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Background: Early guidance recommended a bolus of intravenous heparin at the beginning of leadless pacemaker (LP) implantation procedures. However, due to concern about bleeding complications, more recent practice has tended toward omitting the bolus and only running a continuous heparin infusion through the introducer sheath. The impact of omitting the heparin bolus on procedural outcomes is not clear. Methods: We reviewed all Medtronic Micra LP implants at our institution from 9/2014 to 9/2022. The decision to bolus with heparin was at operator discretion. Results: Among 621 LP implants, 326 received an intravenous heparin bolus, 243 did not, and 52 patients were excluded because heparin bolus status could not be confirmed. There was a trend toward more frequent omission of the heparin bolus with more recent implants. Median follow‐up after LP implant was 14.3 (interquartile range [IQR]: 8.4–27.9) months. There was no difference between heparin bolus and no bolus groups in the number of device deployments/recaptures (1.42 ± 0.81 vs. 1.31 ± 0.66, p =.15). Implant‐related adverse events were also similar between heparin bolus and no bolus groups: access‐site hematoma requiring intervention (7 vs. 5, p =.99), pseudoaneurysm (1 vs. 1, p =.99), cardiac perforation (1 vs. 1, p =.99), intraprocedural device thrombus formation (2 vs. 4, p =.41), 30‐day rehospitalization (21 vs. 15, p =.98), and 30‐day all‐cause mortality (16 vs. 14, p =.70). There was one additional nonfatal cardiac perforation in a patient who was excluded due to unknown heparin bolus status. Regarding device electrical parameters between heparin bolus and no bolus groups, there were no significant differences at the time of implant: pacing capture threshold 0.5 ± 0.4 vs. 0.5 ± 0.3, p =.10; pacing impedance 739.9 ± 226.4 vs. 719.1 ± 215.4, p =.52; R wave sensing 11.7 ± 5.7 vs. 12.0 ± 5.4, p =.34). Long‐term device performance was also similar between groups. Conclusion: Omission of the systemic heparin bolus at the time of LP implantation appears safe in appropriately selected patients. Heparin bolus may still be considered in long cases requiring multiple device deployments or in patients at high risk for thrombotic complications. [ABSTRACT FROM AUTHOR]

Introduction: Transvenous leads have been implicated in tricuspid valve (TV) dysfunction, but limited data are available regarding the effect of extracting leads across the TV on valve regurgitation. The aim of this study is to quantify tricuspid regurgitation (TR) before and after lead extraction and identify predictors of worsening TR. Methods: We studied 321 patients who had echocardiographic data before and after lead extraction. TR was graded on a scale (0 = none/trivial, 1 = mild, 2 = moderate, 3 = severe). A change of >1 grade following extraction was considered significant. Results: A total of 321 patients underwent extraction of a total of 338 leads across the TV (1.05 ± 0.31 leads across the TV per patient). There was no significant difference on average TR grade pre‐ and postextraction (1.18 ± 0.91 vs. 1.15 ± 0.87; p = 0.79). TR severity increased after extraction in 84 patients, but was classified as significantly worse (i.e., >1 grade change in severity) in only 8 patients (2.5%). Use of laser lead extraction was associated with a higher rate of worsening TR postextraction (44.0% vs. 31.6%, p = 0.04). Conclusion: In our single‐center analysis, extraction of leads across the TV did not significantly affect the extent of TR in most patients. Laser lead extraction was associated with a higher rate of worsening TR after extraction. [ABSTRACT FROM AUTHOR]

Introduction: Permanent pacing indications are common after cardiac surgery and transcatheter structural valve interventions. Leadless pacemakers (LPs) have emerged as a useful alternative to transvenous pacemakers. However, current commercially available LPs are unable to provide atrial pacing or cardiac resynchronization and relatively little is known about LP outcomes after cardiac surgery and transcatheter valve interventions. Methods: This retrospective study included patients who received a Micra VR (MicraTM MC1VR01) or Micra AV (MicraTM MC1AVR1) (Medtronic) leadless pacemaker following cardiac surgery or transcatheter structural valve intervention between September 2014 and September 2022. Device performance and clinical outcomes, including ventricular pacing burden, ejection fraction, and need for conversion to transvenous pacing systems, were evaluated during follow‐up. Results: A total of 78 patients were included, of whom 40 received a Micra VR LP implant, and 38 received a Micra AV LP implant. The mean age of the cohort was 65.9 ± 17.9 years, and 48.1% were females. The follow‐up duration for the entire cohort was 1.3 ± 1.1 years: 1.6 ± 1.3 years for the Micra VR group and 0.8 ± 0.5 years for the Micra AV group. Among the cohort, 50 patients had undergone cardiac surgery and 28 underwent transcatheter structural valve interventions. Device electrical performance was excellent during follow‐up, with a small but clinically insignificant increase in ventricular pacing threshold and a slight decrease in pacing impedance. The mean right ventricle pacing (RVP) burden significantly decreased over time in the entire cohort (74.3% ± 37.2% postprocedure vs. 47.7% ± 40.6% at last follow‐up, p <.001), and left ventricle ejection fraction (LVEF) showed a modest but significant downward trend during follow‐up (55.0% ± 10.6% vs. 51.5% ± 11.2% p <.001). Patients with Micra VR implants had significantly reduced LVEF during follow‐up (54.1% ± 11.9% vs. 48.8% ± 11.9%, p =.003), whereas LVEF appeared stable in the Micra AV group during follow‐up (56.1% ± 9.0% vs. 54.6% ± 9.7%, p =.06). Six patients (7.7%) required conversion to transvenous pacing systems, four who required cardiac resynchronization for drop in LVEF with high RVP burden and two who required dual‐chamber pacemakers for symptomatic sinus node dysfunction. Conclusion: Leadless pacemakers provide a useful alternative to transvenous pacemakers in appropriately selected patients after cardiac surgery and transcatheter structural valve interventions. Device performance is excellent over medium‐term follow‐up. However, a significant minority of patients require conversion to transvenous pacing systems for cardiac resynchronization or atrial pacing support, demonstrating the need for close electrophysiologic follow‐up in this cohort. [ABSTRACT FROM AUTHOR]

Introduction: Hemodynamic decompensation during catheter ablation occurs due to prolonged procedure time and irrigant delivery directly into the cardiac chambers. Real‐time hemodynamic monitoring of patients undergoing catheter ablation procedures may identify patients at risk of decompensation; we set out to assess the feasibility of a novel, real‐time, intracardiac pressure monitoring system using a standard irrigated ablation catheter. Methods: We studied 13 consecutive who underwent pressure measurement of the left atrium (LA) and left ventricle (LV) via transeptal access with a Swan Ganz (SG) catheter followed by two commercially available irrigated ablation catheters. Pressure waveform data was extracted to compare LA peak pressure, LV peak systolic pressure, LV end‐diastolic pressure, and waveform analysis. Results: Comparison between the SG and ablation catheters (AblA; AblB) demonstrated that LV systolic pressure (0.61–16.8 mmHg; 1.32–18.2 mmHg), and LV end‐diastolic pressure (−3.4 to 2.8 mmHg; −3.0 to 3.35 mmHg) were well correlated and had accepted repeatability. Ablation waveforms demonstrated an 89.9 ± 6.4% correlation compared to SG waveforms. Conclusion: Pressure measurements derived from an irrigated ablation catheter are accurate and reliable when compared to an SG catheter. Further studies are needed to determine how real‐time pressure monitoring can improve outcomes during ablation procedures. [ABSTRACT FROM AUTHOR]

