Madhavan, Malini

Background Incidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices ( CIED s). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack ( TIA ), or systemic embolism after transseptal ablation in patients with and without CIED s. Methods and Results Using a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity‐matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA 2 DS 2 ‐Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIED s). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA , or systemic embolism for patients with and without CIED s. Impact of oral anticoagulation ( OAC ) use on the endpoint was examined. Over a mean follow‐up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person‐years in patients with CIED s and 1.5 per 100 person‐years in patients without CIED s ( P =0.03). Among patients not on OAC , presence of a cardiac device was associated with an increased risk (hazard ratio [ HR ], 1.71 [1.24–2.35]; P <0.01), whereas there was no association noted among patients treated with OAC ( HR , 0.98 [0.75–1.28]). Conclusion CIED s are associated with an increased risk of stroke, TIA , or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post‐transseptal ablation in patients with CIED warrants further investigation.

BackgroundEndocardial ablation of atrial ganglionated plexi (GP) has been described for treatment of atrial fibrillation (AF). Our objective in this study was to develop percutaneous epicardial GP ablation in a canine model using novel energy sources and catheters.MethodsPhase 1: The efficacy of several modalities to ablate the GP was tested in an open chest canine model (n = 10). Phase 2: Percutaneous epicardial ablation of GP was done in six dogs using the most efficacious modality identified in phase 1 using two novel catheters.ResultsPhase 1: Direct current (DC) in varying doses (blocking [7–12 μA], electroporation [300–500 μA], ablation [3,000–7,500 μA]), radiofrequency ablation (25–50 W), ultrasound (1.5 MHz), and alcohol (2–5 mL) injection were successful at 0/8, 4/12, 5/7, 3/8, 1/5, and 5/7 GP sites. DC (500–5,000 μA) along with alcohol irrigation was tested in phase 2. Phase 2: Percutaneous epicardial ablation of the right atrium, oblique sinus, vein of Marshall, and transverse sinus GP was successful in 5/6 dogs. One dog died of ventricular fibrillation during DC ablation at 5,000 μA. Programmed stimulation induced AF in six dogs, preablation and no atrial arrhythmia in three, flutter in one, and AF in one postablation. Heart rate, blood pressure, effective atrial refractory period, and local atrial electrogram amplitude did not change significantly postablation. Microscopic examination showed elimination of GP, and minimal injury to atrial myocardium.ConclusionPercutaneous epicardial ablation of GP using DC and novel catheters is safe and feasible and may be used as an adjunct to pulmonary vein isolation in the treatment of AF in order to minimize additional atrial myocardial ablation.

AbstractIntroductionThe objective of our study was to investigate cross‐sectional associations of atrial fibrillation with neuroimaging measures of cerebrovascular disease and Alzheimer's disease and their interactions with mild cognitive impairment (MCI).MethodsMagnetic resonance imaging scans of individuals from a population‐based study were analyzed for infarctions, total gray matter, and hippocampal and white matter hyperintensity volumes. A subsample underwent positron emission tomography imaging.ResultsAtrial fibrillation was associated with infarctions and lower total gray matter volume. Compared with subjects with no atrial fibrillation and no infarction, the odds ratio (95% confidence intervals) for MCI was 2.99 (1.57–5.70; P = .001) among participants with atrial fibrillation and infarction, 0.90 (0.45–1.80; P = .77) for atrial fibrillation and no infarction, and 1.50 (0.96–2.34; P = .08) for no atrial fibrillation and any infarction.DiscussionParticipants with both atrial fibrillation and infarction are more likely to have MCI than participants with either infarction or atrial fibrillation alone.

Background Survivors of ventricular fibrillation out of hospital cardiac arrest ( VF ‐ OHCA ) due to a potentially reversible cause such as acute myocardial infarction (MI) or ischemia are considered to be at low risk of recurrent arrhythmia. Implantable cardioverter defibrillators ( ICD ) are not routinely recommended in such patients. However, the outcome of these patients in the era of rapid coronary revascularization and ICD therapy is not known. Methods and Results We examined the outcome of 114 consecutive survivors of VF OHCA due to acute MI or ischemia in Olmsted County, MN from 1990 to 2011. An ICD was implanted in 45/114 patients. ICD recipients had lower EF [median ( IQR ) 38 (26 to 54) versus 48 (35 to 58) %, P =0.04]. During a median ( IQR ) follow‐up of 9.9 (4.4 to 14.6) years, ICD implantation was associated with reduced cardiac mortality ( HR 0.24 [0.07 to 0.88], P =0.031) and a trend towards reduced all‐cause mortality ( HR 0.56 [0.30 to 1.02], P =0.059) after adjusting for the first principal component. One or more appropriate ICD therapies were delivered in 19/45, with half of the patients receiving therapy within 1 year. Patients with EF ≤35% at discharge continued to be at long‐term risk for ICD therapy compared with those with EF >35% who were at increased risk predominantly in the first 8 months. EF and revascularization were not significantly associated with ICD therapy in the multivariable analysis. Conclusions Patients with VF ‐ OHCA in the setting of acute MI or myocardial ischemia remain at high risk of recurrent ventricular arrhythmias, particularly if EF ≤35%. This suggests that ICD implantation may be reasonable if EF ≤35%.

