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To accommodate the surge in patients with coronavirus disease 2019 during the spring of 2020, outpatient areas in our health system were repurposed as inpatient units. These spaces often lacked the same resources as the standard inpatient unit, including telemetry equipment. We utilized mobile cardiac outpatient telemetry (MCOT) in place of traditional telemetry and suggest that MCOT is an appropriate substitution only for patients at low risk of developing arrhythmia given the prolonged time to notification of the care team regarding events and imprecise measurements of the corrected QT interval when compared to 12-lead electrocardiography.

Atrial fibrillation (AF) is a triggered rhythm, and ablation of the trigger is a common strategy for rhythm control. We describe a patient with symptomatic AF who was found to have episodes of AF triggered by premature ventricular complexes, likely by retrograde atrioventricular nodal conduction. (Level of Difficulty: Beginner.), Graphical abstract

The goal of this study was to compare lesion durability between high-power short-duration (HP-SD) and moderate-power moderate-duration (MP-MD) ablation strategies.HP-SD radiofrequency ablation (RFA) was developed to improve pulmonary vein isolation (PVI) by reducing the effect of catheter instability inherent to MP-MD ablation strategies. However, its long-term effect on lesion durability for the treatment of atrial fibrillation is unknown.Patients with atrial fibrillation (n = 112) underwent PVI using HP-SD ablation (45 to 50 W, 8 to 15 s) with contact force-sensing open irrigated catheter. Cavotricuspid isthmus, mitral annular, and roof lines were permitted. A control group (n = 112) underwent ablation using MP-MD ablation (20 to 40 W, 20 to 30 s) with similar technology. Chronic PV reconnection was examined in patients who required a redo procedure (HP-SD ablation, n = 18; MP-MD ablation, n = 23).The rate of PVI at the completion of the initial encirclement was similar between the HP-SD and MP-MD ablation strategies (90.2% vs. 83.0%; p = 0.006). The HP-SD strategy required shorter RFA time (17.2 ± 3.4 min vs. 31.1 ± 5.6 min; p 0.001). The incidence of chronic PV reconnection was lower with HP-SD ablation (16.6% vs. 52.2%; p = 0.03). Areas of chronic reconnection were associated with catheter motion ≥1 mm for ≥50% application duration. In a higher proportion of HP-SD applications, catheter motion was 1 mm during ≥50% duration (88.6% vs. 72.8%; p 0.001), allowing energy delivery with greater stability. Both ablation strategies were effective for cavotricuspid isthmus; however, the HP-SD strategy was less effective for mitral annular lines, requiring ablation at lower power for longer duration to avoid steam pops.HP-SD ablation may improve PVI durability, and it shortens RFA time. However, ablation in thicker myocardium often requires lower power applied for longer duration, allowing deeper lesions without tissue overheating.

Pacemaker infections are one of the most distressing and morbid complications for patients and can present a challenging management problem for physicians. Pacemaker leads, especially those that dwell in the venous system and inside the cardiac chambers, are prone to becoming colonized with bacteria owing to their sizeable surface area, the nature of their external exposed materials (usually silicone or polyurethane) that are prone to biofilm formation, and their close association with the skin surface at the level of the pacemaker pocket.1 Leads that cross the tricuspid valve (TV) may be at additional risk for lead-associated endocarditis owing to contact with infected valvular structures, and the local environment of turbulent, high-velocity jets. Leadless pacemakers, on the other hand, have features that may reduce their risk of becoming infected, including a smaller surface area, a metal-only exposed surface, no interaction with the TV, and no component that has proximity to the skin surface. Micra (Medtronic, Minneapolis, MN) is a battery-operated leadless intracardiac pacemaker that was designed to stay anchored inside the right ventricle, thus reducing the infection risk of conventional pacemakers. The cylindrical device is 26 mm long, about the size of a large pill (a volume of 1 cm3), occupying clinically insignificant space within the right ventricular chamber. The Micra leadless pacemaker is placed with a transvenous implantation catheter via the right femoral vein, so no thoracotomy is required for this procedure.2 We present a case where a Micra leadless pacemaker was used to manage a challenging patient with a history of TV endocarditis, complete heart block, and multiple pacemaker system infections. Key Teaching Points • Standard pacemaker leads are prone to bacterial adherence and chronic colonization in the setting of bacteremia and endocarditis. Full extraction of the pacing system is needed as part of curative treatment when lead-associated endocarditis is present. • Multiple episodes of endocarditis over time can mandate sequential removal of transvenous hardware (including pacemaker leads) in order to achieve definitive control of these infections. The need for multiple lead extractions does not preclude the possibility of long-term cure from relapsing endocarditis. • The Micra (Medtronic, Minneapolis, MN) leadless pacemaker has a lower risk of bacterial colonization than standard transvenous pacemaker leads for several reasons, and may be an appropriate choice for chronic pacing in patients at high risk for bacterial endocarditis.

