continuous or bilevel positive airway pressure-CPAP/BiPAP) with sedation/analgesia is typically limited to hospital units staffed by pulmonary-intensive care or anesthesiology personnel, with monitoring by respiratory therapists or specifically trained nursing staff. NIPPV with sedation has raised concerns if delivered by laboratory staff in procedure rooms, especially in high-risk patients. Literature is sparse on this topic. NIPPV as described is routine at some institutions and prohibited at others. We aimed (1) to test the safety and efficacy of NIPPV with sedation prescribed by cardiologists and administered by trained nurses in a prospective cohort of high-risk patients and (2) to provide data that, if favorable, could lead to revisions of institutional policies. METHODS:We enrolled 50 consecutive consenting patients with known or at high risk for OSA. Three were then excluded (did not qualify, or procedure canceled). Procedures in 47 patients included 21 ICD implants (12 with defibrillation testing), 8 pacemaker implants, 11 ablations, and 7 cardioversions; some patients had combined procedures, e.g., "ablate & pace." Standard NIPPV settings were used. Staff were trained in general NIPPV device monitoring and management. Data collected included vital signs, O2 saturations, hypercapnia, demographics, toleration of NIPPV, and complications. RESULTS:There were no NIPPV-related complications and no long-term adverse sequelae in the 47 patients who participated in the protocol. No patient required intubation or urgent rescue from an anesthesiologist. Most patients (45) tolerated NIPPV including patients without prior experience. CONCLUSIONS:NIPPV with sedation can be safely delivered in high-risk OSA patients by trained non-anesthesiologist/pulmonary/intensive care personnel in an EP lab setting. Policy and procedure manuals may benefit from revision.

Background Despite its clinical benefits, patient compliance to remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) varies and remains under-studied in diverse populations. Objective We sought to evaluate RM compliance, clinical outcomes, and identify demographic and socioeconomic factors affecting RM in a diverse urban population in New York. Methods This retrospective cohort study included patients enrolled in CIED RM at Montefiore Medical Center between December 2017 and May 2022. RM compliance was defined as the percentage of days compliant to RM transmission divided by the total prescribed days of RM. Patients were censored when they were lost to follow-up or at the time of death. The cohorts were categorized into low (≤30%), intermediate (31-69%), and high (≥70%) RM compliance groups. Statistical analyses were conducted accordingly. Results Among 853 patients, median RM compliance was 55%. Age inversely affected compliance (p<0.001), and high compliance was associated with guideline-directed medical therapy (GDMT) usage and implantable cardioverter defibrillator (ICD)/ cardiac resynchronization defibrillator (CRTD) devices. The low-compliance group had a higher mortality rate and fewer regular clinic visits (p<0.001) than high-compliance group. Socioeconomic factors did not significantly impact compliance, while Asians showed higher compliance compared with Whites (OR 3.67; 95% CI 1.08-12.43; p=0.04). Technical issues were the main reason for non-compliance. Conclusion We observed suboptimal compliance to RM, which occurred most frequently in older patients. Clinic visit compliance, optimal medical therapy, and lower mortality were associated with higher compliance, whereas insufficient understanding of RM usage was the chief barrier to compliance.

As one of the essential Committees within the Heart Rhythm Society (HRS), the Scientific and Clinical Documents Committee (SCDC) supports the mission of HRS: to improve the care of patients by promoting research, education, and optimal health care policies and standards. The HRS has been developing clinical practice documents in collaboration and partnership with other professional medical societies since 1996. The task of the SCDC is to lead and oversee the development and endorsement of clinical documents that support heart rhythm specialists, patients, and diverse stakeholders to optimize clinical care of heart rhythm disorders. In 2023, the SCDC developed and published the first HRS-led guideline, the 2023 HRS/APHRS/LAHRS Guideline on Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure, 1 Chung M.K. Patton K.K. Lau C.P. et al. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm. 2023; 20: e17-e91 Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar and 2 HRS-led expert consensus statements, the 2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic2 Ferrick A.M. Raj S.R. Deneke T. et al. 2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic. Heart Rhythm. 2023; 20: e92-e144 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar and the 2023 HRS Expert Consensus Statement on the Management of Arrhythmias During Pregnancy. 3 Joglar J.A. Kapa S. Saarel E.V. et al. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm. 2023; 20: e175-e264 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Guidelines and consensus statements are the most highly cited articles. The SCDC has also endorsed 8 clinical practice documents led by other professional medical organizations in 2023.

