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Very high power short duration (vHPSD) radiofrequency ablation (RFA) may reduce ablation times and improve patient tolerability, permitting pulmonary vein isolation (PVI) under mild conscious sedation (mCS) and promoting same day discharge (SDD).First, a retrospective feasibility study was performed at 2 tertiary cardiac centres in the UK. Consecutive cases of first-time PVI using vHPSD ablation with 90 W lesions for up to 4 s were compared against cases performed using standard RF (sRF) and cryoballoon (Cryo) therapy. Subsequently, a prospective study of patients who had vHPSD or Cryo exclusively under mCS was undertaken. Questionnaires based on Likert and visual analogue scales (VAS) were used to measure anxiety, discomfort and pain.In total, 182 patients (59 vHPSD, 62 sRF and 61 Cryo) were included in the retrospective study, with 53 (90%) of vHPSD cases successfully performed under mCS. PVI ablation time in the vHPSD group (5.8 ± 1.7 min) was shorter than for sRF (16.5 ± 6.3 min, p 0.001) and Cryo (17.5 ± 5.9 min, p 0.001). Fifty-one vHPSD and 52 Cryo patients were included in the prospective study. PVI ablation time in the vHPSD group was shorter than for the Cryo group (6.4 ± 2.9 min vs 17.9 ± 5.7 min, p 0.001), but overall procedure duration was longer (121 ± 39 min vs 95 ± 20 min, p 0.001). There were no differences in the patient experience of anxiety, discomfort or pain. SDD rates were the same in both groups (61% vs 67%, p = 0.49).vHPSD RFA for PVI can be performed under mCS to achieve SDD rates comparable to cryoablation, without compromising patient experience.

Background Ebstein’s anomaly is a rare condition due to incomplete delamination of the tricuspid valve (TV) leaflets with downward displacement of the proximal leaflet attachments. It is associated with a smaller functional right ventricle (RV) and tricuspid regurgitation (TR) that is typically treated with TV replacement or repair. However, future re-intervention poses challenges. We describe a multidisciplinary team approach to re-intervention in a pacing-dependant Ebstein patient with severe bioprosthetic TV regurgitation. Case summary A 49-year-old female patient underwent bioprosthetic TV replacement for severe TR in Ebstein’s. Post-operatively, she developed complete atrioventricular (AV) block necessitating the implantation of a permanent pacemaker which included a coronary sinus (CS) lead as the ventricular lead. Five years later, she presented with syncope due to a failing ventricular pacing lead, and a new RV lead was positioned across the TV bioprosthesis due to the lack of CS options. Two years later, she presented with breathlessness and lethargy with severe TR identified on transthoracic echocardiography. She successfully underwent a percutaneous leadless pacemaker implant, extraction of existing pacing system, and implantation of valve-in-valve TV. Discussion Patients with Ebstein’s anomaly typically undergo TV repair or replacement. Following surgical intervention, owing to the anatomical location, patients can develop AV block requiring a pacemaker. Pacemaker implantation may involve a CS lead to avoid placing a lead across the new TV in efforts to avoid lead induced TR. Over time, these patients not uncommonly require re-intervention that can be challenging especially in pacing-dependant patients with leads across the TV.

Ischaemic heart disease remains a leading cause of premature mortality and morbidity. Understanding the associated pathophysiological mechanisms of cardiac dysfunction arising from ischaemic heart disease and the identification of sites of novel therapeutic intervention requires a preclinical model that reproduces the key clinical characteristics of myocardial ischaemia, reperfusion and infarction. Here we describe and validate a refined and minimally invasive translationally relevant approach to induce ischaemia, reperfusion and infarction in the sheep. The protocol uses clinical cardiology devices and approaches and would be readily adopted by researchers with access to standard fluoroscopic instrumentation. In addition to being minimally invasive, the major refinements associated with the described methodology are the implantation of an intracardiac defibrillator prior to coronary engagement and use of an antiarrhythmic medication protocol during the procedure. These refinements lead to a reduction of intraoperative mortality to 6.7 %. The model produces key characteristics associated with the 4thUniversal Definition of Myocardial Infarction including electrocardiographic changes, elevated cardiac biomarkers and cardiac wall motility defects. In conclusion, the model closely replicates the clinical paradigm of myocardial ischaemia, reperfusion and infarction in a translationally relevant large-animal setting and the applied refinements reduce the incidence of intraoperative mortality typically associated with preclinical myocardial infarction models.

