Saturday, August 13, 2016

A Foreign Material Image In The Coronary Sinus During Coronary Sinus Angiography

Mustafa Yildiz, Gokhan Kahveci, Yunus Emiroglu, Okan Erdogan

A 63-year-old man with history of bedside temporary pacemaker lead insertion a year ago was hospitalized for cardiac resynchronization and defibrillator device implantation. After insertion of the right ventricular shocking lead we tried to engage the ostium of the coronary sinus (CS) and injected some dye to delineate its anatomy. Unfortunately, the proximal portion of the main CS was occluded. In addition, 2 fixed and rounded neighboring foreign materials were incidentally detected within its opacified portion (Fig. 1A, arrow indicates foreign material). A subsequent multislice computed tomography (Fig. 1B, Fig. 1C * indicates foreign material) confirmed CS occlusion and foreign metallic materials (Hounsfield unit: 2686) resembling metallic electrodes most probably originating from the previous inserted temporary pacemaker lead. We suggested that the forceful blunt insertion of the firm lead tip dissected the CS wall and cretaed a subintimal pouche. Further blood accumulation and formation of intense coagulum externally compressed the wall and occluded the lumen of the CS. When the temporary pacing lead that was partly encapsulated and fixed by the fibrocoagulative tissue was forcefully pulled out, the metallic electrodes overlying the lead tip might have been teared off and retained within the CS. This interesting and rare case highlights an unusual cause of CS occlusion and unexpected complication of temporary pacemaker lead insertion. One must be sure that no fragments have been retained or embolized when removing the pacing leads from the body.
Symptoms In Atrial Fibrillation: A Contemporary Review And Future Directions

Steven T. Heidt, Anna Kratz, Kayvan Najarian, Afton L. Hassett, Hakan Oral, Richard Gonzalez, Brahmajee K. Nallamothu, Daniel Clauw, Hamid Ghanbari

Atrial fibrillation (AF) is the most prevalent arrhythmia leading to hospital admissions in the United States. The majority of patients with AF report symptoms associated with this condition that can lead to a decrease in health related quality of life (HRQOL) and functional status. Therefore, along with reducing the risk of stroke and mortality, improvements in such symptoms are important therapeutic goals in the management of patients with AF.  Our current understanding of how AF and symptoms are linked is hampered by the dominant assessment paradigm, where symptoms thought to be associated with AF are measured at a single point in time (frequently at a clinic visit). Unfortunately, this “static” snapshot does not capture the variability of symptoms and heart rhythm within a person over time and does not shed light on how symptoms are related to heart rhythm. This focused review summarizes current methods for assessing symptoms including generic and AF-specific HRQOL and functional status tools.  It also describes gaps in the current assessment paradigm and where future research using mobile applications and digital technology might be able to assist with patient care.
Symptom/Rhythm Correlation With Patient Owned Device: Insights Into Practice And Challenges

Mohammed Shurrab, Anatoly Langer, Eugene Crystal, David Newman

Capturing symptom/rhythm correlation is crucial in patients who have rhythm-related symptoms. Evolving technology has led from 24 hour and 14 day Holter monitors to now external loop recorders to capture symptom/rhythm correlation. In patients with very infrequent and short-lived symptoms, the only recourse is an implantable recording device. Recently, patient activated recording devices have become available. These have the potential to significantly increase the duration for monitoring symptom/rhythm correlations. We report cases of using such devices to demonstrate some of the uses and challenges of this new ECG recording technology.
Arguments to Apply Epinephrine for Pocket Hematoma Reduction. The MAITRE Study