The market of smartwatches is progressively thriving thanks to the recording of atrial fibrillation episodes by electrocardiographic (ECG) strips. 1 Seshadri D.R. Bittel B. Browsky D. et al. Accuracy of Apple Watch for detection of atrial fibrillation. Circulation. 2020; 141: 702-703 Crossref PubMed Scopus (65) Google Scholar However, the limitation of these systems to capture ECGs in the setting of cardiovascular implantable electronic devices (CIEDs) is unknown, particularly after His bundle pacing (HBP) or left bundle branch area pacing (LBBAP).

Fast and accurate identification of cardiac devices can facilitate device programming and interrogation in various medical settings. We have previously demonstrated the accuracy of the PacemakerID machine learning algorithm for mobile phone cardiac device identification. However, the questions of the reproducibility of this algorithm and whether a single trial sufficiently maximizes accuracy have yet to be answered. Here, we examine 502 chest x-rays performed at a single institution on patients with implantable cardioverter-defibrillators and permanent pacemakers. The PacemakerID mobile phone application was used for five sequential trials on each image and the accuracy of one, three, and five trials were compared. A single trial resulted in a 79% accuracy and 82% positive predictive value with no significant difference (p=0.69) as compared to five trials at identifying device manufacturers. Across all devices, the results of a single trial were not significantly different from those of five trials. Our data demonstrate that a single trial is sufficient to maximize diagnostic accuracy with the PacemakerID mobile phone application, facilitating rapid identification for prompt programming and interrogation of cardiac devices.

Wearable devices to monitor heart rhythm allow for rapid correlation of symptoms with ECG. Left Bundle Branch Area Pacing (LBBAP) can be utilized to maintain electrical and mechanical LV synchrony. The limitations of wearable device ECG capture in the setting of LBBAP is not known. We report three cases of patients who reported failure of Apple Watch (AW) ECG recording following implantation of LBBAP systems.

Application of artificial intelligence techniques in medicine has rapidly expanded in recent years. Two algorithms for identification of cardiac implantable electronic devices using chest radiography were recently developed: The PacemakerID algorithm, available as a mobile phone application (PIDa) and a web platform (PIDw) and The Pacemaker Identification with Neural Networks (PPMnn), available via web platform. In this study, we assessed the relative accuracy of these algorithms. The machine learning algorithms (PIDa, PIDw, PPMnn) were used to predict device manufacturer using chest X-rays for patients with implanted devices. Each prediction was considered correct if predicted certainty was >75%. For comparative purposes, accuracy of each prediction was compared to the result using the CARDIA-X algorithm. 500 X-rays were included from a convenience sample. Raw accuracy was PIDa 89%, PIDw 73%, PPMnn 71% and CARDIA-X 85%. In conclusion, machine learning algorithms for identification of cardiac devices are accurate at determining device manufacturer, have capacity for improved accuracy with additional training sets and can utilize simple user interfaces. These algorithms have clinical utility in limiting potential infectious exposures and facilitate rapid identification of devices as needed for device reprogramming. (C) 2020 Elsevier Inc. All rights reserved.

Atrial fibrillation (AF) is an increasingly prevalent arrhythmia; its pathophysiology and progression are well studied. Stroke and bleeding risk models have been created and validated. Decision tools for stroke prophylaxis are evolving, with better options at hand. Utilization of various diagnostic tools offer insight into AF burden and thromboembolic risk. Rate control, rhythm control, and stroke prophylaxis are the cornerstones of AF therapy. Although antiarrhythmic drugs are useful, AF ablation has become a primary therapeutic strategy. Pulmonary vein isolation is the cornerstone of AF ablation, and methods to improve ablation safety and efficacy continue to progress. Ablation of nonpulmonary vein sites is increasingly being recognized as an important strategy for treating nonparoxysmal AF. Several new ablation techniques and technologies and stroke prophylaxis are being explored. This is a contemporary review on the prevalence, pathophysiology, risk prediction, prophylaxis, treatment options, new insights for optimizing treatment outcomes, and emerging concepts of AF.