Introduction: The Micra Coverage with Evidence Development (CED) Study is a novel comparative analysis of Micra (leadless VVI) and transvenous single‐chamber ventricular pacemakers (transvenous VVI) using administrative claims data. To compare chronic complications, device reinterventions, heart failure hospitalizations, and all‐cause mortality after 3 years of follow‐up. Methods: US Medicare claims data linked to manufacturer device registration information were used to identify Medicare beneficiaries with a de novo implant of either a Micra VR leadless VVI or transvenous VVI pacemaker from March 9, 2017 to December 31, 2018. Unadjusted and propensity score overlap‐weight adjusted Fine‐Gray competing risk models were used to compare outcomes at 3 years. Results: Leadless VVI patients (N = 6219) had a 32% lower rate of chronic complications and a 41% lower rate of reintervention compared with transvenous VVI patients (N = 10 212) (chronic complication hazard ratio [HR] 0.68; 95% confidence interval [CI], 0.59−0.78; reintervention HR 0.59; 95% CI 0.44−0.78). Infections rates were significantly lower among patients with a leadless VVI (<0.2% vs. 0.7%, p <.0001). Patients with a leadless VVI also had slightly lower rates of heart failure hospitalization (HR 0.90; 95% CI 0.84−0.97). There was no difference in the adjusted 3‐year all‐cause mortality rate (HR 0.97; 95% CI, 0.92−1.03). Conclusion: This nationwide comparative evaluation of leadless VVI versus transvenous VVI de novo pacemaker implants demonstrated that the leadless group had significantly fewer complications, reinterventions, heart failure hospitalizations, and infections than the transvenous group at 3 years, confirming that the previously reported shorter‐term advantages associated with leadless pacing persist and continue to accrue in the medium‐to‐long‐term. [ABSTRACT FROM AUTHOR]

Introduction: Micra atrioventricular (AV) provides leadless atrioventricular synchronous pacing by sensing atrial contraction (A4 signal). Real‐world operation and reliability of AV synchrony (AVS) assessment using device data have not been described. The purposes of this study were to (1) assess the correlation between AVS and atrial mechanical sensed‐ventricular pacing (AM‐VP) percentages in patients with permanent high‐degree AV block and (2) report on the real‐world effectiveness of Micra AV. Methods: The correlation between ECG‐determined AVS in‐clinic and device‐collected %AM‐VP was assessed using data from 40 patients with high‐degree AV block enrolled in the Micra Atrial tRacking using a Ventricular AccELerometer (MARVEL) 2 study. A retrospective analysis to assess continuously‐sampled %AM‐VP since last session, device programming, and electrical parameters was performed using Micra AV transmissions from the Medtronic CareLink database. Patients with transmissions ≥180 days postimplant were included. Results: Among the 40 MARVEL 2 AV block patients with a median %VP of 99.7%, AVS was highly correlated with AM‐VP (median AVS 87.1%, median AM‐VP 79.1%; R2 = 0.764, p <.001). The CareLink cohort included 4384 patients programmed to VDD mode. The mean A4 amplitude was 2.3 ± 1.8 m/s2 at implant and 2.3 ± 1.6 m/s2 at 28 weeks. In patients with %VP >90% (n = 1662), the median %AM‐VP was 74.7%. For the full cohort, median %VP was 65.6% and median projected battery longevity was 10.5 years. Conclusion: In patients with a high pacing burden, %AM‐VP provides a reasonable estimation of AVS. The first large real‐world analysis of Micra AV patients with >90% VP showed stable atrial sensing over time with a median %AM‐VP, a correlate of AVS, of 74.7%. [ABSTRACT FROM AUTHOR]

Background: Infection remains a major complication of cardiac implantable electronic devices and can lead to significant morbidity and mortality. Implantable devices that avoid transvenous leads, such as the subcutaneous implantable cardioverter‐defibrillator (S‐ICD), can reduce the risk of serious infection‐related complications, such as bloodstream infection and infective endocarditis. While the 2017 AHA/ACC/HRS guidelines include recommendations for S‐ICD use for patients at high risk of infection, currently, there are no clinical trial data that address best practices for the prevention of S‐ICD infections. Therefore, an expert panel was convened to develop a consensus on these topics. Methods: An expert process mapping methodology was used to achieve consensus on the appropriate steps to minimize or prevent S‐ICD infections. Two face‐to‐face meetings of high‐volume S‐ICD implanters and an infectious diseases specialist, with expertise in cardiovascular implantable electronic device infections, were conducted to develop consensus on useful strategies pre‐, peri‐, and postimplant to reduce S‐ICD infection risk. Results: Expert panel consensus on recommended steps for patient preparation, S‐ICD implantation, and postoperative management was developed to provide guidance in individual patient management. Conclusion: Achieving expert panel consensus by process mapping methodology for S‐ICD infection prevention was attainable, and the results should be helpful to clinicians in adopting interventions to minimize risks of S‐ICD infection. [ABSTRACT FROM AUTHOR]

An editorial is presented which discusses the shift towards same-day discharge (SDD) after various cardiac procedures, including percutaneous coronary intervention (PCI) and cardiac implantable electronic device (CIED) implantation. The article explores the safety and benefits of SDD after transvenous lead extraction (TLE), highlighting factors such as noninfectious indications, early procedure times, good social support, and physician judgment aligning with patient decision.

