Obstructive sleep apnea (OSA) is associated with an increased risk of atrial fibrillation (AF). However, the impact of continuous positive airway pressure (CPAP) on the recurrence of AF after catheter ablation (CA) in patients with OSA remains unclear. We systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) and observational studies comparing CPAP vs. no CPAP use for OSA treatment and recurrence of AF following CA. Heterogeneity was assessed with I2 statistics. We included 1 RCT and 10 observational studies with 1536 patients with OSA who underwent CA for AF, of whom 53

BACKGROUND:In patients with mechanical aortic and mitral valves requiring catheter ablation of ventricular tachycardia (VT), a technique for access from the right atrium (RA) to the left ventricle (LV) via puncture of the inferoseptal process of the LV was previously described in a single-center series. OBJECTIVES:This study sought to report the multicenter experience of VT ablation using this novel LV access approach. METHODS:We assembled a multicenter registry of patients with double mechanical valves who underwent VT ablation with RA-to-LV access. RESULTS:Eighteen patients from 10 VT ablation centers were included (15 men; age: 63.9 ± 10 years, LV ejection fraction: 32% ± 10%). In 14 patients, the procedure was performed on uninterrupted anticoagulation, and 4 patients underwent bridging with heparin. A mean of 2.5 VTs were inducible at procedure onset. LV access was successful in all cases with intracardiac echocardiography-guided puncture with a radiofrequency wire (n = 16) or standard transseptal needle (n = 2), followed by balloon dilation. Postablation, complete noninducibility of VT was achieved in 17 (94%) patients. One intramural perimitral annular hematoma was noted after LV access that was managed conservatively without sequelae. No other procedure-related complications were noted, such as new AV block. LV-RA shunt was present by echocardiogram within 24 to 72 hours in 10 (56%) patients. A small residual shunt was noted in 1 of them more than 3 months postablation. During the median follow-up of 10.4 months, 3 (17%) patients experienced VT recurrence. CONCLUSIONS:In this multicenter registry of patients with double mechanical valves, VT ablation with RA-to-LV access was feasible, safe, and effective.

Introduction: Previous studies have noted racial and ethnic disparities in access to leadless pacemaker implantation (LPI), but none have evaluated the socioeconomic disadvantaged (SED). Additionally, few studies have evaluated outcomes of LPI beyond thirty days on a large scale. This study aimed to determine which comorbidities are associated with one-year readmissions and mortality after LPI, including SED via the Social Deprivation Index (SDI). Methods: Patients ages ≥18 were identified in the Healthcare Cost and Utilization Project State Inpatient Databases in New York and Florida from 2016-2019 with follow-up into 2020. These states were chosen due to availability for linkage of the 2018 SDI (1-100, higher scores representing more disadvantage). International Classification of Diseases 10 codes for LPI were used. The risk of readmission and mortality was assessed using Cox proportional hazards first in an unadjusted fashion for each comorbidity in the Charlson Comorbidity Index. In addition to demographic variables, only significant variables from the unadjusted analysis were included in the final adjusted multivariable models. Results: 3,094 patients met inclusion criteria. The readmission and mortality rates at one, three, and twelve months were 17.2%, 31.3%, 50.2% and 5.7%, 7.1%, 10.7%, respectively. The most common diagnoses for readmission were dyspnea/chest pain (9.4%), heart failure (4%), and sepsis (3.8%). Federal insurance, heart failure (CHF), pulmonary disease, diabetes without complications, and renal disease (CKD) were associated with increased risk for twelve-month readmissions. African American race, myocardial infarction, CHF, CKD, and higher SDI were associated with increased risk for twelve-month mortality. Conclusion: CHF and CKD put patients at high risk of readmission and mortality. Sepsis was among the most common causes of readmission at twelve months. Patients of higher SED are at increased risk of mortality within one year after LPI.