BACKGROUND:Wellens' sign is considered to be an ominous sign indicative of underlying significant proximal left anterior descending artery stenosis. We sought to identify the prevalence of the Wellens' pattern in a large ethnically diverse urban population and assess its association with the presence and extent of coronary artery disease.METHODS:We utilized the MUSE ECG database of Montefiore Medical Center, an academic tertiary health care system, to identify ECGs from 2012 to 2019 exhibiting a Wellens' pattern. From a dataset of 1.76 million tracings, six screening diagnosis codes were selected to approximate the Wellens' pattern. These codes were used to generate a cohort of ECGs for manual review by a board certified cardiologist to determine if a Wellens' pattern was present.RESULTS:Of 1,756,742 ECGs performed on 433,218 patients from 2012 to 2019; after initial screening 2186 ECGs were identified for manual review. Of these, 448 (0.1%) patients were confirmed to have a Wellens' pattern. 229 patients underwent cardiac catheterization, while 219 patients were managed medically. No statistical difference was seen in the occurrence of Wellens' Type A and B pattern across the ethnic groups after multivariate analysis. Women were more likely to have Type B Wellens' compared to men (OR 2.40 (1.58, 3.62) P < 0.0001). 80 (35%) patients had single vessel LAD disease of which 22 (10%) had proximal, 40 (17%) had mid, 4 (1%) had distal stenosis, while diffuse LAD disease was seen in 14 (6%) patients. Two vessel disease was seen in 46 (20%) patients with a Wellens' pattern, and triple vessel disease was seen in 23 (10%) patients. Of note, 71 (31%) patients had either normal or nonobstructive coronary disease despite exhibiting a Wellens' pattern ECG.CONCLUSION:Wellens' sign is a rare electrocardiographic pattern which when seen in a patient with an appropriate clinical presentation, suggests but is not definitive for the presence of significant coronary disease, often but not exclusively in an LAD distribution. We found no statistical difference in the occurrence of Wellens' sign among different racial/ethnic groups. Patients with a Wellens' pattern may have critical lesions at a variety of LAD sites as well as in multiple vessels. As such, the interventionalist needs to be prepared for these uncertainties at the time of cardiac catheterization.

Implantable cardioverter-defibrillators (ICD) have been demonstrated to improve survival in patients who have experienced aborted sudden cardiac arrest as well as for primary prophylaxis of sudden cardiac arrest in certain high-risk patients. Despite their established role in the management of patients identified as being at risk for sudden cardiac arrest, inappropriate ICD therapy remains problematic and has been associated with increased cardiovascular mortality. The majority of inappropriate ICD therapy results from either the detection of a variety of supraventricular arrhythmias, T-wave oversensing, or lead failure with concomitant detection of noise.

Hydroxychloroquine, chloroquine, and azithromycin have been used for treatment of COVID-19, but may cause QT prolongation. Minority populations are disproportionately impacted by COVID-19. This study evaluates the risk of QT prolongation and subsequent outcomes after administration of these medications in largely underrepresented minority COVID-19 patients. We conducted an observational study on hospitalized COVID-19 patients in the Montefiore Health System (Bronx, NY). We examined electrocardiograms (ECG) pre/post-medication initiation to evaluate QTc, HR, QRS duration, and presence of other arrhythmias. One hundred five patients (mean age 67 years; 44.8% F) were analyzed. The median time from the first dose of any treatment to post-medication ECG was 2 days (IQR: 1–3). QTc in men increased from baseline (440 vs 455 ms, p < 0.001), as well as in women (438 vs 463 ms, p < 0.001). The proportion of patients with QT prolongation increased significantly (14.3% vs 34.3%, p < 0.001) even when adjusted for electrolyte abnormalities. The number of patients whose QTc > 500 ms was significantly increased after treatment (16.2% vs. 4.8%, p < 0.01). Patients with either QTc > 500 ms or an increase of 60 ms had a higher frequency of death (47.6% vs. 22.6%, p = 0.02) with an odds ratio of 3.1 (95% CI: 1.1–8.7). Adjusting for race/ethnicity yielded no significant associations. Hydroxychloroquine, chloroquine, and/or azithromycin were associated with QTc prolongation but did not result in fatal arrhythmias. Our findings suggest that any harm is unlikely to outweigh potential benefits of treatment. Careful risk-benefit analyses for individual patients should guide the use of these medications. Randomized control trials are necessary to evaluate their efficacies.

