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Background: The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject. Objective: To identify CT characteristics associated with increased TLE difficulty. Methods: All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac‐gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead‐removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty. Results: A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell‐in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead‐removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54–10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89–7.35), respectively. Conclusion: In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead‐associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath. [ABSTRACT FROM AUTHOR]

Introduction: Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. Methods and Results: A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all‐cause mortality. Secondary endpoints included atrial‐arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow‐up duration was 32.9 ± 14.5 months. All‐cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% confidence interval [CI] 0.51−0.83, p =.0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all‐cause mortality was observed with CA. Rates of all‐atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40−0.76, p =.0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6−8.8, p <.00001). Conclusion: CA for AF in patients with HF decreases all‐cause mortality, improves all‐atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated. [ABSTRACT FROM AUTHOR]

Purpose: First-line catheter ablation of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with ischemic cardiomyopathy (ICM) has been associated with improved outcomes; however, most benefit seems to be in patients with moderately depressed left ventricular ejection fraction (LVEF). Herein, outcomes were stratified based on LVEF.Methods: A meta-analysis of randomized controlled trials (RCTs) evaluating first-line ablation versus medical therapy in patients with VT and ICM was performed. Risk estimates and 95% confidence intervals (CI) were measured.Results: Four RCTs with a total of 505 patients (mean age 66 ± 9 years, 89% male, 80% with previous revascularization) were included. Mean LVEF was 35 ± 8%. At a mean follow-up of 24 ± 9 months, a significant benefit in survival-free from appropriate implantable cardioverter-defibrillator (ICD) therapies was observed in all patients undergoing first-line catheter ablation compared with medical management (RR 0.70, 95% CI 0.56-0.86). In patients with moderately depressed LVEF (> 30-50%), first-line VT ablation was associated with a statistically significant reduction in the composite endpoint of survival free from VT/VF and appropriate ICD therapies (HR 0.52, 95% CI 0.36-0.76), whereas there was no difference in patients with severely depressed LVEF (≤30%) (HR 0.56, 95% CI 0.24-1.32). Funnel plots did not show asymmetry suggesting lack of bias.Conclusions: Patients with ICM and VT undergoing first-line ablation have a significantly lower rate of appropriate ICD therapies without a mortality difference compared with patients receiving an initial approach based on medical therapy. The beneficial effect of a first-line ablation approach was only observed in patients with moderately depressed LVEF (> 30-50%). [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous epicardial access (EA) was first described more than two decades ago. Since its initial introduction, indications for its utilization in the field of electrophysiology have expanded dramatically. Discussion: Epicardial mapping and ablation in patients with ventricular tachycardia is routinely performed in tertiary electrophysiology centers around the world. Although limited by lack of randomized controlled trials, epicardial ablation for atrial fibrillation has been suggested as a conjunctive strategy in patients who have failed an initial endocardial catheter ablation attempt, and it is necessary for placement of some left atrial appendage occlusion devices as well. An accurate understanding of the cardiac anatomy is crucial to avoid complications such as inadvertent right ventricular puncture, injury to the coronary arteries, abdominal viscera, phrenic nerves, and esophagus during both EA and catheter ablation. Conclusion: The aim of this review is to provide a comprehensive overview of the cardiac anatomy, technical aspects to optimize the safety of epicardial puncture, recognize and avoid potential complications. [ABSTRACT FROM AUTHOR]

Introduction: Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)‐guided ablation is currently used as an adjunct to PVI, evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM‐guided ablation with or without PVI is associated with a decrease in all‐atrial arrhythmia recurrence as compared to PVI alone. Methods: A systematic review of PubMed, Cochrane, and Embase was performed for head‐to‐head study designs comparing outcomes of patients who underwent FIRM‐guided ablation with or without PVI to those who underwent PVI alone. The primary efficacy endpoint was all‐atrial arrhythmia recurrence. The secondary endpoints were complications rates and procedural characteristics. Results: Overall, six studies comprising 674 patients undergoing either FIRM‐guided ablation ± PVI versus PVI were included (mean age 63.4 ± 9.2, male 74%, 9% paroxysmal AF, 91% nonparoxysmal AF). After a mean follow‐up of 18.8 months, FIRM‐guided ablation with or without PVI was not associated with improvement in all‐atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs. 45.9%, risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.77–1.47; p =.70). No statistically significant difference was noted in complication rates between the two groups (RR: 1.66; 95% CI: 0.08–34.54; p =.74). Conclusion: In this meta‐analysis of head‐to‐head comparison studies, FIRM‐guided ablation with or without PVI did not provide any benefit in improving all‐atrial arrhythmia recurrence at follow‐up when compared to PVI alone. [ABSTRACT FROM AUTHOR]