Background Innominate vein stenosis and venous tortuosity are common findings during cardiac implantable electronic device upgrades or replacements and present a challenge to the implanting physician. Various techniques have been described to facilitate lead placement, including serial dilation, balloon venoplasty, and percutaneous access medial to the stenosis, each with its own benefits and risks. Objective The purpose of this study was to assess the feasibility, safety, and efficacy of the wire countertraction ("body flossing") technique to facilitate sheath placement through tortuous and stenotic vessels. Methods Patients undergoing cardiac implantable electronic device procedures requiring the body flossing technique due to inability to place vascular sheaths over the wire through stenoses or tortuosity were retrospectively analyzed. Clinical characteristics, procedural equipment, and outcomes were analyzed. Results Simultaneous countertraction was successful in all attempted cases, including 8 patients with stenoses and 2 with tortuosity. In 2 of the stenosis cases, venoplasty had previously failed. No complications occurred. Conclusion Simultaneous countertraction (body flossing) is an effective tool to overcome venous stenosis and tortuosity that are amenable to wire advancement but not to vascular sheaths. It seems to be a safe and effective alternative to other techniques used in these scenarios.

To curb transmission of SARS-CoV-2 and preserve hospital resources, elective procedures were postponed in the United States, affecting patients previously scheduled for electrophysiology (EP) procedures. We aimed to understand patients’ perceptions related to procedural postponements during the first wave of the SARS-CoV-2 pandemic. We performed a telephone survey between May 1-15 2020, of consecutive patients who experienced procedural postponement from March-April. Of 112 patients, 20% may have been lost to follow up and 12% lost interest in having their procedures done. The level of anxiety related to postponement was moderate to high in more than two thirds of patients.

Transseptal puncture is a critical procedural step in pursuing left-sided catheter ablations. Most centers use either fluoroscopic and/or intracardiac echocardiographic (ICE) guidance.1, 2 However, not uncommonly, these routinely used approaches may not be sufficient to repeatedly obtain transseptal access in a safe manner.3 We present a recently described novel approach to transseptal puncture using a concomitant ablation catheter in the left atrium (LA) in 2 challenging cases.

BACKGROUND Guidance for wound management of the vacated generator pocket in cardiac implantable electronic device (CIED) pocket infections after removal of all hardware and tissue debridement is limited. The typical surgical technique for management of a purulent wound is to allow healing by secondary intention. An alternative approach uses negative pressure wound therapy with or without delayed primary closure. While effective in managing infection, these approaches increase hospital length of stay and costs. We present our experience with a third option: modified early primary wound closure over a suction device. METHODS All patients with CIED pocket infections who presented to our institution between September 2018 and October 2020 underwent extraction of hardware and modified primary wound closure over a negative pressure Jackson-Pratt drain. Length of hospital and postoperative stay, complications, and recurrent infections were recorded. RESULTS During the study period, 14 patients underwent modified primary wound closure for CIED pocket infections. Mean length of hospital stay was 6.64 days ± 4.01 days (standard deviation [SD]). Mean postoperative length of stay was 3.92 ± 2.21 days (SD). Two patients (both on intravenous heparin for mechanical valve prostheses) required re-exploration for bleeding. No patients developed recurrent infection at a mean follow up of 363 ± 245 days (SD). CONCLUSION Based on our experience, early modified primary wound closure for CIED pocket infections appears to be safe and allows for prompt discharge with no observed re-infections.