Introduction: Transvenous implantable cardioverter‐defibrillators (TV‐ICD) infection is a serious complication that frequently requires complete device removal for attempted cure, which can be associated with patient morbidity and mortality. The objective of this study is to assess mortality risk associated with TV‐ICD infection in a large Medicare population with de novo TV‐ICD implants. Methods: A survival analysis was conducted using 100% fee‐for‐service Medicare facility‐level claims data to identify patients who underwent de novo TV‐ICD implantation between 7/2016 and 1/2018. TV‐ICD infection within 2 years of implantation was identified using International Classification of Disease, 10th Edition and current procedural terminology codes. Baseline patient risk factors associated with mortality were identified using the Charlson Comorbidity Index categories. Infection was treated as a time‐dependent variable in a multivariate Cox proportional hazards model to account for immortal time bias. Results: Among 26,742 Medicare patients with de novo TV‐ICD, 518 (1.9%) had a device‐related infection. The overall number of decedents was 4721 (17.7%) over 2 years, with 4555 (17%) in the noninfection group and 166 (32%) in the infection group. After adjusting for baseline patient demographic characteristics and various comorbidities, the presence of TV‐ICD infection was associated with an increase of 2.4 (95% CI: 2.08–2.85) times in the mortality hazard ratio. Conclusion: The rate of TV‐ICD infection and associated mortality in a large, real‐world Medicare population is noteworthy. The positive association between device‐related infection and risk of mortality further highlights the need to reduce infections [ABSTRACT FROM AUTHOR]

Background: The feasibility and outcomes of concomitant atrioventricular node ablation (AVNA) and leadless pacemaker implant are not well studied. We report outcomes in patients undergoing Micra implant with concomitant AVNA. Methods: Patients undergoing AVNA at the time of Micra implant from the Micra Transcatheter Pacing (IDE) Study, Continued Access (CA) study, and Post‐Approval Registry (PAR) were included in the analysis and compared to Micra patients without AVNA. Baseline characteristics, acute and follow‐up outcomes, and electrical performance were compared between patients with and without AVNA during the follow‐up period. Results: A total of 192 patients (mean age 77.4 ± 8.9 years, 72% female) underwent AVNA at the time of Micra implant and were followed for 20.4 ± 15.6 months. AVNA patients were older, more frequently female, and tended to have more co‐morbid conditions compared with non‐AVNA patients (N = 2616). Implant was successful in 191 of 192 patients (99.5%). The mean pacing threshold at implant was 0.58 ± 0.35 V and remained stable during follow‐up. Major complications within 30 days occurred more frequently in AVNA patients than non‐AVNA patients (7.3% vs. 2.0%, p <.001). The risk of major complications through 36‐months was higher in AVNA patients (hazard ratio: 3.81, 95% confidence interval: 2.33–6.23, p <.001). Intermittent loss of capture occurred in three AVNA patients (1.6%), all were within 30 days of implant and required system revision. There were no device macrodislodgements or unexpected device malfunctions. Conclusion: Concomitant AVN ablation and leadless pacemaker implant is feasible. Pacing thresholds are stable over time. However, patient comorbidities and the risk of major complications are higher in patients undergoing AVNA. [ABSTRACT FROM AUTHOR]

Micra leadless pacemaker has progressed from a single chamber pacemaker that can deliver VVIR pacing to a pacing device that can provide atrio‐ventricular (AV) synchrony via a unique pacing algorithm that relies on identifying mechanical atrial contraction. This novel algorithm has its own limitations and intricacies. In this paper, we review this algorithm, suggest steps for troubleshooting and programming these devices and provide clinical examples of Micra AV cases that required changes in programming for adequate tracking of atrial activity. [ABSTRACT FROM AUTHOR]

Background: Data on the management of Micra transcatheter pacing system (TPS) at the time of an upgrade or during battery depletion is limited. Objective: We sought to evaluate the management patterns of patients implanted with a Micra TPS during long‐term follow‐up. Methods: We retrospectively identified patients who underwent Micra implantation from April 2014 to November 2019. We identified patients who underwent extraction (n = 11) or had an abandoned Micra (n = 12). Results: We identified 302 patients who received a Micra during the period of the study. Mean age was 72.7 ± 15.4 years, 54.6% were men, and left ventricular ejection fraction was 51.9 ± 5.2%. Mean follow‐up was 1105.5 ± 529.3 days. Procedural complications included pericardial tamponade (n = 1) treated with pericardiocentesis, significant rise in thresholds (n = 6) treated with reimplantation (n = 4), and major groin complications (n = 2). Indications for extraction included an upgrade to cardiac resynchronization therapy (CRT) device (n = 3), bridging after extraction of an infected transvenous system (n = 3), elevated thresholds (n = 3), and non‐Micra‐related bacteremia (n = 2). The median time from implantation to extraction was 78 days (interquartile range: 14–113 days), with the longest extraction occurring at 1442 days. All extractions were successful, with no procedural or long‐term complications. Indications for abandonment included the need for CRT (n = 6), battery depletion (n = 2), increasing thresholds/failure to capture (n = 3), and pacemaker syndrome (n = 1). All procedures were successful, with no procedural or long‐term complications. Conclusion: In this large single‐center study, 6% of patients implanted with a Micra required a system modification during long‐term follow‐up, most commonly due to the requirement for CRT pacing. These patients were managed successfully with extraction or abandonment. [ABSTRACT FROM AUTHOR]

Background: Women undergoing atrial fibrillation catheter ablation (AFCA) have higher rates of vascular complications and major bleeding. However, most studies have been underpowered to detect differences in rarer complications such as stroke/transient ischemic attack (TIA) and procedural mortality. Methods: We performed a systematic review of databases (PubMed, World of Science, and Embase) to identify studies published since 2010 reporting AFCA complications by sex. Six complications of interest were (1) vascular/groin complications; (2) pericardial effusion/tamponade; (3) stroke/TIA; (4) permanent phrenic nerve injury; (5) major bleeding; and (6) procedural mortality. For meta‐analysis, random effects models were used when heterogeneity between studies was ≥50% (vascular complications and major bleeding) and fixed effects models for other endpoints. Results: Of 5716 citations, 19 studies met inclusion criteria, comprising 244,353 patients undergoing AFCA, of whom 33% were women. Women were older (65.3 ± 11.2 vs. 60.4 ± 13.2 years), more likely hypertensive (60.6% vs. 55.5%) and diabetic (18.3% vs. 16.5%), and had higher CHA2DS2‐VASc scores (3.0 ± 1.8 vs. 1.4 ± 1.4) (p <.0001 for all comparisons). The rates of all six complications were significantly higher in women. However, despite statistically significant differences, the overall incidences of major complications were very low in both sexes: stroke/TIA (women 0.51% vs. men 0.39%) and procedural mortality (women 0.25% vs. men 0.19%). Conclusion: Women experience significantly higher rates of AFCA complications. However, the incidence of major procedural complications is very low in both sexes. The higher rate of complications in women may be partially attributable to older age and a higher prevalence of comorbidities at the time of ablation. More detailed studies are needed to better define the mechanisms of increased risk in women and to identify strategies for closing the sex gap. [ABSTRACT FROM AUTHOR]

Background: Infection is a well‐recognized complication of cardiovascular implantable electronic device (CIED) implantation, including the more recently available subcutaneous implantable cardioverter‐defibrillator (S‐ICD). Although the AHA/ACC/HRS guidelines include recommendations for S‐ICD use, currently there are no clinical trial data that address the diagnosis and management of S‐ICD infections. Therefore, an expert panel was convened to develop consensus on these topics. Methods: A process mapping methodology was used to achieve a primary goal – the development of consensus on the diagnosis and management of S‐ICD infections. Two face‐to‐face meetings of panel experts were conducted to recommend useful information to clinicians in individual patient management of S‐ICD infections. Results: Panel consensus of a stepwise approach in the diagnosis and management was developed to provide guidance in individual patient management. Conclusion: Achieving expert panel consensus by process mapping methodology in S‐ICD infection diagnosis and management was attainable, and the results should be helpful in individual patient management. [ABSTRACT FROM AUTHOR]

