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Many studies have analyzed the cost-effectiveness of implantable cardioverter defibrillators (ICDs), but hospital costs have not been as thoroughly reported. This study reviewed the associated hospital costs for non-surgical patients who received ICDs from 2015 to 2019. We performed a retrospective single-center analysis of patients who received an ICD between 2015 and 2019. ICD cost was analyzed with respect to time using linear regression t-test analysis. For 304 patients, we trended cost of the devices over time. 168 (55.2%) cases were single-chamber devices, 53 (17.4%) were dual-chamber, 59 (19.4%) were cardiac resynchronization therapy-defibrillators (CRT-D), and 24 (7.9%) were subcutaneous devices. The cost of all ICDs decreased by -$1.82/day (p

Summary: The most common cause of cardiovascular mortality in man is the outcome from myocardial infarction. Accordingly, it is necesarry to study the corresponding process of heart injury recovery in many mouse models relevant to human cardiovascular disease. This protocol describes the surgical induction of myocardial injury via 1) permanent ligation of a coronary artery in the heart (myocardial infarction), 2) cryoinjury, and 3) transient occlusion of a coronary artery followed by reperfusion (ischemia-reperfusion injury).

Summary: Hypertension in man can be modeled in the mouse by introducing a constriction in the major artery (aorta) thereby obstructing outflow and increasing the afterload to the heart. This protocol describes the procedure for aortic banding aka transverse aortic constriction (TAC).

Summary: The most common cause of cardiovascular mortality in man is the outcome from myocardial ischemic injury. Accordingly, it is necesarry to study the corresponding process of heart injury recovery in many mouse models relevant to human cardiovascular disease. This protocol describes the surgical induction of myocardial injury via transient occlusion of a coronary artery followed by reperfusion (ischemia-reperfusion injury).

Introduction Since the first implantable cardioverter defibrillator (ICD) in 1980, the technological improvement of this device has been groundbreaking and rapid; 40 years later, these devices are now significantly more compact and are capable of new functions such as anti-tachycardia and biventricular pacing. As the functionality of ICDs has increased, the cost associated with ICDs is potentially problematic for their widespread application. While many studies have prospectively analyzed the cost-effectiveness of ICDs for patients, literature concerning the associated institutional costs is very limited. The associated hospital costs for non-surgical patients who received implantable cardioverter defibrillators at the University of Maryland Medical Center from 2015 to 2019 were reviewed. Methods We performed a retrospective analysis of patients who received an implantable cardioverter defibrillator at the University of Maryland Medical Center between 2015 and 2019. Patients admitted for surgical encounters and those who had received an ICD before November 2015 were excluded. Results A total of 423 patients who received implantable cardioverter defibrillators were reviewed. 118 patients admitted for surgical encounters were excluded and an additional 39 patients admitted before November 2015 were excluded for missing cost data. Of the remaining 267 patients, linear regression was used to compare costs vs. time. Overall cost showed little change during this study period. Mean overall variable cost was $34,003.92 with R2 = 3.2 × 10−5 when trended from 2015 to 2019. Mean supply cost was $21,920.78 with R2 = 0.05. Further analysis of the supply cost showed that the mean ICD cost was $16,142.50 with R2 = 0.056. Mean drug cost was $1,544.31 with R2 = 0.0004. Mean laboratory testing cost was $786.65 with R2 = 0.0023. Mean radiology cost was $1,849.94 with R2 = 0.009. Mean labor costs for nursing and physical/occupational therapy were $7,353.04 with R2 = 0.02 and $1,102.67 with R2 = 0.047, respectively. Conclusion From 2015 to 2019, the overall variable cost, encompassing laboratory testing, pharmaceutical costs, operating room costs, imaging, and labor, for non-surgical patients who received an implantable cardioverter defibrillator has not significantly changed. The variable cost of all types of ICDs has not statistically changed during this timeframe. Initial evaluation of ICD costs showed significantly higher costs before the change in the electronic medical record at the University of Maryland Medical Center due to related changes in cost accounting. While this study was limited by the availability of financial data, detailed longitudinal analysis should provide greater insight into changes in the institutional and corresponding healthcare costs for patients receiving ICDs.

Summary: The most common cause of cardiovascular mortality in man is the outcome from myocardial ischemic injury. Accordingly, it is necesarry to study the corresponding process of heart injury recovery in many mouse models relevant to human cardiovascular disease. This protocol describes the surgical induction of myocardial injury via transient occlusion of a coronary artery followed by reperfusion (ischemia-reperfusion injury).

Summary: Hypertension in man can be modeled in the mouse by introducing a constriction in the major artery (aorta) thereby obstructing outflow and increasing the afterload to the heart. This protocol describes the procedure for aortic banding aka transverse aortic constriction (TAC).