Aims: Left atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation.Methods and Results: A systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42-0.69; P < 0.0001]. A 46% relative risk reduction and 22.9% absolute risk reduction in atrial-arrhythmia recurrence was noted with LAAEI. Rates of cerebral thromboembolism were not significantly different between the two groups (LAAEI 3% vs. standard ablation 1.6%, respectively; RR 1.76; 95% CI 0.61-5.04; P = 0.29). Furthermore, there was no significant difference in the acute procedural complication rates between the two groups (LAAEI 4% vs. standard ablation 3%, respectively; RR 1.29; 95% CI 0.83-2.02; P = 0.26).Conclusion: At long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events. [ABSTRACT FROM AUTHOR]

Purpose: Cardiac involvement with COVID-19 infection has become evident by elevated troponin, cardiac arrhythmias, ST segment elevation, myocarditis, fulminant heart failure, and sudden cardiac death. We aimed to describe the association of COVID-19 and T-wave inversion (TWI) in a large case series. Methods: We conducted an observational, retrospective study of confirmed COVID-19 cases with at least one electrocardiogram (ECG) in a large hospital in New York City (March 23, 2020–April 23, 2020). Patients with new TWI or pseudonormalization were further analyzed. Mortality and the need for invasive mechanical ventilation were the main outcomes. Results: A total of 3225 patients were screened; 195 (6%) were selected for further analysis: 181 with TWI and 14 with T-wave pseudonormalization. Mean age was 66 ± 7 years; 51% were male. TWI were more commonly noted in the lateral (71%), followed by anterior (64%), inferior (57%), and septal (26%) leads. A total of 44 patients (23%) had elevated troponin. A total of 50 patients died (26%). Mortality rates of 35%, and 52% were observed in patients with diffuse TWI, and elevated troponin, respectively. Mortality rate of 80% was observed in patients with both elevated troponin and diffuse TWI. Additionally, 30% of the entire cohort and 58% of patients with elevated troponin required invasive mechanical ventilation. Conclusion: Our study demonstrates that new TWI is a relatively common finding in COVID-19 patients. Importantly, our findings suggest that new TWI or T-wave pseudonormalization, particularly with elevated troponin, was associated with higher rates of mechanical ventilation and in-hospital mortality. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for paroxysmal atrial fibrillation (AF). However, for persistent and long‐standing persistent AF, there are no established strategies to improve the success rate of CA. Despite studies indicating that prophylactic cavotricuspid isthmus (CTI) ablation provides no or limited incremental benefit in patients with AF, it is still routinely performed worldwide. Objective: We sought to examine whether CTI ablation for AF is associated with improvement in recurrence of all‐atrial arrhythmias, compared with PVI alone in patients with and without typical atrial flutter (AFL). Methods: A systematic review of PubMed, Cochrane, and Embase was performed for clinical studies including AF patients, reporting outcomes of CTI + PVI versus PVI alone. The primary efficacy endpoint was recurrence of all‐atrial arrhythmias. Results: Five studies comprising 1400 patients undergoing CTI + PVI versus PVI alone were included; 1110 patients had AF without AFL, and 290 patients had coexistent AF and AFL. After a mean follow‐up of 14.4 ± 4.8 months, CTI + PVI was not associated with improvement in recurrence of all‐atrial arrhythmias when compared with PVI alone (risk ratio [RR]: 1.29; 95% confidence interval [CI]: 0.93–1.79;p =.13). In the subgroup analysis, there were no differences between both groups in patients with AF without AFL (RR: 1.55; 95% CI: 0.96–2.48; p =.07), and in patients with AF and AFL (RR: 0.91; 95% CI: 0.6–1.39; p =.68). Conclusion: In AF patients, irrespective of the presence of typical AFL, additional CTI ablation is not associated with improvement in recurrence of all‐atrial arrhythmias, compared with PVI alone. [ABSTRACT FROM AUTHOR]

