BackgroundProlonged invasive mechanical ventilation (IMV) following out-of-hospital cardiac arrest (OHCA) is associated with increased mortality, complications, and long-term functional impairment. Identification of early interventions that may reduce the duration of IMV is therefore clinically relevant.ObjectiveTo evaluate the association between the timing of bronchoscopy and the duration of IMV in patients successfully resuscitated after OHCA.MethodsWe performed a retrospective observational study of patients admitted to a cardiac intensive care unit after successful cardiopulmonary resuscitation for OHCA who required IMV for more than 24 h. Patients receiving mechanical circulatory support or those with poor neurological prognosis were excluded. The primary outcome was the total duration of IMV according to the timing of bronchoscopy. Secondary outcomes included associations between IMV duration and return of spontaneous circulation (ROSC) time, initial serum lactate levels, and the impact of bronchoscopy on antibiotic therapy.ResultsA total of 38 patients (29 men and 9 women; median age 53 years) were included. Bronchoscopy performed within 24 h of ICU admission was associated with a significantly shorter duration of IMV compared with delayed bronchoscopy (98 ± 15 vs 243 ± 49 h; p < .05). A moderate positive correlation was observed between ROSC duration and IMV duration (Pearson r = .44; p = .006). Initial serum lactate levels were not significantly correlated with IMV duration. Early bronchoscopy led to modification of antibiotic therapy in 56% of patients.ConclusionsEarly bronchoscopy after OHCA was associated with a substantial reduction in the duration of IMV. These findings suggest that early bronchoscopic evaluation may represent a readily available ICU intervention to reduce the risk of prolonged mechanical ventilation in selected post-cardiac arrest patients.

Immediate initiation of extracorporeal membrane oxygenation (ECMO) has not demonstrated benefit in individuals diagnosed with cardiogenic shock based on the presence of hypotension. The relationship between other hemodynamic or metabolic parameters and clinical outcomes, with or without ECMO, is not fully understood. The Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock (ECMO-CS) trial randomly assigned 117 patients diagnosed with cardiogenic shock to 2 groups: immediate initiation of ECMO or early conservative strategy. The present post-hoc analysis investigated the clinical efficacy of immediate ECMO therapy in subgroups with cardiogenic shock-more specific characteristics: low cardiac index, low venous oxygen saturation (SvO2) and high partial carbon dioxide pressure (pCO2) gap. The primary endpoint for this analysis was 1-year all-cause mortality; the secondary endpoint was a composite of mortality or hemodynamic worsening requiring ECMO. Data regarding cardiac index were available for 58 patients. In the subgroup with cardiac index < 2.2 L/min/m2, immediate ECMO initiation was associated with a reduced risk for all-cause death (hazard ratio [HR] 0.48 [95

Background Visually guided laser balloon ablation is known as an effective pulmonary vein (PV) isolation device. The third-generation laser balloon ablation system (X3) equipped with compliant balloon and an automated motor-driven laser output mechanism, namely RAPID mode, has been clinically proven for PV isolation. Methods PV isolation with X3 was performed in all the patients with paroxysmal and early-stage persistent atrial fibrillation (AF). Acute data for PV isolation and clinical outcomes including supraventricular tachyarrhythmia (SVT: AF, atrial flutter, or atrial tachycardia)-free survival rate beyond 1 year were analyzed. Results A total of 110 patients (62 ± 13 years old, 80% of paroxysmal AF) were treated with X3. RAPID mode with was utilized to achieve PV isolation in all cases. In combination with RAPID mode and spot mode laser ablation, 91.1% (380/417) of veins were isolated on the first circumferential lesion set and did not require touch-up ablation and during the index procedure 100% of attempted veins were isolated. The mean procedure time was 77.0 ± 22.7 min and LA dwell time was 61.9 ± 22.0 min. Total duration of laser application was 5.1 ± 2.3 min per vein. At 1 year, SVT-free survival rate was 93.7% in paroxysmal AF patients, and 81.1% in persistent AF patients. Conclusions A novel continuous automatic laser balloon ablation system was proved to be safe and effective for both paroxysmal and persistent AF patients. The clinical result demonstrated that PV isolation with X3 could achieve a high SVT-free survival rate.