The highly organized transverse tubule (t-tubule) network facilitates cardiac excitation–contraction coupling and synchronous cardiac myocyte contraction. In cardiac failure secondary to myocardial infarction (MI), changes in the structure and organization of t-tubules result in impaired cardiac contractility. However, there is still little knowledge on the regional variation of t-tubule remodelling in cardiac failure post-MI. Here, we investigate post-MI t-tubule remodelling in infarct border and remote regions, using serial block face scanning electron microscopy (SBF-SEM) applied to a translationally relevant sheep ischaemia reperfusion MI model and matched controls. We performed minimally invasive coronary angioplasty of the left anterior descending artery, followed by reperfusion after 90 min to establish the MI model. Left ventricular tissues obtained from control and MI hearts eight weeks post-MI were imaged using SBF-SEM. Image analysis generated three-dimensional reconstructions of the t-tubular network in control, MI border and remote regions. Quantitative analysis revealed that the MI border region was characterized by t-tubule depletion and fragmentation, dilation of surviving t-tubules and t-tubule elongation. This study highlights region-dependent remodelling of the tubular network post-MI and may provide novel localized therapeutic targets aimed at preservation or restoration of the t-tubules to manage cardiac contractility post-MI. This article is part of the theme issue ‘The cardiomyocyte: new revelations on the interplay between architecture and function in growth, health, and disease’.

The highly organised transverse tubule (t-tubule) network consisting of invaginations of the cell sarcolemma facilitates synchronous cardiac myocyte contraction. This study aimed to investigate post-myocardial infarction (MI) t-tubule remodelling in infarct border and remote regions in a translationally relevant ischaemia reperfusion injury MI model. Six adult sheep were used in this study (n=3 MI, n=3 control). Eight weeks after MI, left ventricular tissue was collected from the remote and border MI regions and from control sheep, processed and imaged using 3D scanning electron microscopy. The t-tubule network was manually segmented using 3dmod. One-way ANOVA with Tukey’s post-hoc correction, unpaired t-tests or Mann-Whitney U test were used where appropriate. Marked disorganisation of the t-tubule network was observed in the border region following MI. Quantitative analysis revealed that in comparison to the control sheep myocardium, the MI border zone had a decreased t-tubule count (0.07 ± 0.007 tubules per μm3 in control vs 0.05 ± 0.004 tubules per μm3 in border; p = 0.02) and showed t-tubule dilation (405 ± 22 nm in control vs 533 ± 30 nm in border; p = 0.02). Whilst there was minimal disorganisation and loss of t-tubules in the MI remote region, we observed increased t-tubule length as a fraction of the cell diameter (0.41 ± 0.04 in control vs 0.56 ± 0.04 in remote; p = 0.045). In addition to gross t-tubule remodelling, we also noted post-MI fragmentation of t-tubules, particularly in the border region. In comparison to control, the number of t-tubule fragments per μm3 was increased in the post MI heart (control, 0.17 ± 0.1 fragments per μm3; border, 2.21 ± 0.7 fragments per μm3; remote, 1.20 ± 0.4 fragments per μm3; p = 0.04 border vs control; p = 0.02 remote vs control). The volume occupied by fragments as a percentage of the cell volume was also higher following MI (control, 0.003 ± 0.002 %; border, 0.071 ± 0.023 %; remote 0.014 ± 0.005 %; p = 0.003 border vs control; p = 0.013 border vs remote). Whilst there was no difference in fragments density between the remote and border regions, there was an increase in the volume of cell occupied by fragments in the MI border region compared to remote. This is explained by a larger average fragment volume in the border region (0.04 ± 0.006 μm3 in border vs 0.01 ± 0.002 μm3 in remote; p Our research shows remodelling of the t-tubule network in the post-MI sheep myocardium. We noted reduced t-tubule count, t-tubule fragmentation, and dilation of remaining t-tubules. Importantly our work shows that these changes occur in a regional manner, being most pronounced in the border region. These changes may reflect regional wall stresses post-MI, and we speculate that our observations may result in region-specific changes to systolic calcium and contractility post-MI. Conflict of Interest Authors declare that there is no conflict of interest.

