Citations

ABSTRACT Background Transvenous lead removal (TLR) is a Class I indication for patients with cardiac implantable electronic device (CIED) infections. However, disparities in the utilization of TLR have not been fully explored, particularly concerning demographic and socioeconomic factors. Objectives This study aims to examine whether disparities exist among patients hospitalized for CIED infections with respect to the utilization of TLR, focusing on sex, race, and income characteristics. Methods We utilized the 2019 National Inpatient Sample (NIS) to assess patients hospitalized with CIED infections and identify those who underwent TLR. Multiple logistic regression was used to examine risk factors for TLR utilization, including age, sex, race/ethnicity, and socioeconomic characteristics. Results A total of 56 709 patients were hospitalized for CIED infection in the United States in 2019, of which 9867 (17.4%) underwent TLR. On an adjusted analysis, females and Black patients were found to have lower odds of undergoing TLR compared to males and White patients (OR: 0.62; 95% CI: 0.59–0.78; p < 0.01; and OR: 0.47; 95% CI: 0.39–0.57; p < 0.01, respectively). Hispanic patients also had reduced odds of TLR (OR: 0.73; 95% CI: 0.58–0.93; p = 0.01). No significant associations were observed between income or insurance status and the likelihood of receiving TLR after adjustment. Conclusions This study identified significant disparities in the utilization of TLR among patients hospitalized for CIED infections. Female, Black, and Hispanic patients were significantly less likely to receive TLR.

Abstract Aims Catheter ablation is commonly performed in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) for management of ventricular arrhythmias (VAs). The impact of catheter ablation on cardiac function is unknown. The aim is to assess the impact of catheter ablation for VAs on cardiac function in patients with ARVC. Methods and results This retrospective study included consecutive patients with ARVC who underwent catheter ablation for VAs. Cardiac and valvular functions were assessed on pre- and post-procedure cardiac imaging. The severities of tricuspid regurgitation, pulmonic regurgitation, right ventricular (RV) enlargement, and RV systolic dysfunction was graded as absent (=0), mild (=1), mild-moderate (=2), moderate (=3), moderate-severe (=4), or severe (=5). Thirty-four patients were included. Median age at the time of ablation was 49 [inter-quartile range (IQR), 23] years, and 10 (29%) patients were female. After a median follow-up of 1 (IQR, 0) day, 11 (34%) patients had worsening RV function, and 4 (12%) patients had worsening left ventricular ejection fraction (LVEF) &gt;5%. Five (15%) patients required inotropic support. After a median follow-up of 6.5 (IQR, 6.4) months, 20 (59%) patients had repeat transthoracic echocardiograms. Among patients with worsening RV function post-ablation, one-sixth (17%) had improvement in the RV function at follow-up. In contrast, among patients who had an acute drop in LVEF post-ablation, two-thirds (67%) had improvement at follow-up. Conclusion Right ventricular dysfunction following catheter ablation in patients with ARVC is common, affecting one-third of patients. Patients undergoing catheter ablation of VAs should be counselled on the potential negative impact of ablation on cardiac function.

Atrial fibrillation (AF) and cancer are increasingly recognized as interrelated conditions, with cancer patients showing elevated incidences of AF, and there is evidence that AF may sometimes precede cancer diagnoses. This comprehensive review investigates the epidemiology, pathophysiology, and management challenges associated with AF in cancer patients. Epidemiologically, several cancers are more closely related to increased rates of AF, including lung, colorectal, gastrointestinal, and hematologic malignancies. Mechanistically, both AF and cancer share pathophysiological pathways centered on inflammation, oxidative stress, and common cardiovascular risk factors, such as hypertension, obesity, and diabetes. The inflammatory microenvironment in tumors, marked by increased cytokines and growth factors, promotes atrial remodeling and AF susceptibility. Elevated reactive oxygen species (ROS) levels, driven by the metabolic demands of cancer, further contribute to atrial fibrosis and structural changes. Moreover, many anticancer treatments exacerbate AF risk. Management of AF in cancer patients presents many unique challenges and requires a multidisciplinary approach. Rate and rhythm control strategies are complicated by potential drug–drug interactions and limited data surrounding early implementation of rhythm control strategies in cancer patients. Interventional approaches such as catheter ablation, though effective in maintaining sinus rhythm, carry significant perioperative risk in patients with malignancy. Stroke prevention with anticoagulants is essential but requires cautious administration to avoid heightened bleeding risks, particularly in patients undergoing chemotherapy. Further, the limited applicability of standard risk stratification tools like CHA2DS2-VASc in this population complicate decisions regarding anticoagulation. This review highlights the bidirectional relationship between AF and cancer, the difficulties in management, and the critical need for further research in this field.