AimsAmong patients with cardiogenic shock, immediate initiation of extracorporeal membrane oxygenation (ECMO) did not demonstrate any benefit at 30 days. The present study evaluated 1‐year clinical outcomes of the Extracorporeal Membrane Oxygenation in the therapy of Cardiogenic Shock (ECMO‐CS) trial.Methods and resultsThe ECMO‐CS trial randomized 117 patients with severe or rapidly progressing cardiogenic shock to immediate initiation of ECMO or early conservative strategy. The primary endpoint for this analysis was 1‐year all‐cause mortality. Secondary endpoints included a composite of death, resuscitated cardiac arrest or implantation of another mechanical circulatory support device, duration of mechanical ventilation, and the length of intensive care unit (ICU) and hospital stays. In addition, an unplanned post‐hoc subgroup analysis was performed. At 1 year, all‐cause death occurred in 40 of 58 (69.0%) patients in the ECMO arm and in 40 of 59 (67.8%) in the early conservative arm (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.66–1.58; p = 0.93). The composite endpoint occurred in 43 (74.1%) patients in the ECMO group and in 47 (79.7%) patients in the early conservative group (HR 0.83, 95% CI 0.55–1.25; p = 0.29). The durations of mechanical ventilation, ICU stay and hospital stay were comparable between groups. Significant interaction with treatment strategy and 1‐year mortality was observed in subgroups according to baseline mean arterial pressure (MAP) indicating lower mortality in the subgroup with low baseline MAP (<63 mmHg: HR 0.58, 95% CI 0.29–1.16; pinteraction = 0.017).ConclusionsAmong patients with severe or rapidly progressing cardiogenic shock, immediate initiation of ECMO did not improve clinical outcomes at 1 year compared to the early conservative strategy. However, immediate ECMO initiation might be beneficial in patients with advanced haemodynamic compromise.

AIMS:We report our single-centre experience of mid-term to long-term retrieval and reimplantation of a tine-based leadless pacemaker [Micra transcatheter pacing system (TPS)]. The TPS is a clinically effective alternative to transvenous single-chamber ventricular pacemakers. Whereas it is currently recommended to abandon the TPS at the end of device life, catheter-based retrieval may be favourable in specific scenarios. METHODS AND RESULTS:We report on nine consecutive patients with the implanted TPS who subsequently underwent transcatheter retrieval attempts. The retrieval system consists of the original TPS delivery catheter and an off-the-shelf single-loop 7 mm snare. The procedure was guided by fluoroscopy and intracardiac echocardiography. After an implantation duration of 3.1 ± 2.8 years (range 0.4-9.0), the overall retrieval success rate was 88.9% (8 of 9 patients). The mean procedure time was 89 ± 16 min, and the fluoroscopy time was 18.0 ± 6.6 min. No procedure-related adverse device events occurred. In the one unsuccessful retrieval, intracardiac echocardiography revealed that the TPS was partially embedded in the ventricular tissue surrounding the leadless pacemaker body in the right ventricle. After retrieval, three patients were reimplanted with a new TPS device. All implantations were successful without complications. CONCLUSION:A series of transvenous late retrievals of implanted TPS devices demonstrated safety and feasibility, followed by elective replacement with a new leadless pacing device or conventional transvenous pacing system. This provides a viable end-of-life management alternative to simple abandonment of this leadless pacemaker.

Pulsed field ablation (PFA) is a nonthermal energy modality that largely spares collateral structures like the esophagus and phrenic nerve. However, a recent study indicates that subclinical coronary artery vasospasm is common during PFA of the cavo-tricuspid isthmus. There is also a case report of left circumflex artery (LCx) vasospasm during PFA at the mitral isthmus (MI).