Introduction: Atrioventricular node reentry tachycardia (AVNRT) ablation is typically performed with solid tip catheters set to temperature control (TC) mode. Radiofrequency (RF) output, tip temperature (T), and junctional rhythm response (JRR) during RF application have been well defined. JRR in an intermittent burst, sinus-junction-junction, or sinus-junction-sinus pattern is associated with successful modification of the AV nodal slow pathway (SP). Irrigated force-sensing catheters (IFSC) are often utilized for mapping and ablation of the SP. Despite this, parameters for IFSC used in TC mode resulting in JRR have not been well described. Hypothesis: Parameters predicting JRR and successful SP modification with IFSC include power (P), force (F), impedance drop (I), and target temperature (T). Methods: Consecutive patients that underwent electrophysiologic study and successful ablation of typical AVNRT with an IFSC were studied. Lesion parameters including P, T, F, time and I change were analyzed. Lesions producing JRR were considered efficacious. Independent T-Test and ANOVA were used to determine significance between the two groups (efficacious and non-efficacious lesions). Results: 296 lesions in 39 patients (age 52+/-14) were analyzed. All patients had successful SP modification without complication. Average F producing JRR was 8g, average T producing JRR was 41 o C, average I drop producing JRR was 9 Ohms, and average P producing JRR was 28W. Only RF lesion time was a significant predictor of JRR (p=0.009). (Table 1). Conclusions: Successful SP modification with IFSC was accomplished with catheter contact force as low as 2g. Lower average tip T, and lower average P settings compared to parameters typically used with solid tip catheters were observed. Parameters including P, F, T, and I change were not predictive of JRR. Additional studies controlling for catheter location while varying parameters are indicated.

BACKGROUND:Subxyphoid active left ventricular epicardial (LVE) lead implants or VT ablation are attractive but remain a challenge due to concerns of coronary artery damage. We aimed to see if Doppler-guided positioning could permit safe LVE lead placement without coronary angiography. We evaluated the feasibility of a Doppler flow-guided subxyphoid epicardial screw-in lead fixation in a swine model.METHODS:Acute subxyphoid access to the pericardial space was performed in an anesthetized swine model using a deflectable sheath and a modified needle-derived Doppler flow meter. The audio signal and visual display from the Doppler flow meter were recorded. Coronary angiography was performed to verify the catheter location. A SelectSecure Model 3830 lead (Medtronic) was used to assess pacing in the procedure.RESULTS:In both of two swine, the deflectable catheter was inserted into pericardial space via subxyphoid access. The tip of the deflectable catheter with the Doppler was directed to several locations, from quiet (no nearby coronary artery expected) to typical rhythmic pulsatile sound locations which were maximal when superimposed on a coronary artery. Repeated coronary angiograms confirmed the expected findings. A 3830 active lead was fixed into a quiet location for LVE pacing, and confirmed by angiography as distant from a coronary artery.CONCLUSIONS:Doppler-guided subxyphoid epicardial screw-in lead placement is feasible once the catheter tip is directed and stabilized in a desired LVE location. This obviates the need for repeated (or any) coronary angiography. The Doppler-guided subxyphoid epicardial procedure may also be applicable for epicardial ventricular arrhythmia ablation procedures.

Atrial fibrillation (AF) is an increasingly prevalent arrhythmia; its pathophysiology and progression are well studied. Stroke and bleeding risk models have been created and validated. Decision tools for stroke prophylaxis are evolving, with better options at hand. Utilization of various diagnostic tools offer insight into AF burden and thromboembolic risk. Rate control, rhythm control, and stroke prophylaxis are the cornerstones of AF therapy. Although antiarrhythmic drugs are useful, AF ablation has become a primary therapeutic strategy. Pulmonary vein isolation is the cornerstone of AF ablation, and methods to improve ablation safety and efficacy continue to progress. Ablation of nonpulmonary vein sites is increasingly being recognized as an important strategy for treating nonparoxysmal AF. Several new ablation techniques and technologies and stroke prophylaxis are being explored. This is a contemporary review on the prevalence, pathophysiology, risk prediction, prophylaxis, treatment options, new insights for optimizing treatment outcomes, and emerging concepts of AF. • AF is a cardiovascular pandemic with a complex pathophysiology and contributes to significant patient morbidity and mortality. • Emphasis is on early detection and intervention for stroke prophylaxis and disease progression. • Significant progress has been made in paroxysmal AF, but better understanding is needed on substrate progression, evolution of non-PV triggers, and a comprehensive approach to multisystem risk factor modification.