Description of Cases: Case 1: A 72 year old male with atrial fibrillation (AF) and tachy-brady syndrome underwent Micra implantation. On post-procedure day 2, pacing thresholds were unacceptably elevated. A new Micra device was deployed; subsequently, a microsnare was placed through the Micra delivery catheter and the docking button of the old Micra was successfully snared (Figure A). The old Micra was then captured over the delivery catheter and removed from the body. Case 2: A 76 year old male underwent Micra implantation and AV node ablation for AF with persistent tachycardia. One month later, he presented with heart failure and interval decrease in ejection fraction from 66% to 33%. After biventricular leads were implanted, an Agilis catheter was advanced towards the Micra. The docking button was successfully snared with a gooseneck snare (Figure B), and the Micra was extracted with gentle traction. Case 3: A 76 year old male with complete heart block and longstanding persistent AF received a Micra. Nine months later, he presented with heart failure and interval decrease in ejection fraction from 55% to 25%. A defibrillator lead was implanted but no suitable CS branch was identified. The Aveir retrieval catheter was advanced and the Micra docking button was captured with the triloop snare (Figure C). The protective sleeve was advanced over the Micra and it was successfully removed. Subsequently, a left bundle area lead was placed. Discussion: Although uncommon, extraction of the tined leadless pacemaker (Micra) may be indicated at times. As rates of implantation continue to increase, establishing uniform procedures for extraction becomes increasingly important. These three cases highlight unique options for Micra extraction, and the feasibility of each approach. However, a dedicated tool and protocol would be ideal for patient safety and consistency. No complications occurred with the above cases.

Background: Transthyretin cardiac amyloidosis (ATTR-CA) carries an elevated risk of developing ventricular arrhythmias (VA) but there remains limited evidence supporting the role of catheter ablation in this population. Purpose: To assess the safety and efficacy of catheter ablation for VA in ATTR-CA. Methods: An electronic database was used to identify all patients suspected of having ATTR-CA who underwent catheter ablation for VA at our institution between January 2010 and December 2023. Patients who did not meet the diagnosis of ATTR-CA and had a negative workup who underwent catheter ablation for ventricular tachycardia (VT) or premature ventricular contractions (PVCs) were used to form a control group matched for age, sex and left ventricular ejection fraction at a ratio of 2:1. Results: 20 controls and 10 cases of ATTR-CA were identified. Examining the two groups at baseline (Table 1), the mean age at index ablation was 67.7±7.0 and 68.6±8.1 years (p=0.359), mean follow-up time was 4.1±3.1 and 4.2±2.6 years (p=0.494), and the proportion of males was 100% and 90% respectively. The ATTR-CA group had a significantly higher proportion of chronic kidney disease (90% vs. 50%, p=0.032) and prior stroke or thrombotic events compared to the control group (50% vs. 10%, p=0.026) with similar CHA 2 DS 2 VASc scores (4.2±1.6 vs. 3.8±1.3, p=0.233). Both groups had comparable left ventricular ejection fraction (41.4%±14% vs. 46.9%±15.2%, p=0.173), VT/PVCs at presentation (40%/60% vs. 25%/75%, p=0.77), use of antiarrhythmics (70% vs. 60%, p=0.592), and high proportion of atrial fibrillation/flutter (70% vs. 90%, p=0.168). Procedural (261.2±101.2 vs. 265.7±125.6 mins, p=0.449) and total energy delivery time (1442.9±1509.1 vs. 1744.6±956.2 secs, p=0.296) was not significantly different in the two groups. Both groups had a significant decrease in PVC burden postablation with a reduction from 26.8% to 3.8% (p=0.024) and from 27.1% to 13.6% (p=0.028) in the ATTR-CA and control group respectively. A downward trend was seen in antitachycardia pacing events for VT postablation in the ATTR-CA (14.7±9.8 vs. 5.3±6.7, p =0.184) and control (193±387.6 vs. 0.67±1.2. p=0.139) groups. No major complications occurred after ablation (Table 2). Mean time to recurrence post-index ablation was similar between both groups (1620.4±483.8 vs. 1498.8±291.4 days, p=0.987, Figure 1). Conclusions: Catheter ablation appears to be safe and effective for VT and PVCs in patients with ATTR-CA.

AbstractIntroductionLittle is known regarding the prevalence and prognostic implications of non‐sustained ventricular tachycardia (NSVT) in patients with wild‐type transthyretin cardiac amyloidosis (ATTRwt‐CA). We aimed to investigate the prevalence of NSVT in patients with ATTRwr‐CA, and the association of NSVT with sustained ventricular arrhythmias (VA) and all‐cause mortality.MethodsIn a cohort of ATTRwt‐CA patients from 2011 to 2022 without prior sustained VA, we ascertained the presence and characteristics of NSVT during clinically indicated ambulatory Holter monitoring. Patients were stratified based on the presence of NSVT at baseline. The primary and secondary endpoints of sustained VA and all‐cause mortality, respectively, were assessed during follow‐up.ResultsThe cohort included 217 patients with ATTRwt‐CA (95% males, median age 75 years; median NYHA class 2). Baseline Holter monitoring demonstrated NSVT in 116 (53%) patients. During a median follow‐up of 27 months (IQR 16–45) after the index Holter monitor, 11 (5.1%) patients reached the primary endpoint of sustained VA (incidence 1.8 per 100 person‐years, all monomorphic VT), and 46 (21%) patients died. In univariable Cox proportional hazard model, NYHA class 3 or 4 heart failure (p = .048), the presence of NSVT (p = .04), the duration of longest NSVT run (p = .029), and the percentage of ventricular ectopy (p < .001) were associated with the primary outcome. When adjusting for age and NYHA class 3 or 4 heart failure, the presence of NSVT remained associated with the primary outcome (p = .03). All‐cause mortality was not significantly different between patients with and without NSVT. A cutoff for ventricular ectopy burden of 0.5%, the median for all patients in this study, was associated with increased risk in sustained VA (log‐rank p = .004) and mortality (log‐rank p = .02).ConclusionNSVT is highly prevalent among ATTRwt‐CA patients undergoing clinically indicated Holter monitoring and may confer an increased risk of incident sustained VA.