Background: Outcomes of catheter ablation for persistent atrial fibrillation (PeAF) are suboptimal. The convergent procedure (CP) may offer improved efficacy by combining endocardial and epicardial ablation. Methods: We reviewed 113 consecutive patients undergoing the CP at our institution. The cohort was divided into two groups based on the presence (n = 92) or absence (n = 21) of continuous rhythm monitoring (CM) following the CP. Outcomes were reported in two ways. First, using a conventional definition of any atrial fibrillation/atrial tachycardia (AF/AT) recurrence lasting >30 seconds, after a 90 day blanking period. Second, by determining AF/AT burden at relevant time points in the group with CM. Results: Across the entire cohort, 88% had either persistent or long‐standing persistent AF, mean duration of AF diagnosis before the CP was 5.1 ± 4.6 years, 45% had undergone at least one prior AF ablation, 31% had impaired left ventricle ejection fraction and 62% met criteria for moderate or severe left atrial enlargement. Mean duration of follow‐up after the CP was 501 ± 355 days. In the entire cohort, survival free from any AF/AT episode >30 seconds at 12 months after the blanking period was 53%. However, among those in the CM group who experienced recurrences, mean burden of AF/AT was generally very low (<5%) and remained stable over the duration of follow‐up. Ten patients (9%) required elective cardioversion outside the 90 day blanking period, 11 patients (9.7%) underwent repeat ablation at a mean of 229 ± 178 days post‐CP and 64% were off AADs at the last follow‐up. Procedural complications decreased significantly following the transition from transdiaphragmatic to sub‐xiphoid surgical access: 23% versus 3.8% (P =.005) Conclusions: In a large, consecutive series of patients with predominantly PeAF, the CP was capable of reducing AF burden to very low levels (generally <5%), which appeared durable over time. Complication rates associated with the CP decreased significantly with the transition from transdiaphragmatic to sub‐xiphoid surgical access. Future trials will be necessary to determine which patients are most likely to benefit from the convergent approach. [ABSTRACT FROM AUTHOR]

Background: There are limited data on cardiac implantable electronic device implantation (CIED) in patients with persistent left superior vena cava (PLSVC). Objective: To describe the outcomes of implanting CIEDs with a focus on cardiac resynchronization therapy (CRT) in patients with PLSVC. Methods: We identified all patients with a PLSVC that underwent CIED implantation from December 2008 until February 2019 at our institution by querying the electronic medical record (n = 34). We then identified controls in a 3:1 fashion (n = 102) by matching on device type (CRT vs non‐CRT). Procedure success, complications, fluoroscopy and procedural time were recorded. Outcomes were compared using a two‐way analysis of variance test and conditional regression modeling for continuous and categorical variables, respectively. Results: A total of 34 patients with PLSVC underwent 38 procedures. Four patients underwent dual chamber system implantation followed by a subsequent upgrade to CRT. Thirteen patients underwent CRT implantation: one was implanted via the right subclavian while the rest were implanted via the PLSVC. Left ventricular (P =.06). Procedure and fluoroscopy times were significantly higher in the PLSVC as compared with the control group (97.7 vs 66.1 minute, P <.001 and 18.1 minute vs 8.7 minutes, P =.005, respectively). Conclusion: CIED implant in patients with PLSVC is feasible but technically more challenging and appears to be associated with higher risk of right ventricular lead dislodgment. [ABSTRACT FROM AUTHOR]

Introduction: Infections of cardiac implantable electronic devices remain a prevalent health concern necessitating the advent of novel preventative strategies. Based on the observation that bacterial infections of the Micra transcatheter pacemaker device are extremely rare, we examine the effect of parylene coating on bacterial adhesion and growth. Methods: Bacterial growth was compared on polyurethane coated, bare, or parylene coated titanium surfaces. Eight test samples per bacterial species and material combination were incubated with Staphylococcus Aureus or Pseudomonas aeruginosa for 24 hours and then assayed for bacterial growth. The surface contact angle was also characterized by measuring the angle between the tangent to the surface of a liquid droplet made with the surface of the solid sample. Results: The mean bacterial colony counts were significantly reduced for both parylene coated titanium versus bare samples (3.69 ± 0.27 and 4.80 ± 0.48 log[CFU/mL] respectively for S. aureus [P <.001] and 5.51 ± 0.27 and 6.08 ± 0.11 log[CFU/mL] respectively for P. aeruginosa [P <.001]), and for parylene coated titanium versus polyurethane samples (4.27 ± 0.42 and 5.40 ± 0.49 log[CFU/mL] respectively for S. aureus [P <.001] and 4.23 ± 0.42 and 4.84 ± 0.32 log[CFU/mL] respectively for P. aeruginosa [P =.006]). Parylene coated titanium samples had a higher contact angle compared with bare titanium, but lower compared with polyurethane (mean contact angle 87.5 ± 3.1 degrees parylene, 73.3 ± 3.7 degrees titanium [P <.001 vs parylene], and 94.8 ± 3.7 degrees polyurethane [P =.002 vs parylene]). Conclusions: Parylene coating significantly reduced the ability of bacteria to grow in colony count assays suggesting that this could contribute to the reduction of bacterial infections of Micra transcatheter pacemakers. [ABSTRACT FROM AUTHOR]

Extraction of transvenous leads via the femoral route might be needed when extraction via the implant vein fails or when retained lead fragments exist. The skill set required for this procedure is unique as it relies on the ability to snare and the use of a variety of shelf tools. In this era of leadless pacing, this skill set might be called upon more frequently. In this article, we review the data, tools, and procedural steps of femoral lead extraction and retrieval/extraction of leadless pacemakers. [ABSTRACT FROM AUTHOR]

Background: The Micra clinical trials have enrolled more than 2500 patients without any reported device‐related infections that required removal during follow‐up. Leadless pacemakers might be more resistant to bacterial seeding due to smaller surface area and a greater tendency for encapsulation. Objective: To analyze the incidence and outcomes of serious infectious events (SIEs: bacteremia or endocarditis) that developed during follow‐up in patients with history of Micra leadless pacemaker implantation. Methods: SIE and outcomes were characterized based upon adverse event reports. Among 720 patients implanted with Micra in the investigational device exemption trial, we identified 16 patients who had documented 21 SIEs during follow‐up. Results: Among patients with SIEs, mean age was 71.9 ± 11.7 years. SIEs occurred at a mean 4.8 ± 4.5 months after implant and patients were followed for 13.1 ± 9.1 months after documentation of SIE. All events were adjudicated as unrelated to the Micra device or procedure. Bacteremia was documented to be related to a gram‐positive organism in 13 events (seven Staphylococcus, three Streptococcus, two Enterococcus, and one uncharacterized gram‐positive bacteria), and gram‐negative organisms in three events. In five events, the type of organism was not characterized (two patients with endocarditis). No persistent cases of bacteremia after antibiotic cessation were seen over the duration of follow‐up Conclusion: In this small series of Micra patients who developed SIEs postimplant, the occurrence of bacteremia and/or endocarditis did not appear to lead to persistent bacteremia off antibiotics; most events resolved with antibiotic treatment. [ABSTRACT FROM AUTHOR]