Background: The pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt. Objective: The aim of this meta‐analysis is to assess the outcomes of ARVC patients undergoing combined endo‐epicardial VT ablation, as compared to endocardial ablation alone. Methods: A systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo‐epicardial VT ablation vs endocardial‐only VT ablation in patients with ARVC. Fixed‐Effect model was used if I2 < 25 and the Random‐Effects Model was used if I2 ≥ 25%. Results: Nine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow‐up of 48.1 ± 21.5 months, endo‐epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45‐0.75; P <.0001). No significant differences were noted between endo‐epicardial and endocardial VT ablation groups in terms of all‐cause mortality (RR, 1.19; 95% CI, 0.03‐47.08; P =.93) and acute procedural complications (RR, 5.39; 95% CI, 0.60‐48.74; P =.13). Conclusions: Our findings suggest that in patients with ARVC, endo‐epicardial VT ablation is associated with a significant reduction in VA recurrence as opposed to endocardial ablation alone, without a significant difference in all‐cause mortality or acute procedural complications. [ABSTRACT FROM AUTHOR]

Background: Hyponatremia is a well-established poor prognostic marker in patients with heart failure. Whether the mortality risk is comparable among different races of patients with heart failure and hyponatremia is unknown. Materials and methods: Consecutive patients admitted with acute decompensated heart failure and an admission sodium level<135 mEq/L from 1/1/2001 through 12/31/10 were identified. Patients were divided into four groups based on self-reported race: white, African American, Hispanic and other. African Americans were used as the reference group for statistical analysis. The primary outcome was all-cause mortality. Results: We included 4,343 patients, from which 1,356 (31%) identified as white, 1,248 (29%) as African American, 780 (18%) as Hispanic and 959 (22%) as other. During a median follow-up of 23 months, a total of 2,384 patients died: 678 were African American, 820 were white, 298 were Hispanic and 588 were other. After adjusting for baseline demographics, comorbidities and medication use, Hispanic patients had a 45% less risk of death as compared to African Americans (HR .55, CI .48-.64, p<0.05). There was no difference in mortality between white and African American patients (HR 1.04, CI .92–1.2, p = 0.79). Conclusion: Hispanic patients admitted for heart failure and who were hyponatremic on admission had an independent lower risk of mortality compared to other groups. These findings may be due to the disparate activity of the renin-angiotensin-aldosterone system among various racial groups. This observational study is hypothesis generating and suggests that treatment of patients with heart failure and hyponatremia should perhaps be focused more on renin-angiotensin-aldosterone system reduction in certain racial groups, yet less in others. [ABSTRACT FROM AUTHOR]

The authors discuss pericardial drain removal after atrial fibrillation ablation. Topics mentioned include percutaneous pericardiocentesis combined with protamine reversal of systemic heparinization, addition of 4-factor prothrombin complex concentrate in patients undergoing catheter ablation with uninterrupted factor Xa inhibition, and fear of rebleeding and reaccumulation of pericardial fluid necessitating repeat pericardiocentesis.

Two decades ago, a landmark paper identified the pulmonary veins (PVs) as the most frequent trigger source for atrial fibrillation (AF) [[1]]. PW ablation is thought to eliminate potential re-entry and focal triggers for AF, "debulk" the left atrium (LA), re-enforce PVI, and cause autonomic denervation by ablation of ganglionated plexi. Out of 33 patients undergoing redo ablation, 91% of patients had successful PWI with cryoablation alone with the remaining patients requiring adjunct RFA. 26 Kuniss M, Greiss H, Pajitnev D. Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation. [Extracted from the article]