Arrhythmogenic Substrate of Ventricular Arrhythmias at the AMCIntroductionCatheter ablation of ventricular arrhythmia (VA) at the fibrous aortic mitral continuity (AMC) has been described, yet the nature of the arrhythmogenic substrate remains unknown.MethodsProcedural records of 528 consecutive patients undergoing ablation of VA at Mayo Clinic, Rochester, MN, were reviewed. The electrocardiographic and electrophysiologic characteristics of patients with successful ablation at the AMC were analyzed to characterize the underlying arrhythmogenic substrate.ResultsOf the 21 patients (mean age 53.2 ± 13.4 years, 47.6% male) who underwent ablation of VA at the AMC with acute success, prepotentials (PPs) were found at the ablation sites preceding the ventricular electrogram (VEGM) during arrhythmias in 13 (61.9%) patients and during sinus rhythm in 7 (53.8%) patients. VAs with PPs were associated with a significantly higher burden of premature ventricular complexes (PVCs; 26.1 ± 10.9% vs. 14.9 ± 10.1%, P = 0.03), shorter VEGM to QRS intervals (9.0 ± 28.5 milliseconds vs. 33.1 ± 8.8 milliseconds, P = 0.03), lower pace map scores (8.7 ± 1.6 vs. 11.4 ± 0.8, P = 0.001), and a trend toward shorter V‐H intervals during VA (32.1 ± 38.6 milliseconds vs. 76.3 ± 11.1 milliseconds, P = 0.06) as compared to those without PP. A strong and positive correlation was found between V‐H interval and QRS duration during arrhythmia in those with PPs (B = 2.11, R2 = 0.97, t = 13.7, P < 0.001) but not in those without PPs.ConclusionLocal EGM characteristics and relative activation time of the His bundle suggest the possibility of conduction tissue as the origin for VA arising from the fibrous AMC. Specific identification and targeting of PPs when ablating VAs at this location may improve procedural success.

RVOT Atypical VariantsBackgroundRight ventricular outflow tract (RVOT) arrhythmias are a common form of ventricular tachycardia (VT) in patients with structurally normal heart. The underlying mechanism is due to triggered activity. Mapping and ablation is relatively straightforward targeting the earliest point of activation. Previously reported causes of difficult ablation in the RVOT region include under recognized right ventricular cardiomyopathy/sarcoidosis, presence of endocavitary structures, close proximity to the coronary vasculature, and origin from non‐RVOT structures.Methods and ResultsWe identified all patients undergoing PVCs/sustained RVOT VT ablation from January 2013 to December 2013. This included 33 patients. Of these, we identified procedures that were considered difficult despite a single morphology arrhythmia being targeted and no underlying cardiomyopathy present. Difficulty was specifically considered when ablation at the earliest site of activation was not successful and eventual successful ablation was at a distance of greater than 15 mm from the early activation site. We identified 3 patients (n = 3, 100% male) with evidence of reentrant arrhythmia based on slow conduction zones necessary for the tachycardia/arrhythmia, mid diastolic signals during VT or preceding bigeminal PVCs, pace mapping from the site abnormal signals reproducing the arrhythmia morphology but with prominent conduction delay, the entire cycle length of the tachycardia or coupling interval for the PVCs being mapping, or based on reset characteristics.ConclusionIn patients with atypical forms of RVOT VT, careful mapping and ablation of the myocardial sleeves near the pulmonic valve can eliminate the arrhythmia.