Nikolay Ilov, Anatoly Nechepurenko, Albert Abdulkadyrov, Damir Paskeev, Elena Damrina, Elena Kulikova, Marina Terent’eva, Dinara Stompel, Dmitry Tarasov
Pocket hematoma (PH) is a common complication of implantations of cardiac electrophysiological devices with occurring at a particularly high rate in patients on oral anticoagulation or antiplatelet treatment. Different pharmacological agents with hemostatic effect are used to avoid PH. We supposed that the vasoconstrictor effects of epinephrine may reduce bleeding extent and be effective in prevention of PH. Maitre is the first clinical trial conducted with an aim to show the safety and efficacy of epinephrine in PH prophylaxis. We randomized 133 patients to receive either epinephrine or saline solution, which were added to a local anesthetic administered during pacemaker implantation. In cases of diffuse bleeding a method of pocket drainage was effectively used. Results showed that risk of PH was significantly higher in the group receiving epinephrine. We conclude that a local epinephrine effect may lead to a false impression of adequate hemostasis and force a surgeon to refuse from drainage insertion.
Interactive In-Vitro Training In Physics Of Radiofrequency Ablation For Physicians And Medical Engineering Students

Haber T, Kleister G, Selman B, Härtig J, Melichercik J, Ismer B

Radiofrequency (RF) ablation requires a complex set of devices as well as profound electrophysiological experience and substantial knowledge of physical science basics. To establish RF ablation in-vitro teaching-system, six workstations were equipped with computer-controlled RF ablation generators. Universal connection boxes allow ablation-essays with catheters of different make and model. Special wetlabs were developed combining a basin containing isotonic saline solution with a thermostat and a pump to simulate blood flow. This hands-on teaching system can be used to demonstrate differences in lesion-forming dependent on tip-electrodes, sensor technology and ablation techniques, influence of blood flow and electrode-angle to the myocardium. It was also utilized to reproduce industrial in-vitro tests.
Influence Of Novel Electrocardiographic Features Of Provocable Brugada ECG In Arrhythmogenic Cardiomyopathy And Its Exclusion By Lead AVR

Stefan Peters

In 19 patients (14 females, mean age 49.1 ± 11.3 years) with typical arrhythmogenic cardiomyopathy and provocable type I Brugada ECG pattern by ajmaline administration were analysed by novel electrocardiographic features as having “true” or “false” Brugada syndrome. Three patients turned out as having false Brugada syndrome, the diagnosis is pure arrhythmogenic cardiomyopathy.
In 16 patients, however, true Brugada syndrome could be provoked. In these patients the diagnosis was arrhythmogenic cardiomyopathy associated by provocable Brugada syndrome.
Clinical Use And Limitations Of Non-Invasive Electrophysiological Tests In Patients With Atrial Fibrillation

Valentina D.A, Corino, Luca T, Mainardi, Frida Sandberg, Leif Sörnmo, Pyotr G. Platonov

Atrial fibrillation (AF) is a complex arrhythmia, that has been studied non-invasively assessing atrial refractory period, atrioventricular node (AV) node refractory period, and ventricular response. The AV node plays a fundamental role as it filters many of the numerous irregular atrial impulses bombarding the node. Despite its importance, the electrophysiological (EP) characteristics of the AV node are not routinely evaluated since conventional EP techniques for assessment of refractory period or conduction velocity of the AV node are not applicable in AF. Since rate-control drugs control ventricular response through their effect on the AV node, noninvasive assessment of AV node electrophysiology may be useful. The RR series, though being highly irregular, contains information that can be used for risk stratification and prediction of outcome. In particular, RR irregularity measures during AF have been shown to be related to clinical outcome. This paper reviews the attempts done to noninvasively characterize the AV node and the ventricular response, highlighting clinical applications and limitations of the noninvasive techniques.
Surgical Ablation of Atrial Fibrillation: is Electrical Isolation of the Pulmonary Veins a Must?

Bart Maesen, Ines Van Loo, Laurent Pison, Mark La Meir
Ablation of atrial fibrillation (AF) is a well-established treatment option for patients with symptomatic AF refractory to antiarrhythmic drugs. The cornerstone of catheter ablation is electrical isolation of the pulmonary veins, since the pulmonary veins are the most common location for triggers of AF. Electrical reconnection of the pulmonary veins is associated with arrhythmia recurrence and therefore diminishes long-term success of catheter ablation of AF. Therefore, durable pulmonary vein isolation remains a condition sine qua non for catheter ablation of AF. The Cox-Maze procedure is considered an effective surgical cure of AF, however it has never been widely adopted due to its procedural complexity. Since the development of minimal invasive techniques for surgical AF treatment, surgical ablation of AF has regained interest. Most of the minimal invasive surgical AF ablations performed around the globe include pulmonary vein isolation as a part of the procedure. In this review, we explore the necessity of electrical isolation of the pulmonary veins in surgical AF ablation.
Recurrent Atrial Fibrillation After Catheter Ablation:  Considerations For Repeat Ablation And Strategies To Optimize Success