Background: Implantation of the MICRA Leadless pacemaker requires the use of a 27 French introducer, blunt delivery system and device fixation to the myocardium via nitinol tines. While prior studies have proven its safety, it is unclear whether performing this procedure with uninterrupted anticoagulation exposes patients to increased risks. We sought to investigate the feasibility and safety of continuing therapeutic anticoagulation during the periprocedural period. Methods: We evaluated all patients undergoing MICRA placement at our institution between April 2014 and August 2018 with complete follow‐up data (n = 170). Patients were stratified into two groups: those on active anticoagulation (OAC, n = 26), defined as having an International normalized ratio >2.0 or having continued a direct oral anticoagulant, and those not anticoagulated (Off‐OAC, n = 144). We evaluated for a composite outcome of all major complications, including access site complications and pericardial effusion. Results: OAC and Off‐OAC groups had similar mean age (74 ± 13 vs 75 ± 13 years; P = .914). The OAC group had a nonsignificantly lower prevalence of end‐stage renal disease (8% vs 17%; P = .375) and aspirin use (27% vs 47%; P = .131). Those in the OAC group were more likely to be on warfarin than those in the Off‐OAC group (81% vs 30%; P < .001). The rate of the composite endpoint was similar between the OAC and Off‐OAC groups (3.8 % vs 1.4%, respectively; P = .761). Length of stay was similar between groups (1.3 ± 2.6 vs 2.3 ± 3.4 days; P = 0.108). Conclusion: Continuation of therapeutic anticoagulation during MICRA implantation appears to be feasible, safe and associated with shorter hospitalization among appropriately selected individuals. [ABSTRACT FROM AUTHOR]

Background: Consensus statements on lead extraction give consideration to open surgical removal in the setting of large vegetations, to mitigate the risk of massive embolism that may occur with percutaneous lead removal. Vacuum‐assisted debulking (VD) of large vegetations as an adjunct to percutaneous lead extraction may provide an opportunity to mitigate these risks. Methods: We retrospectively identified all patients undergoing lead extraction at our institution for endovascular infection from 2012 to 2018 and stratified them into two groups based on presence of adjunctive VD (n = 6) or without VD (no‐VD, n = 39). VD was performed with the AngioVac system (Angio‐Dynamics, Latham, NY, USA). Results: Across the cohort, mean age was 62 ± 15 years, ejection fraction was 41 ± 16%, and 39% had end‐stage renal disease on dialysis. Defibrillator systems were present in 71%, and 22% had cardiac resynchronization devices. Mean duration of the oldest extracted lead was 6.3 ± 4.9 years. There were no significant differences in baseline covariates between groups. Those in the VD group were significantly less likely to have Staphylococcus aureus as a causative organism (P =.04). In the VD group, vegetations targeted for debulking ranged in size from 1.8 to 6 cm (longest dimension). There were no operative deaths or clinically evident embolic events in either group. The overall nonfatal complication rate in the VD group was higher (33.3% vs 2.3%, P =.043). Conclusion: : VD can be performed as an adjunct to percutaneous lead extraction with a reasonable safety profile. The relative safety and efficacy of this approach removal requires further study. [ABSTRACT FROM AUTHOR]

Introduction: Leadless pacemakers may provide a safe and attractive pacing option to patients with cardiac implantable electronic device (CIED) infection. We describe the characteristics and outcomes of patients with a recent CIED infection undergoing Micra implant attempt. Methods and Results: Patients with prior CIED infection and device explant with Micra implant within 30 days, were identified from the Micra post approval registry. Procedure characteristics and outcomes were summarized. A total of 105 patients with prior CIED infection underwent Micra implant attempt ≤30 days from prior system explant (84 [80%] pacemakers and 13 [12%] ICD/CRT‐D). All system components were explanted in 93% of patients and explant occurred a median of 6 days before Micra implant, with 37% occurring on the day of Micra implant. Micra was successfully implanted in 99% patients, mean follow‐up duration was 8.5 ± 7.1 months (range 0‐28.5). The majority of patients (91%) received IV antibiotics preimplant, while 42% of patients received IV antibiotics postprocedure. The median length of hospitalization following Micra implant was 2 days (IQR, 1‐7). During follow‐up, two patients died from sepsis and four patients required system upgrade, of which two patients received Micra to provide temporary pacing support. There were no Micra devices explanted due to infection. Conclusion: Implantation of the Micra transcatheter pacemaker is safe and feasible in patients with a recent CIED infection. No recurrent infections that required Micra device removal were seen. Leadless pacemakers appear to be a safe pacing alternative for patients with CIED infection who undergo extraction. [ABSTRACT FROM AUTHOR]

Background: Defibrillation threshold (DFT) testing is recommended with the subcutaneous implantable cardioverter defibrillator (SICD).Objective: To describe first shock efficacy for appropriate SICD therapies stratified by the presence of implant DFT testing.Methods: We reviewed all patients receiving SICDs at our institution and stratified them based on whether implant DFT testing was performed. Appropriate shocks were reviewed to see if ventricular tachycardia/ventricular fibrillation (VT/VF) terminated with a single shock. First shock efficacy was stratified by implant DFT status.Results: 178 patients implanted with SICDs and followed in our center were included in this study. Of these, 135 (76%) underwent DFT testing (DFT(+) group). In the DFT(+), 80 appropriate shocks were needed to treat 69 episodes of VT/VF. The first shock was effective in 61 out of 69 episodes (88.4%), whereas multiple shocks were required to terminate VT/VF in the remaining eight episodes. Among 43 patients without implant DFT testing (DFT(-) group), 20 appropriate shocks to treat 17 episodes of VT/VF occurred in seven patients. VT/VF was successfullyterminated with the first shock in 16 out of 17 episodes (first shock efficacy 94.1%). There was no significant difference in first shock effectiveness between those with and without implant DFT testing (P=0.97).Conclusion: A strategy that omits DFT testing at implant did not appear to compromise the effectiveness of the SICD. These data suggest that routine DFT testing at SICD implant might not be necessary. Randomized trials are needed to confirm this finding. [ABSTRACT FROM AUTHOR]