Renal Vein Stimulation Increases Blood PressureBackgroundNeurocardiogenic syncope (NCS) is a common and sometimes debilitating disorder, with no consistently effective treatment. NCS is due to a combination of bradycardia and vasodilation leading to syncope. Although pacemaker devices have been tried in treating the bradycardic aspect of NCS, no device‐based therapy exists to treat the coexistent vasodilation that occurs. The renal sympathetic innervation has been the target of denervation to treat hypertension. We hypothesized that stimulation of the renal sympathetic nerves can increase blood pressure and counteract vasodilation in NCS.Methods and ResultsHigh‐frequency stimulation (800–900 pps, 10 V, 30–200 seconds) was performed using a quadripolar catheter in the renal vein of 7 dogs and 1 baboon. A significant increase in blood pressure (BP; mean [SD] systolic BP 117 [±28] vs. 128 [±33], diastolic BP 75 [±19] vs. 87 [±29] mmHg) was noted during the stimulation, which returned to baseline after cessation of stimulation. The mean increase in systolic and diastolic BP was 13.0 (±3.3) (P = 0.006) and 10.2 (±4.6) (P = 0.08), respectively.ConclusionWe report the first ever study of feasibility and safety of high‐frequency electrical stimulation of the renal sympathetic innervation to increase BP in animal models. This has potential applications in the treatment of hypotensive states such as NCS.

Electromagnetic Interference with Ventricular Assist DeviceBackgroundHemodynamic instability hinders activation and entrainment mapping during ventricular tachycardia ablation. The Impella 2.5 microaxial flow device (MFD; Abiomed Inc., Danvers, MA, USA) is used to prevent hemodynamic instability during electrophysiologic study. However, electromagnetic interference (EMI) generated by this device can preclude accurate electroanatomic mapping.MethodsImpella was placed in the left ventricle of 7 canines for circulatory support. Electroanatomic mapping during sinus rhythm, ventricular pacing, and ventricular fibrillation (VF) was performed using magnet‐ (CARTO3, Biosense Webster Inc., Diamond Bar, CA, USA) and impedance‐ (EnSite Velocity System/EnSite NavX, St. Jude Medical Inc., St. Paul, MN, USA) based systems. Distance from device to points with severe EMI precluding acquisition was compared to points with mild/no EMI. Two methods were used to reduce EMI: (1) titration of MFD performance, and (2) impedance‐only mapping combined with manual annotation of activation.ResultsSevere EMI did not occur during impedance‐based mapping. Severe EMI was observed using CARTO3 at 9.4% of all points attempted at maximum performance level (P8) of device. Severe EMI occurred at points closer to device (40.1 ± 16.8 mm) versus (55.5 ± 20.0 mm) for mild/no EMI, P < 0.0001. Severe EMI using CARTO3 was resolved by either (1) reduction of performance from P8 to P6 or (2) impedance‐only mapping with manual annotation.ConclusionConcurrent use of MFD caused EMI to prevent acquisition of points with magnet‐based mapping. Predictors for EMI were distance from device and performance level. Temporary reductions to P6 or impedance‐only mapping are 2 methods to resolve EMI.

BackgroundEndocardial ablation approaches targeting the retroatrial cardiac ganglia to treat atrial fibrillation (AF) have been proposed. However, the potential value using this approach is unknown. Disruption of the autonomic inputs with orthotropic heart transplant (OHT) provides a unique opportunity to study the effects of autonomic innervation on AF genesis and maintenance. We hypothesized that due to denervation, the risk of postoperative AF would be lower following OHT compared to surgical maze even though both groups get isolation of the pulmonary veins.Methods and ResultsWe reviewed 155 OHTs (mean age 52 ± 11 years, 72% males) and used 1:1 age‐, sex‐, and date‐of‐surgery‐matched two control groups from patients undergoing surgical maze or only coronary artery bypass grafting (CABG). Using conditional logistic regression we compared the odds of AF within 2 weeks following OHT versus controls. Postoperative AF occurred in 10/155 (6.5%) OHT patients. The conditional odds of postoperative AF were lower for OHT as compared to controls (vs maze: odds ratio [OR] 0.27 [95% confidence interval (CI) 0.13–0.57], vs CABG: OR 0.38 [0.17–0.81], P = 0.003; and on additional adjustment for left atrial enlargement, vs maze: OR 0.28 [0.13–0.60], vs CABG: OR 0.14 [0.04–0.47], P = 0.0009).ConclusionsRisk of postoperative AF is significantly lower with OHT as in comparison to surgical maze. As both surgeries entail isolation of the pulmonary veins but only OHT causes disruption of autonomic innervation, this observation supports a mechanistic role of autonomic nervous system in AF. The benefit of targeting the cardiac autonomic system to treat AF needs further investigation.