Andrew E. Darby

Recurrent AF after catheter ablation occurs in at least 20 to 40% of patients. Repeat ablation is primarily considered for those with symptomatic AF recurrences (often drug-refactory) occurring at least 3 months or more post-ablation. Pulmonary vein reconnection is almost universally encountered, and repeat isolation of electrically connected pulmonary veins should be the primary ablation strategy. Beyond repeat PVI and possible ablation of non-PV triggers, there is little to no evidence that additional substrate modification improves outcomes. In addition to repeat ablation, it is critical to address and treat comorbid conditions which increase arrhythmia risk post-ablation. Specifically, obesity, hypertension, and sleep-disordered breathing should be targeted and modified to increase the likelihood of success.
Internal Jugular Vein Complete Thrombosis After Dual Chamber Pacemaker Implant

Angelo Placci, Maria Mattioli, Maria Francesca Notarangelo, Gianluca Gonzi, Marco Zardini

Venous thrombosis after pacemaker implant is a known, although often underrecognized condition that can challenge system revision or upgrading, leading occasionally to thromboembolic complications. Several factors are considered to promote thrombus formation. Among them, alteration of blood flow mechanics due to the presence of catheters in the vessel lumen may itself play a pivotal role. Hereby we present the case of a 65-year old men who underwent a dual-chamber pacemaker implant in another institute for sick sinus syndrome by means of left cephalic venous access. About two months later he started experiencing neck swelling, pain and dysphagia. Six months later, ultrasonography and CT-scan revealed complete jugular vein thrombosis caused by a lead loop at the level of the left subclavian vein. Of note, thrombosis occurred despite proper oral anticoagulation with warfarin undertaken for coexisting atrial fibrillation. It’s important to keep in mind this possible complication of pacemaker implant to allow for early diagnosis and better treatment chances. This case report is an example of how proximal catheter displacement may promote thrombus formation, probably by affecting blood flow mechanics, even in spite of proper oral anticoagulation.
Junctional Beats During Cryo-Ablation Of The Slow Pathway For The Elimination Of Atrioventricular Nodal Reentrant Tachycardia

Murat Sucu, Vedat Davutoglu, Esra Polat

The patient was a 39-year-old female with recurrent paroxysmal, regular narrow QRS complex tachycardia. Atrioventricular nodal reentrant tachycardia (AVNRT) was induced. The cryo-ablation attempts (-80°C, 240 second) were performed in the inferior–posterior triangle of Koch.  We observed several junctional beats during cryo-ablation. After successful cryo-ablation, AVNRT induction was repeatedly checked during a waiting period of 30 minutes without recurrence. In our case we demonstrated that junctional beats can be observed during cryo-ablation. We believe this to be the first description of junctional beats occurring during cryo-ablation of AVNRT.
Safety And Utility Of Cardiac MRI In A Patient With Pericardial Effusion And A Recently Implanted Conventional Pacemaker

Hussam Ali, Gianluca Epicoco, Antonio Sorgente, Pierpaolo Lupo, Riccardo Cappato

Cardiac MRI is usually not recommended in the acute phase after pacemaker implantation, particularly for conventional devices. This case concerns a 66-year-old patient who developed significant pericardial effusion subacutely after implantation of a dual-chamber, conventional pacemaker. Cardiac MRI was planned to elucidate the characteristics of the pericardial effusion and was performed under controlled conditions without any consequences. Images analysis was very helpful to reveal the non-hemorrhagic nature of the pericardial effusion and correct endocardial position of the leads. In conclusion, cardiac MRI might be feasible and useful, under controlled conditions, in selected non-pacing dependent patients with conventional pacemakers.
Concomitant Left Atrial Appendage Clipping  During Minimally Invasive Mitral Valve Surgery: Technically Feasible and Safe