Summary: The most common cause of cardiovascular mortality in man is the outcome from myocardial infarction. Accordingly, it is necesarry to study the corresponding process of heart injury recovery in many mouse models relevant to human cardiovascular disease. This protocoldescribes the surgical induction of myocardial injury via 1) permanent ligation of a coronary artery in the heart (myocardial infarction), 2) cryoinjury, and 3) transient occlusion of a coronary artery followed by reperfusion (ischemia-reperfusion injury).

Background: Knowledge of clinical practice guidelines for Implantable Cardioverter Defibrillator (ICD) therapy is a pre-requisite for effective application of this life-saving technology. The level of trainee familiarity with these guidelines is unknown. The objective of this study was to assess trainee familiarity with clinical practice guidelines for ICD therapy.Methods: This study surveyed 32 clinicians of varying training levels in internal medicine and cardiology at a large VA medical center. This is a survey study conducted from a population of all trainees in internal medicine at the medical center; the sample included trainees from PGY-1 through PGY-7 as well as attending physicians in internal medicine. Analysis of the collected survey data was performed using either Chi-square tests for comparison of categorical variables or unpaired t-tests forcomparison of means.Results: Of all respondents, 69% reported that they were familiar with published guidelines, and consistent with previously published data. Cardiologists were significantly more likely to report familiarity than internists (85% vs 42%, P=0.01). Most respondents (75%) reported satisfactory or better knowledge of published guidelines, though only 34% self-reported their knowledge as good or very good. The majority of respondents (86%) underestimated the usual cost of ICD implantation,while most respondents (78%) agreed that implantation of an ICD was cost-effective for secondary prevention, cardiologists were far more likely to agree than internists (95% vs. 50%, PConclusion: There are considerable knowledge gaps evident among trainees with regard to clinical practice guidelines for ICD therapy. This likely represents a modifiable barrier to ICD implantation.Structured education for medical trainees on the appropriate use and referral practices consistent with practice guidelines may reduce knowledge gaps and increase appropriate ICD implantation.Keywords: IMPLANTABLE CARDIOVERTER DEFIBRILLATORS, SURVEY, TRAINING, CLINICAL PRACTICE GUIDELINES

Hybrid Lead Extraction for High-Risk Leads Introduction Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a “hybrid” technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique. Methods and Results Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism. Conclusions Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.

Background: It has been established that areas of slow conduction within a myocardial scar identified by isochronal mapping during sinus rhythm harbor the functional substrate that is involved in sustaining ventricular tachycardia (VT). We sought to test the hypothesis that targeting the region of slowest conduction during sinus rhythm would reduce VT recurrence following ablation. Methods and Results: 32 subjects underwent ablation for sustained monomorphic VT associated with structural heart disease from 2013 to 2014. Sustained VT recurred in 12 patients (37.5%). Isochronal late activation maps were created to display activation during sinus rhythm in the region of bipolar scar. The scar was divided into three zones of equal activation time. The zone with the densest isochrones was designated as having the slowest conduction . We retrospectively analyzed isochronal maps and measured the proportion of the slowest zone that was ablated (median 14%, IQR 0-50). During a mean follow-up of 6 months, recurrence of ventricular arrhythmia was significantly associated with ablation of the slowest zone (OR 0.126, CI 0.024-0.68, p 0.016). Furthermore, univariate logistic regression demonstrated reduction of 30% in the 6-month VT recurrence rate for every 10% increase in percent of the slowest zone ablated (OR 0.7, 95% CI 0.5-1.0, p=0.05). Conclusions: Patients who had ablation in the region of slowest conduction were significantly less likely to have recurrence of ventricular tachycardia. Our data suggests a strategy to target the slowest region of conduction for substrate modification may hold promise for improving outcomes of scar-mediated VT ablation.

Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique.Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism.Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.

This retrospective study characterized the recurring ventricular arrhythmias with an electrogram-storing defibrillator in survivors of sudden cardiac death who had no inducible sustained ventricular arrhythmias at baseline electrophysiologic testing (EPS). The study group was composed of 24 selected patients with documented ventricular fibrillation (VF) without need of revascularization or chronic antiarrhythmic therapy. The EPS protocol usually consisted of three extrastimuli at two drive cycles at two right ventricular sites. Nonischemic cardiomyopathy was the most frequent structural abnormality ( n = 11) followed by coronary artery disease ( n = 7). The mean ejection fraction was 0.37 ± 0.13. Cardiac status did not appear to change during a mean follow-up period of 16.4 ± 12.5 months, and eight (33%) patients received appropriate shocks in that time period. On the basis of intracardiac electrograms, 7 (88%) patients experienced VF and 1 (12%) patient had ventricular tachycardia as the first recurring arrhythmia. Four patients had additional recurrences and all were VF episodes. VF was usually present from the onset of the arrhythmia. In addition, 9 (38%) patients had nonsustained ventricular arrhythmias that were solely VF in 6 (67%). In conclusion, VF of sudden onset was the most frequent recurring sustained ventricular arrhythmia in this group.