ObjectiveAtrial fibrillation (AF) ablation services were significantly affected by the COVID-19 pandemic. We aimed to evaluate a symptom-based clinician prioritisation scheme for waiting list management compared with patient-completed quality of life (QoL) scores. We also sought to understand factors influencing QoL, particularly the impact of COVID-19, on patients awaiting AF ablation, via a bespoke questionnaire.MethodsPatients awaiting AF ablation were sent two QoL questionnaires (Atrial Fibrillation Effect on QualiTy of Life (AFEQT) and EuroQol 5D (EQ5D-5L)) and the bespoke questionnaire. At a separate time point, patients were categorised as C1—urgent, C2—priority or C3—routine by their cardiologist based on review of clinic letters.ResultsThere were 118 patients included with priority categorisation available for 86 patients. Median AFEQT scores were lower in C2 (30.4; 17.2–51.9) vs C3 patients (56.5; 32.1–74.1; pConclusionThe QoL of patients awaiting AF ablation is impaired and AFEQT helps to identify patients at risk of admission, over and above physician assessment. COVID-19 influenced patients seeking medical attention with symptomatic AF when they normally would. Regular exercise is associated with better QoL in patients awaiting AF ablation.

TITLE PAGE TITLE : LEVEL OF BLOCKDESCRIPTION :Electrograms recorded from an electrophysiological study and ablation of manifest left lateral accessory pathway with demonstration of site of block during the case.

Background Patients requiring congenital and structural heart interventions often require large-sized sheath insertion into femoral veins and arteries. Clinical outcome data on the use of suture-mediated devices for femoral venous access site closure are limited. Objective To assess the efficacy and safety of the Perclose™ (Abbott Vascular Devices, CA) suture-mediated device using the preclosure technique, in achieving haemostasis at femoral venous access site following large sheath insertion (≥8 Fr). Design and Setting Two hundred and forty-three consecutive patients underwent 310 access site closures with the Perclose™ device using the preclosure technique. There were 151 (62%) women, mean age 43 (±16) years. 234/243 (96%) received heparin. Mean venous access site sheath diameter was 11.5 (±3) Fr. Results Immediate haemostasis (

Patients requiring congenital and structural heart interventions often require large-sized sheath insertion into femoral veins and arteries. Clinical outcome data on the use of suture-mediated devices for femoral venous access site closure are limited.To assess the efficacy and safety of the Perclose™ (Abbott Vascular Devices, CA) suture-mediated device using the preclosure technique, in achieving haemostasis at femoral venous access site following large sheath insertion (≥8 Fr).Two hundred and forty-three consecutive patients underwent 310 access site closures with the Perclose™ device using the preclosure technique. There were 151 (62%) women, mean age 43 (±16) years. 234/243 (96%) received heparin. Mean venous access site sheath diameter was 11.5 (±3) Fr.Immediate haemostasis (2 min) was achieved in 304/310 (98%) sites. No patients had major complications. Short-term follow-up at 3 months revealed no evidence of haematoma or fistula formation or clinical evidence of vessel occlusion. On medium-term clinical follow-up (mean follow-up of 14 ± 12 and median of 12.4 months), no complications were seen at the venous access sites.Preclosure of large-size femoral venous access sheath sites using the suture-mediated Perclose™ device is efficacious in achieving rapid haemostasis in the presence of anticoagulation in the venous site. On 1-year follow-up, there was no clinical evidence of vascular complications in the venous access sites.

Report by: Charlene Pius , Foundation House Officer Search checked by: Margaret Maloba , Consultant in Emergency Medicine Institution : Royal Albert Edward Infirmary, Wigan, UK A short-cut review was carried out to establish whether repeated administration of chlordiazepoxide for the symptoms of alcohol withdrawal actually promotes further fits (the kindling effect). A total of 155 papers were found using the reported searches, of which two presented the best evidence to answer the clinical question. The author, date and country of …