Ashraf Alqaqa, Shabiah Martin, Aiman Hamdan, Fayez Shamoon, Kourosh T. Asgarian

Background: It is believed that most of thrombi form in the left atrial appendage (LAA)before they emboli. Different surgical and percutaneouse approaches were suggested to manage the LAA. In this study we are evaluating the safety of clipping the LAA via minithoractotomy approach.
Method: All consecutive patients who had minimally invasive mitral valve surgery with concomitant LAA clipping between December 2012 and February 2014 were included in the study. LAA exclusion was performed using AtriClip® LAA Exclusion System (Cincinnati, Ohio, AtriCure®). The patient s’ clinical characteristics, intraoperative complications, and in-hospital coarse were obtained by reviewing the medical records.
Result: Total of 22 patients(50% males) were included in the study. The median ages was 66.0 years (IQR: 50.8 to 81.3). Eight(36%) had mitral valve replacement and the rest had mitral repair surgery. Five(23%) patients needed blood product transfusion during the surgery. No clip related bleeding was observed and no perioperative mortality was recorded.
Conclusion: During minimally invasive mitral valve surgery, Concomitant exclusion of the left atrial appendage using AtriClip® can be performed rapidly and safely.
Assessment Of Sinoatrial Node Function In Patients With Persistent And Long-Standing Persistent Forms Of Atrial Fibrillation After Maze III Procedure Combined With Mitral Valve operation

Dr. Kulikov A.A

Research objective: Assessment of sinoatrial node function after Maze III procedure combined with a mitral valve operation.
Methods: 100 patients were included in the research with persistent and long-standing persistent forms of atrial fibrillation (AF) and need of operative treatment concerning valve disease.
The following preoperative preparation methods were executed to all patients: 1. Electrocardiogram in 12 standard assignments; 2. Two-dimensional echocardiographic with assessment of systolic and diastolic functions of the left ventricle, size of the left atrium and grade of valve disease; 3. Transesophageal echocardiography for exclusion of blood clots in the left atrium and left atrial appendage; 4. Coronary angiography for exclusion of coronary heart disease; 5. Computer tomography for examination of cardiac chambers and anatomic characteristics of pulmonary veins.
Electric cardioversion in X-ray operating room conditions was performed on all patients. After successful restoration of sinus rhythm, electrophysiological examination (EP) of heart was carried out. Then, on the first or second day after EP study, Maze III procedure combined with a mitral valve operation was performed.
Results: Following the results of Maze III procedure combined with correction of valve disease, disposal of AF was observed in 95% of patients. 46% of patients had stable sinus rhythm to the moment of discharge from the hospital. 24% of patients had atrial rhythm with the maximum heart rate of 80-110 bpm (according to results of 24-hour Holter monitoring). For 25% of patients, it was necessary to implant a pacemaker. According to results of EP study, 13% of these patients suffered from sick sinus syndrome before operation. For 9% of the remaining 12% of patients, the indications for pacemaker implantation were atrioventricular nodal rhythm with low heart rate and pauses more than 3 sec long. For 1% of patients the indication was second degree AV block (type 2) and second degree SA block (type 2); for 1% the indication was complete heart block, and for 1% it was atrial rhythm and pauses more than 3 sec long.
13% of patients with an atrial rhythm and normal heart rate developed typical atrial flutter (AFL) in the early postoperative period. For all of them the RF catheter ablation with linear ablation of the right atrial isthmus and creation of isthmus block was effective, and further recurrence of AFL was not observed.
Conclusions: In the early postoperative period Maze III procedure combined with a mitral valve operation proved to be an effective surgical technique of treatment of persistent and long-standing persistent forms of AF. Only 12% of patients had dysfunction of sinus node work due to iatrogenesis.
Myocardial Biopsy In “Idiopathic» Atrial Fibrillation And Other Arrhythmias: Nosological Diagnosis, Clinical And Morphological Parallels, And Treatment

O.V.Blagova, A.V.Nedostup, E.A.Kogan, V.A.Sulimov, S.A.Abugov, A.G.Kupryanova,V.A.Zaydenov, 
A.E.Donnikov, E.V.Zaklyazminskaya, E.A.Okisheva