Introduction: Gender and racial disparities have been shown to impact outcomes with percutaneous left atrial appendage closure (LAAC) though no studies have directly evaluated the role of socioeconomic disadvantage. The Social Deprivation Index (SDI) is a metric designed to quantify socioeconomic variation in health outcomes. We aimed to evaluate if SDI increases the risk of readmission within one year after LAAC in patients with atrial fibrillation (AF). Methods: Patients ages ≥18 were identified in the Healthcare Cost and Utilization Project State Inpatient Databases in New York (NY) and Florida (FL) from 2016-2019 with follow-up into 2020. These states were chosen due to availability for linkage of the 2018 SDI data. International Classification of Diseases 10 codes for AF and LAAC were used. The risk of readmission was assessed using multivariable Cox proportional hazards regression with covariates age, sex, race, insurance, Charlson Comorbidity Index (0 vs ≥ 1 comorbidity), and SDI deciles. SDI is scored 1-100 with higher scores representing more disadvantage. Results: 7,786 patients underwent LAAC in NY and FL 2016-2019. The readmission rate at one, three, and twelve months was 10.1%, 21.5%, and 44%. The most common admitting diagnoses at readmission were dyspnea/chest pain (11.4%) and GI bleed (8.8%). Female sex, African American race, ≥ 1 Charlson comorbidity, and those with from areas with a higher SDI had a higher one-, three-, and twelve-month risk of readmission. Those with federal insurance had a higher three- and twelve-month risk of readmission. Conclusion: After adjustment, socioeconomic disadvantage was observed to place patients at higher risk of readmission within one year after LAAC. GI bleed remains a common complication post LAAC. Given the link between differential care and healthcare disparities, it is essential to raise awareness to ensure successful post-procedure management and equitable cardiovascular care.

BACKGROUND:The boundaries of critical isthmuses for re-entrant ventricular tachycardia (VT) are formed by wavefront discontinuities (fixed lines of block, slow propagation, and rotational propagation) seen during baseline rhythm. It is unknown whether wavefront discontinuities can be automatically identified and targeted for ablation using electroanatomic mapping systems. OBJECTIVES:The purpose of this study was to assess the electrophysiologic characteristics of automatically projected wavefront discontinuity lines (WADLs) and outcomes of an ablation strategy targeting WADLs in a mixed cohort of VT patients. METHODS:Late activation substrate maps were analyzed from 1 or more baseline rhythm wavefronts. WADLs were identified using the Carto Extended Early Meets Late module. Number, total length, and distance to critical VT sites were measured. VT recurrence and VT-free survival were followed. RESULTS:In total, 49 patients underwent 52 ablations with 71 unique substrate maps analyzed (18.8% epicardial; 62.0% right ventricular paced, 28.2% sinus rhythm, 9.9% left ventricular paced). A total of 28 VT critical sites were identified in 24 patients. WADLs were present in 49 of 71 (69.0%) maps. WADLs were present regardless of cardiomyopathy etiology, mapping wavefront, or surface. At a WADL threshold of 30%, 73.9% of critical VT sites were in close proximity (≤15 mm) to a WADL. VT-free survival was 62% at 1 year, with a competing risk model estimating a 1-year risk of VT recurrence of 23%. CONCLUSIONS:WADLs can be automatically projected in a majority of patients in a mixed cohort of cardiomyopathy etiology, mapped wavefronts, and myocardial surfaces mapped. Targeting WADLs results in low rate of VT recurrence at 1 year.

Introduction: Gender and race have been shown to impact access and outcomes regarding rhythm control management such as atrial fibrillation (AF) ablation. We aimed to evaluate the role of the Area Deprivation Index (ADI), a validated metric that represents the social disadvantage of communities, to determine if socioeconomic disadvantage (SED) increases the risk of readmission within one year after AF ablation. Methods: Patients ages ≥18 were identified in the Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Databases in New York and Florida from 2016-2019 with follow-up into 2020 into the inpatient setting. These states were chosen due to availability for linkage of the 2020 ADI. International Classification of Diseases 10 and Current Procedural Terminology codes for AF and AF ablation were used. The risk of readmission was assessed using multivariable Cox proportional hazards with covariates age, sex, race, insurance, Charlson Comorbidity Index (0 vs ≥ 1 comorbidity), and ADI quartiles. ADI is scored 1-100 with higher scores representing more disadvantage. Results: 14,078 patients met inclusion criteria. The readmission rate at one, three, and twelve months was 6.1%, 9.9%, and 20.9% respectively. The most common readmission diagnoses at twelve months were AF (22.8%), followed by symptoms such as chest pain, dyspnea, palpitations, and syncope (13%). In the adjusted model, older age, female sex, federal insurance, ≥ 1 Charlson comorbidity, and higher ADI had higher one-, three-, and twelve-month risks of readmission. Hispanic ethnicity had a higher risk of one month readmission. Conclusion: Readmission for AF after ablation is common at twelve months. Higher risk of readmission after AF ablation was observed with SED. Enhanced awareness and additional research regarding SED as a risk factor for readmission may help improve post-ablation AF outcomes and equitable access to cardiovascular care.