Background: Atrioventricular junctional (AVJ) ablation and pacemaker implantation are indicated when pharmacotherapy fails to achieve adequate rate control in atrial fibrillation (AF). The purpose of our study is to assess the feasibility and safety of concurrent Micra leadless transcatheter pacemaker implantation and AVJ ablation. Methods:We retrospectively assessed patients who underwent Micra implantation and concurrent AVJ ablation at three institutions between August 2014 and March 2016. All patients and devices were followed at baseline and at 1, 3, 6, and 12months postimplantion. Results: Twenty-one patients with permanent AF (median age 77 [range: 62-88], female 15 [71.4%]) underwent successful Micra implantation followed by concurrent AVJ ablation. There was no device dislodgement or malfunction during the 12-month follow-up. Complete 12-month electrical performance data were available in 14 patients (67%). Among patients with the complete data set, median pacing thresholds at implant and at 1, 3, 6, and 12months were 0.5V(range: 0.25-0.88), 0.44 V (range: 0.25-2.0), 0.5 V (range: 0.25-1.63), 0.5 V (range: 0.25-1.13), and 0.5 V (range: 0.25-1.13) at a pulse width of 0.24 msec, respectively. Two patients died due to noncardiac causes during follow-up. There were no patients with major device-related complications. Conclusions: Concurrent Micra implantation and AVJ ablation is feasible and appears safe. There was no device dislodgement, malfunction, or significant pacing threshold rise requiring device reimplantation during the 12-month follow-up. This combined approach can be considered for patients with AF with suboptimal rate control who have failed AF catheter ablation and/or pharmacotherapy. [ABSTRACT FROM AUTHOR]

Background The efficacy of implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death (SCD) has not been studied in patients with end-stage renal disease (ESRD) and left ventricular dysfunction. We sought to identify predictors of long-term survival among ICD recipients with and without ESRD. Methods Patients implanted with an ICD at our institution from January 2006 to March 2014 were retrospectively identified. Clinical and demographic characteristics were collected. Patients were stratified by the presence of ESRD at the time of ICD implant. Mortality data were collected from the Social Security Death Index (SSDI). Results A total of 3453 patients received an ICD at our institution in the pre-specified time period, 184 (5.3%) of whom had ESRD. In general, ESRD patients were sicker and had more comorbidities. Kaplan Meier survival curve showed that ESRD patients had worse survival as compared with non-dialysis patients ( p <0.001). Following adjustment for differences in baseline characteristics, patients with ESRD remained at increased long-term mortality in the Cox model. The one-year mortality in the ESRD patients was 18.1%, as compared with 7.7% in the non-dialysis cohort ( p <0.001). The three-year mortality in ESRD patients was 43%, as compared with 21% in the non-dialysis cohort ( p <0.001). Conclusion ESRD patients are at significantly increased risk of mortality as compared with a non-dialysis cohort. While the majority of these patients survive more than one year post-diagnosis, the three-year mortality is high (43%). Randomized studies addressing the benefits of ICDs in ESRD patients are needed to better define their value for primary prevention of SCD. [ABSTRACT FROM AUTHOR]

Background Octogenarians account for a significant percentage of patients with indwelling pacemakers or defibrillators. Objectives To determine procedural outcomes and long-term survival after lead extraction (LE) in octogenarians. Methods We retrospectively identified all patients who underwent defibrillator or pacemaker LE at our institution between January 1, 2007 and May 31, 2016. Patients were stratified based on age into two groups: <80 years old (Group 1, n = 674) or ≥80 (Group 2, n = 100). Outcomes were determined by medical records review and query of the Social Security Death Index. Results Patients in Group 2 were more likely to be hypertensive (77% vs 61%, P = 0.02), more like to have coronary artery disease (50% vs 39%, P = 0.049), and more likely to be extracted for infectious indications (47% vs 33%, P = .009). The number of leads extracted per procedure was 2.0 ± 0.8 and the mean dwell time of the oldest extracted lead was 5.6 ± 4.3 years, without significant differences between groups. Extraction procedure success (Group 1: 94.7%, Group 2: 96%, P = 0.808) and procedural deaths (Group 1: 0.9% vs Group 2: 0%, P = 1.0) were similar. There was no significant difference in survival up to 3 years following LE between groups. Conclusion At experienced centers, LE can be performed safely in octogenarians with procedural success rates and long-term survival comparable to younger individuals. [ABSTRACT FROM AUTHOR]

Objectives This study compared risks associated with magnetic resonance imaging (MRI) in patients with non-MRI conditional and MRI conditional pacing and defibrillator systems with particular attention to clinically actionable outcomes. Background While recipients of new MRI conditional pacemaker and defibrillator systems may undergo MRI scanning with very low risk, safety and regulatory concerns persist regarding such scanning in recipients of non-MRI conditional systems. Methods Patients with any cardiac device who were referred for MRI were prospectively enrolled at a single center and underwent scanning at 1.5 Tesla. Pre- and postscan lead characteristic changes, system integrity, and symptoms were analyzed. A comparison was made between non-MRI conditional and MRI conditional devices. Results 105 patients were evaluated allowing for comparison of 97 scans with non-MRI conditional devices and 16 scans with MRI conditional devices. The cohort included those with pacemaker dependency, defibrillator, and cardiac resynchronization devices. Small, nonsignificant changes were observed in lead characteristics following scanning, and there was no significant difference when comparing non-MRI and MRI conditional devices. Lead parameter changes did not require lead revision or programming changes. No device reset, failures, or premature scan termination was observed. Conclusions 1.5 T MRI scanning in patients with MRI conditional and non-MRI conditional cardiac devices was performed with similar, low clinical risk. [ABSTRACT FROM AUTHOR]

Driven in large part by the aging of the population and the increasing prevalence of cardiovascular comorbidities associated with atrial fibrillation ( AF), there is a burgeoning epidemic of AF in elderly adults. Although there is a large body of literature to guide management of people with AF, elderly adults with AF are frequently underrepresented in clinical trials. This review provides a contemporary update on management of elderly adults with AF with a particular focus on the two main clinical challenges that AF poses: stroke risk reduction and control of symptoms. The evidence to support novel AF treatment strategies in elderly adults is reviewed, including novel oral anticoagulants and left atrial appendage closure for stroke risk reduction and catheter ablation for control of symptoms. [ABSTRACT FROM AUTHOR]

Background The UNTOUCHED study will assess the safety and efficacy of the subcutaneous implantable cardioverter defibrillator (S-ICD) in the most common cohort of patients receiving ICDs. The primary goal is to evaluate the inappropriate shock (IAS)-free rate in primary prevention patients with a reduced ejection fraction (EF) and compare with a historical control of transvenous ICD patients with similar programming. Methods and Results The UNTOUCHED study is a global, multicenter, prospective, nonrandomized study of patients undergoing de novo S-ICD implantation for primary prevention of sudden cardiac death with a left ventricular EF ≤35%. The primary end point of this trial is freedom from IAS at 18 months. The lower 95% confidence bound of the observed incidence will be compared to a performance goal of 91.6%, which was derived from the IAS rate in MADIT-RIT. The secondary end points are all-cause shock-free rate at 18 months, and system- and procedure-related complication-free rate at 1 month and 6 months. Enrollment of a minimum of 1,100 subjects from up to 200 centers worldwide is planned based on power calculations of the primary and principal secondary end points. Conclusions This trial will provide important data regarding the rates of inappropriate and appropriate shock therapy in real-world use of the S-ICD in the most common group of patients receiving ICDs. [ABSTRACT FROM AUTHOR]