Background: The nosological nature of “idiopathic” arrhythmias and the effect of etiotropic and pathogenetic treatment are often unknown.
Methods And Results: 19 patients (42.6±11.3 years, 9 women) with atrial fibrillation (n = 16), supraventricular (n = 10) and ventricular (n = 4) premature beats, supraventricular (n = 2) and ventricular tachycardia (n = 1), left bundle branch block (n= 2), AV block (n = 2) without structural heart changes. Viruses were identified (polymerase chain reaction, PCR) along with measurement of anti-heart antibodies (AHA) and endomyocardial biopsy (EMB).
EMB allowed to establish diagnosis in all patients: 1) infectious-immune myocarditis (n = 11, parvovirus-positive in 1), 2) parvovirus-positive endomyocarditis (n = 1), 3) systemic (n = 2) and myocardial (n = 1) vasculitis, 4) Fabry’s disease (n = 1), 5) arrhythmogenic right ventricular dysplasia (n = 1), 6) unspecified genetic cardiomyopathy (n = 2, herpes virus 6 one positive). Level of AHA had the greatest significance for myocarditis diagnostics. All patients with myocarditis/vasculitis had background therapy: acyclovir (n = 10), IV immunoglobulin (n = 2), meloxicam (n = 12), hydroxychloroquine (n = 15), steroids (n = 14, 31.1±12.5 mg/day), azathioprine 150 mg/day (n = 2). Median follow-up was 4 years. Treatment significantly reduced the rate of arrhythmias (8 [5;8] to 3 [1.25;7.75] points); disappearance of bundle branch block was noted.
Conclusion: EMB allowed to diagnose immune-mediated inflammatory diseases in 78.9% patients with ‘idiopathic’ arrhythmias and genetic diseases in 21.1%. Background therapy of myocarditis improved the antiarrhythmic efficiency, and allowed the best premed for interventional treatment.
The Role of NOACs in Atrial Fibrillation Management: A Qualitative Study

Katherine Kirley, Goutham Rao, Victoria Bauer, Christopher Masi

Patients with atrial fibrillation (AF) benefit from anticoagulation to reduce stroke risk. However, 30-60% of patients with AF are not anticoagulated. This study explored physicians’ reasons for under-treatment of AF, focusing on the role of the novel oral anticoagulants (NOACs). We interviewed primary care physicians and cardiologists involved in AF management in a variety of practice settings. We conducted interviews using a semi-structured format and analyzed the data using the Framework Method. Four themes emerged. First, the likelihood of physicians to prescribe NOACs depends upon their willingness to try new medications and their successful experience with them.  Second, physicians typically balance the benefits and risks of anticoagulation in AF patients, although not always accurately. Third, patient convenience and preferences, as well as physician convenience, are important when considering anticoagulation. Finally, concerns regarding the out-of-pocket cost of NOACs deter many physicians from prescribing them. The persistence of under-treatment in AF despite the availability of effective therapies suggests that new strategies are needed to improve physician knowledge and practice. These strategies should enhance physician awareness of AF under-treatment, emphasize accurate assessment of bleeding risk among AF patients, compare the safety, efficacy, and convenience of NOACs relative to warfarin, and address physician concerns regarding the out-of-pocket cost of NOACs. Guidelines and decision supports which promote physician knowledge in these areas have the potential to increase oral anticoagulant use and reduce preventable morbidity and mortality.
Comparison of the Influence of Right Atrial Septal Pacing and Appendage Pacing on an Atrial Function and Atrial Fibrillation in the Clinical Situation

Mariko Tanaka, Kanae Su, Maki Oi, Yasuyo Motohashi, Kousuke Takahashi, Euihong Ko, Koji Hanazawa, Mamoru Toyofuku, Masahiko Kitada, Yousuke Yuzuki, Takashi Tamura