Catheter ablation of ventricular tachycardia (VT) is an important therapy to reduce morbidity associated with both infarct-related and nonischemic cardiomyopathies. 1 Sapp J.L. Wells G.A. Parkash R. et al. Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs. N Engl J Med. 2016; 375: 111-121 Crossref PubMed Scopus (554) Google Scholar , 2 Martinez B.K. Baker W.L. Konopka A. et al. Systematic review and meta-analysis of catheter ablation of ventricular tachycardia in ischemic heart disease. Heart Rhythm. 2020; 17: e206-e219 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar , 3 Al-Khatib S.M. Stevenson W.G. Ackerman M.J. et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol. 2018; 72e91–e220 Crossref Scopus (234) Google Scholar , 4 Tung R. Xue Y. Chen M. et al. First-line catheter ablation of monomorphic ventricular tachycardia in cardiomyopathy concurrent with defibrillator implantation: the PAUSE-SCD randomized trial. Circulation. 2022; 145: 1839-1849 Crossref PubMed Scopus (51) Google Scholar Although activation and entrainment mapping of VT allow detailed assessment of the VT circuit and optimal locations for ablation, in many cases VTs are noninducible, not sustained, or not hemodynamically tolerated. Studies using hemodynamic support to allow mapping during sustained VT have not shown a clear benefit to this approach. 5 Turagam M.K. Vuddanda V. Atkins D. et al. Hemodynamic support in ventricular tachycardia ablation: an international VT ablation center collaborative group study. JACC Clin Electrophysiol. 2017; 3: 1534-1543 Crossref PubMed Scopus (46) Google Scholar Therefore, multiple substrate-based ablation strategies, in which the location of the critical parts of VT circuits are inferred from electrogram characteristics in sinus rhythm or ventricular pacing, have emerged as critical alternatives to induction and mapping of sustained VT and have expanded the population of patients who can potentially benefit from VT ablation. 6 Santangeli P. Marchlinski F.E. Substrate mapping for unstable ventricular tachycardia. Heart Rhythm. 2016; 13: 569-583 Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar A novel automated peak frequency annotation algorithm for identifying deceleration zones and ventricular tachycardia ablation sitesHeart RhythmVol. 21Issue 1PreviewCurrent annotation of local fractionated signals during ventricular electroanatomic mapping (EAM) requires manual input subject to variability and error. Full-Text PDF

INTRODUCTION:Numerous P-wave indices have been explored as biomarkers to assess atrial fibrillation (AF) risk and the impact of therapy with variable success. OBJECTIVE:We investigated the utility of P-wave alternans (PWA) to track the effects of pulmonary vein isolation (PVI) and to predict atrial arrhythmia recurrence. METHODS:This medical records study included patients who underwent PVI for AF ablation at our institution, along with 20 control subjects without AF or overt cardiovascular disease. PWA was assessed using novel artificial intelligence-enabled modified moving average (AI-MMA) algorithms. PWA was monitored from the 12-lead ECG at ~1 h before and ~16 h after PVI (n = 45) and at the 4- to 17-week clinically indicated follow-up visit (n = 30). The arrhythmia follow-up period was 955 ± 112 days. RESULTS:PVI acutely reduced PWA by 48%-63% (p < .05) to control ranges in leads II, III, aVF, the leads with the greatest sensitivity in monitoring PWA. Pre-ablation PWA was ~6 µV and decreased to ~3 µV following ablation. Patients who exhibited a rebound in PWA to pre-ablation levels at 4- to 17-week follow-up (p < .01) experienced recurrent atrial arrhythmias, whereas patients whose PWA remained reduced (p = .85) did not, resulting in a significant difference (p < .001) at follow-up. The AUC for PWA's prediction of first recurrence of atrial arrhythmia was 0.81 (p < .01) with 88% sensitivity and 82% specificity. Kaplan-Meier analysis estimated atrial arrhythmia-free survival (p < .01) with an adjusted hazard ratio of 3.4 (95% CI: 1.47-5.24, p < .02). CONCLUSION:A rebound in PWA to pre-ablation levels detected by AI-MMA in the 12-lead ECG at standard clinical follow-up predicts atrial arrhythmia recurrence.