Leadless Implant Procedure Two major studies have shown that leadless pacemakers are safe and effective for patients requiring right ventricular rate responsive pacing therapy. This positive result recently led to FDA approval of one of the available leadless pacing devices. While this new technology is promising, it requires a different skill set for safe implantation. In this article, we review in detail the different steps required for implantation of tine-based leadless pacemakers while providing tips and tricks to minimize complications. [ABSTRACT FROM AUTHOR]

Background New-onset postoperative atrial fibrillation (POAF) occurs in up to 30% of patients undergoing coronary artery bypass grafting (CABG). POAF is associated with short- and long-term mortality. Methods To identify the true incidence and time course of recurrent atrial fibrillation (AF) in patients with POAF, we prospectively assigned 23 patients with POAF to receive an implantable loop recorder (ILR; Medtronic Inc., Minneapolis, MN, USA) for the detection of recurrent AF. Two electrophysiologists independently adjudicated monthly ILR transmissions to classify recurrent AF. We defined AF as any episode lasting ≥6 minutes. Results The cohort included 23 subjects averaging 69.1 ± 7.2 years of age. Their mean CHADS2 score averaged 1.9 ± 0.8. Note that 26.1% underwent direct current cardioversion prior to discharge; 95.7% left the hospital taking amiodarone and 26.1% warfarin. A total of 14 patients (60.9%) experienced recurrent AF. AF first recurred within 3 months in nine patients (39.1%), and in 10 patients AF emerged or continued beyond 3 months. Eight of 17 (47.1%) patients followed for at least 1 year experienced AF recurrence beyond 1 year of CABG. The time from surgery to first AF episode averaged 143 ± 22.5 days. Long-term monitoring shows that 60.9% of patients with POAF develop recurrent AF. Conclusion POAF may represent a propensity for recurrent paroxysmal atrial fibrillation, and not simply a transient consequence of postoperative stress and inflammation. Better detection of recurrent AF might identify patients at risk for stroke who would benefit from continuing anticoagulation. [ABSTRACT FROM AUTHOR]

Background T wave oversensing (TWOS) is a major drawback of the subcutaneous implantable cardioverter defibrillator (S-ICD). Data on predictors of TWOS in S-ICD recipients are limited. We sought to investigate predictors of TWOS in a cohort of patients receiving an S-ICD at our institution. Methods S-ICD recipients at our center were identified retrospectively and stratified based on the presence or absence of TWOS. Clinical and electrocardiographic parameters were collected and compared between the 2 groups. Results Ninety-two patients underwent an S-ICD implantation at our institution between April 2010 and January 2015. Six (6.5%) patients had TWOS. These patients were younger (38.1±13.7 vs. 52.3±16.1 years, p =0.04) and had higher left ventricle ejection fractions (48.5±14.9% vs. 28.4±12.2%, p <0.01) than patients without a history of TWOS. Baseline 12-lead electrocardiogram (ECG) parameters were not different between the 2 groups. Leads I, II, and avF (which mimic the sensing vectors of the S-ICD) were further inspected to identify ECG characteristics that could predict TWOS. The QRS amplitude in ECG lead I was significantly smaller in the TWOS group than in the non-TWOS group (3.7 vs. 7.4 mV, p =0.02). Conclusion In this study, younger age, higher ejection fraction, and lower QRS amplitude were associated with TWOS. These findings could help identify patients referred for S-ICD at high-risk of TWOS. [ABSTRACT FROM AUTHOR]

Background: St. Jude Riata/Riata ST defibrillator leads (St. Jude Medical, Sylmar, CA, USA) were recalled by the Food and Drug Administration in 2011 for an increased rate of failure. More than 227,000 leads were implanted and at least 79,000 patients still have active Riata leads. Studies have examined clinical predictors of lead failure in Riata leads, but none have addressed the effect of implantable cardioverter defibrillator (ICD) generator exchange on lead failure. The purpose of this study is to assess the effect of ICD generator exchange on the rate of electrical failure in the Riata lead at 1 year. Methods: A retrospective chart review was conducted in patients who underwent implantation of a Riata/Riata ST lead at one center. Patients with a functioning Riata lead (with/without externalized conductor) at the time of ICD exchange were compared to controls with Riata leads implanted for a comparable amount of time who did not undergo generator replacement. Results: Riata leads were implanted in 1,042 patients prior to the recall and 153 of these patients underwent generator exchange without lead replacement. Conductor externalization was noted in 21.5% of Riata leads in the ICD exchange cohort, which was not different from the control group (19.2%; P = 0.32). Two leads failed in the first year after generator replacement (1.5%) which did not significantly differ from the control group (2.0%; P = 0.57). At change-out, 54% received a commanded shock (18.6 ± 0.9 J) that did not result in any change in the high-voltage lead impedance (46.1 ± 1.1 ohms). Conclusions: Conductor externalization was seen frequently in our cohort of patients. ICD generator exchange did not accelerate the rate of Riata lead failure at 1 year. Although both the control and the change-out cohorts failed at a rate much greater than nonrecalled leads, generator exchange did not appear to add to the problem. [ABSTRACT FROM AUTHOR]

Background Little data exist on long-term outcomes following extraction of implantable cardioverter defibrillator (ICD) leads, particularly for noninfectious indications. We sought to identify predictors of long-term survival after ICD lead extraction. Methods We retrospectively reviewed ICD lead extractions at our institution (n = 508). Procedural outcomes and long-term survival were ascertained by medical records review. Results Indication for lead extraction was infection in 32.5% and lead failure in 61.8%. Mean dwell time of the oldest extracted lead was 5.1 ± 5.9 years. Complete procedural success was achieved in 96.5% of cases. Major procedure-related complications occurred in 1.6% with six periprocedural deaths. During a mean follow-up of 866 ± 798 days, survival was significantly worse among patients with infection as the indication for extraction. At 1 year after extraction, survival among those with infection was 88.2%, compared to 95.0% in the lead failure cohort (P < 0.001). Procedural failure was a significant predictor of long-term mortality, even after excluding periprocedural deaths. In multivariate models, the presence of chronic kidney disease, increased number of leads requiring extraction, lower ejection fraction, and procedural failure were predictors of mortality. Conclusion Despite high rates of procedural success, infectious indication for ICD lead extraction is associated with increased long-term mortality. In contrast, among patients undergoing extraction for lead failure, long-term survival was excellent. The presence of procedural failure was a significant predictor of long-term mortality. Further studies will be necessary to better understand the mechanisms by which procedural failure may adversely impact long-term outcomes. [ABSTRACT FROM AUTHOR]