BACKBROUND Radiofrequency ablation is extensively used to achieve pulmonary veins isolation for the cure of atrial fibrillation. Luminal esophageal temperature can be monitored by means of suitable probes to prevent the onset of lesions.
OBJECTIVE To compute the thermal field generated by the ablation, to investigate the interaction between the electromagnetic field and the probe sensors, and to provide a safe interpretation of the temperature detected by the probe, supported by clinical data.
METHODS A mathematical model is formulated and the is computed. Experiments have been performed to assess the solution energy deposition rate on the probe sensors. Clinical data have been collected during RF isolation of pulmonary veins in patients with atrial fibrillation.
RESULTS The direct interaction between the radiofrequency source and the probe sensors is found to be negligible. Numerical simulations show that the outer esophageal wall can be much warmer than the lumen. Theoretical heating curves are compared with the clinical data selecting the maximal slope as the reference quantity. The clinical values range between 0.01�C/s and 0.15�C/s agree with the computed predictions and demonstrate that reducing the esophagus-atrium distance by 1mm causes a slope increase of 0.06�C/s.
CONCLUSION The use of esophageal thermal probes is absolutely safe and necessary in order to prevent the occurrence of thermal lesions. The model is reliable, and describes effectively the generated thermal field. The external esophageal temperature can be considerably higher than the luminal one.
Quality measures in Atrial Fibrillation therapy – AF ablation and Get with the Guidelines AFIB registries

Dhanunjaya (DJ) Lakkireddy, Andrea Natale

Dear Colleagues Welcome to the summer issue of JAFIB. Hope everyone had a chance to enjoy the season and related travels. As MACRA and Pay for Performance continue to evolve to be the guiding force on physician reimbursement, quality becomes an important piece we need to focus on. It doesn't mean that we are not providing quality care to our patients now, but we need a special effort to document our quality work through various registries and quality bench marks. AF ablation has become an important area of focus for all the professional societies including HRS, ACC and AHA. One such effort is the recently released NCDR�s AFib registry. It's relatively comprehensive dataset that attempts to track outcomes and quality in a systematic way. Eventhough, it may not be very extensive and lead to long term follow up, it is a good start.

Thursday, June 2, 2016

Cryoballoon Versus Radiofrequency Ablation For Paroxysmal Atrial Fibrillation: Review Of Current Literature 

Syed Rafay Ali Sabzwari, MD; Dhanunjaya Lakkireddy, MD, FACC, FHRS

Atrial fibrillation is the most common arrhythmia affecting an estimated 3 million people in US and 20 million around the world. In the realm of rhythm control antiarrhythmic drugs (AAD) were utilized until transcatheter ablation techniques emerged. Circumferential pulmonary vein isolation (PVI) is the standard and recommended approach for catheter ablation of paroxysmal atrial fibrillation refractory to medical therapy. The first introduced and most commonly used method is radiofrequency (RF) ablation and the second most common and more recent is cryoballoon (CB) ablation. To benefit from their efficacies and optimize their usage, in the past there have been many mostly nonrandamoised single center prospective registries showing equivocal efficacy of the two techniques with slightly lower complications such as cardiac tamponade and perforation with cryoballoon technique. However in addition to the three prior randomized controlled trials, the recently published FIRE and ICE Trial by Kuck et al1 which is a large, multicenter, randomized trial compared radiofrequency and cryoballoon techniques used for ablation of paroxysmal atrial fibrillation. 
Rate Control Vs Rhythm Control For Atrial Fibrillation After Cardiac Surgery: Review Of Current Literature

Syed Rafay Ali Sabzwari, MD; Dhanunjaya Lakkireddy, MD, FACC, FHRS

Atrial fibrillation (AF) after cardiac surgery is a common phenomenon reaching an incidence of 20-50% with a significant toll on postoperative complications, hospital stay, readmission and utilization of resources. Such patients have increased morbidity from stroke, myocardial infarction, congestive heart failure, arrhythmias from antiarrhythmic drugs and bleeding caused by anticoagulant use. Although there have been multiple studies done in the past to address post cardiac surgery atrial fibrillation majority of them focused on prevention strategies using prophylactic measures. The AFFIRM trial7 addressed rate vs rhythm control in nonsurgical patients, however conclusive evidence of whether this could be extrapolated to post cardiac surgery atrial fibrillation was lacking. This article explores the current literature on post cardiac atrial fibrillation rate versus rhythm control.