BACKGROUND:Myocardial electrical heterogeneity is critical for normal cardiac electromechanical function, but abnormal or excessive electrical heterogeneity is proarrhythmic. The spatial ventricular gradient (SVG), a vectorcardiographic measure of electrical heterogeneity, has been associated with arrhythmic events during long-term follow-up, but its relationship with short-term inducibility of ventricular arrhythmias (VAs) is unclear. OBJECTIVE:This study was designed to determine associations between SVG and inducible VAs during electrophysiology study. METHODS:A retrospective study was conducted of adults without prior sustained VA, cardiac arrest, or implantable cardioverter-defibrillator who underwent ventricular stimulation for evaluation of syncope and nonsustained ventricular tachycardia or for risk stratification before primary prevention implantable cardioverter-defibrillator implantation. The 12-lead electrocardiograms were converted into vectorcardiograms, and SVG magnitude (SVGmag) and direction (azimuth and elevation) were calculated. Odds of inducible VA were regressed by logistic models. RESULTS:Of 143 patients (median age, 69 years; 80% male; median left ventricular ejection fraction [LVEF], 47%; 52% myocardial infarction), 34 (23.8%) had inducible VAs. Inducible patients had lower median LVEF (38% vs 50%; P < .0001), smaller SVGmag (29.5 vs 39.4 mV·ms; P = .0099), and smaller cosine SVG azimuth (cosSVGaz; 0.64 vs 0.89; P = .0007). When LVEF, SVGmag, and cosSVGaz were dichotomized at their medians, there was a 39-fold increase in adjusted odds (P = .002) between patients with all low LVEF, SVGmag, and cosSVGaz (65% inducible) compared with patients with all high LVEF, SVGmag, and cosSVGaz (4% [n = 1] inducible). After multivariable adjustment, SVGmag, cosSVGaz, and sex but not LVEF or other characteristics remained associated with inducible VAs. CONCLUSION:Assessment of electrical heterogeneity by SVG, which reflects abnormal electrophysiologic substrate, adds to LVEF and identifies patients at high and low risk of inducible VA at electrophysiology study.

Background: Pulmonary vein isolation (PVI) is superior to antiarrhythmics for the management of atrial fibrillation, but repeat ablation is often required for durable rhythm control. Factors influencing first-pass isolation (FPI) and whether FPI predicts durable isolation are not well known. Objective: The study sought to determine factors associated with FPI and rates of chronic reconnection among those with and without FPI at index PVI in patients undergoing repeat ablation. Methods: We retrospectively identified 483 patients at our institution who underwent first-time PVI in 2021. Of these, 63 who had repeat ablation between 2021 and 2023 were included in the study. Logistic regression was used for statistical analysis for predictors of FPI during index PVI. Results: The mean age was 65 years, 67% of patients were male, 90% were White, and 73% had persistent atrial fibrillation. At index PVI, FPI was achieved in 58% of left pulmonary veins (PVs), 48% of right PVs, and 25% of posterior wall isolations. Bilateral FPI was achieved in 35% of patients. At redo PVI, the right superior PV (47%) was most frequently reconnected. Lack of PFI of the right PVs at index PVI was associated with a 14-fold risk of chronic reconnection. Elevated left atrial voltage predicted the absence of FPI of the right PVs but not the left PVs. Conclusion: Increased left atrial voltage predicts a lack of FPI in the right PVs but not in the left PVs. Lack of FPI of right PVs predicts chronic reconnection.

With the expanding use of cardiac implantable electronic device (CIED) therapy, intravascular device infections are becoming more common. In the case of transvenous implantable cardioverter-defibrillator (ICD) infections requiring extraction for bacterial clearance, there remains no standard method to deliver temporary ICD therapy following device removal. We present a case of persistent bacteremia complicated by monomorphic ventricular tachycardia (VT) electrical storm where biventricular ICD system extraction was performed and a temporary transvenous dual-coil lead with an externalized ICD generator was used to treat VT episodes prior to the re-implantation of a new permanent system. This case demonstrates the utility of a temporary externalized transvenous ICD system in the successful detection and pace-termination of VT, thereby reducing episodes of painful and potentially harmful external defibrillator shocks during the treatment of CIED infection.