Subcutaneous ICD in Dialysis Patients Background Although the subcutaneous ICD (S-ICD®) is an attractive alternative in patients with end-stage renal disease (ESRD), data on S-ICD outcomes in dialysis patients are lacking. Methods Patients with cardiomyopathy undergoing S-ICD implantation in our center were stratified by need for chronic dialysis at the time of implant. The primary endpoint was incidence of death, heart failure hospitalization or appropriate S-ICD shocks, and secondary endpoints were incidence of inappropriate shocks or implant related complications requiring surgical re-intervention. Mean follow-up was longer in the nondialysis cohort (514 ± 495 vs. 227 ± 233 days, P = 0.006), so all endpoints were analyzed using time-dependent comparisons and reported as annual event rates. Results Out of 79 S-ICD implants included in this analysis, 27 patients were on dialysis. Dialysis patients were older and more likely to be diabetic. Mean ejection fraction across the entire cohort was 26.9% without significant difference between dialysis and nondialysis groups. Although not significant, the incidence of the primary endpoint was higher in the dialysis cohort (23.8%/year vs. 10.9%/year, P = 0.317), driven primarily by a higher rate of appropriate shocks. The rate of inappropriate shocks was similar between groups (dialysis 6.0%/year vs. nondialysis 6.8%/year, P = 0.509). No patients in the dialysis cohort had complications requiring surgical re-intervention versus 6 patients in the nondialysis cohort (P = 0.086). Conclusions Our data suggest that S-ICD implantation in dialysis patients is not associated with an excess risk of implant related complications or inappropriate shocks. [ABSTRACT FROM AUTHOR]

The author discusses a study by Adelstein and colleagues on pacemaker leads performance in their center. He discusses indications that Abbott sensing algorithms are not responsible for the higher rate of noise encountered with Tendril leads, the need of physicians to be proactive about reporting their experience, and an overview of studies assessing performance of tendril lead family.

Modern implantable devices capable of pacing are armed with a multitude of programmable and automated features. While some features represent important advances in device safety and performance, many can also mimic device malfunction. This article discusses these features in terms of the confusion they may cause and highlights important clinical clues that aid in their recognition. [ABSTRACT FROM AUTHOR]

Patent foramen ovale and/or atrial septal aneurysm occur in up to 20% of the general population, and have been linked to cryptogenic ischemic strokes in younger individuals. The pathophysiologic basis of this association remains unclear, with growing evidence suggesting a role for thrombosis and embolization. Aspirin and warfarin constitute the current mainstay of medical therapy, with a variety of secondary prevention studies assessing their impact on stroke recurrence. To date, the quality of published data preclude the development of strict recommendations, but a number of suggestions can be derived from available literature. Patients with isolated patent foramen ovale or atrial septal aneurysm and a first ischemic stroke respond well to either aspirin or warfarin therapy. On the other hand, oral anticoagulation seems to be the preferred medical therapy in higher-risk patients with both patent foramen ovale and atrial septal aneurysm or those with multiple strokes on aspirin. Percutaneous or surgical patent foramen ovale closures have been proposed as alternative therapies and seem effective in reducing stroke recurrence. In the absence of randomized, controlled trials comparing medical and invasive approaches, the adoption of a particular therapy should take into consideration the individual's preference, clinical presentation, risk profile, lifestyle, and the expertise of the local interventional and surgical teams. [ABSTRACT FROM AUTHOR]

Background Objective Methods Results Conclusion Most studies of device‐detected atrial fibrillation (AF) have recommended indefinite anticoagulation once a patient crosses a particular threshold for AF duration or burden. However, durations and burdens are known to fluctuate over time, but little is known about the magnitude of spontaneous fluctuations and the potential impact on anticoagulation decisions.To quantify spontaneous fluctuations in AF duration and burden in patients with implantable loop recorders (ILRs)We reviewed all ILR interrogations for patients with non‐permanent AF at our institution from 2018 to 2023. We excluded patients treated with rhythm control. The duration of longest AF episode at each interrogation was classified as < 6, 6–24, and > 24 h, and the AF burden reported at each interrogation was classified as < 2%, 2%–11.4%, and > 11.4%.Out of 156 patients, the mean age at ILR implant was 70.9 ± 12.5 years, CHA2DS2‐VASc score was 4.2 ± 1.8, duration of ILR follow‐up was 23.4 ± 11.2 months, and number of ILR interrogations per patient was 18.0 ± 8.9. The duration of longest AF episode at any point during follow‐up was < 6 , 6–24 , and > 24 h in 110, 30, and 16 patients, respectively. Among the 30 patients with a longest AF episode of 6–24 h at some point during follow‐up, out of 594 total ILR interrogations, only 75 (12%) showed a longest episode of 6–24 h. In the remaining 519 interrogations, the longest episode was < 6 h. In patients with a longest episode of > 24 h at any point during follow‐up (n = 16), only 47 out of 320 total ILR interrogations (15%) showed an episode of > 24 h. When evaluating AF burden, 96, 38, and 22 patients had maximum reported AF burdens of < 2%, 2%–11.4%, and > 11.4% at any point during ILR follow‐up. Among those with a maximum burden of 2%–11.4% at some point during follow‐up (n = 38), out of 707 ILR interrogations, only 76 (11%) showed a burden of 2%–11.4%. In the remaining 631 interrogations, the burden was < 2%. In the 22 patients with a burden > 11.4% at some point during follow‐up, only 80 out of 480 interrogations (17%) showed a burden of > 11.4%. In 65% of interrogations, the burden was < 2%.Significant, spontaneous fluctuations in AF burden and duration are common in patients with ILRs. Even in patients with AF episodes of 6–24 h or > 24 h at some point during follow‐up, the vast majority of interrogations show episodes of < 6 h. Similarly, in patients with burdens of 2%–11.4% or > 11.4% at some point during follow‐up, the vast majority of interrogations show burdens of < 2%. More data are needed to determine whether crossing an AF burden or duration threshold once is sufficient to merit lifelong anticoagulation or whether spontaneous fluctuations in AF burden and duration should impact anticoagulation decisions. [ABSTRACT FROM AUTHOR]

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common supraventricular tachycardia. Ablation of the slow pathway is the treatment of choice for recurrent episodes despite adequate medical therapy. We present an uncommon case of AVNRT ablation using a superior vena cava approach in a patient with bilateral common femoral vein occlusion. This approach appears to be a safe alternative in patients with an absence of an inferior venous access. [ABSTRACT FROM AUTHOR]

The author presents a case of ischemic cardiomyopathy in a man with a dual chamber implantable cardioverter defibrillator. Analysis of stored information in the device raised concerns about sensing abnormalities that were found to be due to a misalignment of marker notations. Concerns about misdiagnosis are discussed.

The article describes the condition of a 36-year-old man who had palpitations since his childhood and was evaluated via an electrophysiologic study. The mechanism of tachycardia, atrial stimulation, atypical atrioventricular nodal reentrant tachycardia, low septal atrial tachycardia, and orthodromic reciprocating tachycardia, a conducting accessory pathway, and premature ventricular contraction are discussed.