There are substantial differences in autonomic nervous system activation among heart (cardiac) failure (CF) patients. The effect of acute CF on autonomic function has not been well explored. The aim of our study was to assess the effect of experimental acute CF on heart rate variability (HRV). Twenty-four female pigs with a mean body weight of 45 kg were used. Acute severe CF was induced by global myocardial hypoxia. In each subject, two 5-min electrocardiogram segments were analyzed and compared: before the induction of myocardial hypoxia and >60 min after the development of severe CF. HRV was assessed by time-domain, frequency-domain and nonlinear analytic methods. The induction of acute CF led to a significant decrease in cardiac output, left ventricular ejection fraction and an increase in heart rate. The development of acute CF was associated with a significant reduction in the standard deviation of intervals between normal beats (50.8 [20.5–88.1] ms versus 5.9 [2.4–11.7] ms, p < 0.001). Uniform HRV reduction was also observed in other time-domain and major nonlinear analytic methods. Similarly, frequency-domain HRV parameters were significantly changed. Acute severe CF induced by global myocardial hypoxia is associated with a significant reduction in HRV.

While pulsed field ablation (PFA) has emerged as a novel energy modality for ablation of atrial arrhythmias and is accompanied by a theoretically safer profile given its tissue selectivity and sparing of collateral structures, a recent study has highlighted the occurrence of subtotal coronary vasospasm during atrial fibrillation (AF) ablation on the cavo-tricuspid isthmus with PFA. While these observations were subclinical, there is at least one case report of left circumflex (LCx) coronary artery vasospasm during PFA at the mitral isthmus (MI) during AF ablation.

Leadless cardiac pacemakers (LCPs) are an effective and safe alternative to transvenous pacemakers for single-chamber ventricular pacing. Feasibility of retrieving and replacing long-term implanted LCPs is not well established.

Pulsed field ablation (PFA) has been touted to have important safety benefits, including no esophageal damage, pulmonary vein stenosis or permanent phrenic nerve paralysis. However, recent data suggest that when PFA is performed adjacent to a coronary artery, there is a susceptibility for vasospasm. In a study of right coronary artery (RCA) angiography during PFA of the cavo-tricuspid isthmus (CTI), there was universally severe RCA spasm. While these phenomena were all subclinical, there are other reports of clinically evident vasospasm during PFA.

Leadless cardiac pacemakers (LPs) are an effective and safe alternative to transvenous pacemakers for single-chamber ventricular pacing. However, the feasibility of retrieving and replacing chronically implanted LPs is not well understood.

Data from clinical trials of pulsed field ablation (PFA) to treat atrial fibrillation (AF) indicate highly-efficient workflow, an excellent safety profile, good clinical outcomes with few AF recurrences. Also strikingly, protocol-directed invasive remapping procedures revealed a high degree of durability of the pulmonary vein isolation (PVI) lesion sets. While quite favorable, PVI durability in carefully-monitored protocols may not translate to day-to-day clinical practice. Assessing durability with routine invasive remapping is not possible in routine clinical practice, but the "electrical status" of the PVs during clinical redo procedures provides compelling insights into the technical efficacy of the index procedure.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive therapeutic procedure with a consistent, linear increase in the number of implantations worldwide. Recently, TAVR has been rapidly expanding into lower-risk populations. Sporadic cases of late prosthesis-related Stanford type A dissection have been documented in self-expanding, as well as balloon-expandable TAVR valves, manifested primarily as acute aortic syndrome. We present the case of a 76-year-old male, who experienced refractory in-hospital cardiac arrest with non-shockable rhythm due to the obstruction of coronary flow caused by aortic dissection type A, with entry directly adjacent to the aortic prosthesis according to autopsy. The patient died despite the engagement of extracorporeal cardiopulmonary resuscitation. Aortic dissection developed one year after a transfemoral TAVR procedure using an Edwards SAPIEN 3 29 mm self-expanding valve. TAVR-associated late aortic dissection type A represents a rare, life-threatening condition with various clinical manifestations. The risk factors have not been well described and the differential diagnosis may be challenging. As the number of TAVR recipients and their life expectancy is increasing, we may face this complication more often in future.