Background The incidence of atrial fibrillation (AF) is lower in nonwhites than in whites despite a higher burden of AF risk factors. However, the incidence of new AF after cryptogenic stroke in minorities is unknown. Objective The purpose of this study was to determine the incidence of AF after cryptogenic stroke in different racial/ethnic groups. Methods We retrospectively analyzed 416 consecutive patients undergoing insertable cardiac monitor implantation at our hospital from 2014 through 2019. Incidence of AF was identified through the review of device monitoring, including adjudication of AF episodes for accuracy, and compared by race. Results The mean follow-up time was 1.5 ± 1.1 years. The predominantly nonwhite cohort included 244 (59%) blacks and 109 (26%) Hispanics, and 45% (n=189) were male. The mean age was 62 ± 12 years; Blacks and Hispanics had more hypertension, diabetes, and chronic kidney disease and higher body mass index than did whites. In blacks and Hispanics, the cumulative incidences of AF at 1, 2, and 3 years were 14.1%, 19.9%, and 24% and 12.9%, 18.3%, and 20.9%, respectively. By comparison, the incidence in whites was significantly higher: 20.8%, 34.3%, and 40.3%. In a Cox proportional hazards model adjusting for common AF risk factors, blacks (hazard ratio 0.49; confidence interval 0.26–0.82; P = .03) and Hispanics (hazard ratio 0.39; confidence interval 0.18–0.83; P = .01) were less likely to have incident AF than whites. Conclusion In patients with an insertable cardiac monitor after cryptogenic stroke, the incidence of newly detected AF is approximately double in whites compared with both blacks and Hispanics. This has important implications for the investigation and treatment of nonwhites with cryptogenic stroke.

Introduction: Non-white patients have been reported to face barriers to left atrial appendage occlusion (LAAO). Hypothesis: We hypothesized that white vs. non-white patients would have disparate wait times for and post-procedural treatment course after LAAO. Methods: We identified consecutive patients undergoing LAAO (Watchman TM ) at our institution between November 2015 - March 2020. In white vs. non-white patients, we compared patient characteristics, indications for LAAO, procedural wait time from index event (IE) and cardiology encounter to LAAO procedure, complications, post-procedure anticoagulation regimen, and adherence to 45-day post-procedural transesophageal echocardiogram (TEE). Results: Of 109 consecutive patients receiving LAAO implants, 45% were white (n = 49). White patients were less likely to have prior cerebral vascular accident (14% vs. 43%, p=0.001), heart failure (18% vs. 48%, p=0.001), and end stage renal disease (0% vs. 20%, p Conclusions: Whites and non-whites had similar indications for LAAO, procedural wait time, risk of procedural complications, and adherence to post-procedural TEE, despite a higher burden of co-morbidities. White patients may be more likely to be discharged on oral anticoagulation.

Background: To curb transmission of SARS-CoV-2 and to preserve hospital resources, elective procedures were indefinitely postponed nationally, affecting many patients previously scheduled for electrophysiology (EP) procedures. Procedural wait times may affect patient satisfaction and retention, yet patient perceptions of procedural postponements during the SARS-CoV-2 pandemic are currently unknown. Methods: We performed a phone survey of consecutive patients who experienced EP procedural postponement from March – April 2020. Surveys were performed between May 1 – May 15. Sociodemographics, SARS-CoV-2 testing history, notification circumstances, and perceptions were obtained from patients. Results: Of 112 patients postponed, 77 patients consented to the survey, most of whom were minorities (black 43%, Hispanic 20%), 30% were below the poverty line, and 67% had ≤ high school education. Catheter ablation accounted for 33% of procedures and device procedure 44%. Half of patients (51%) were informed of their postponement by their electrophysiologist. In response to when patients thought their procedure would occur, 37% believed it would occur within 12 weeks of the survey. Perceptions and testing history are shown ( Figure ). Patients who had undergone SARS-CoV-2 testing were more likely to disagree with postponement than those who had not undergone testing (30% of those tested disagreed vs. 2% of those not tested, p Conclusion: Within an urban population, most patients agreed with procedural postponement and felt their procedure would occur soon. Interim SARS-CoV-2 testing was associated with disagreement with postponement and one third of patients had high anxiety about postponement. In our experience, patient retention was high.

Introduction: The incidence of atrial fibrillation (AF) is lower among non-whites compared to whites, despite a higher burden of AF risk factors. Current knowledge of first detection of AF after cryptogenic stroke (CS) by an implantable cardiac monitor (ICM) is based on a predominantly white cohort. The incidence of new AF after CS among minorities is unknown. We hypothesized that the incidence of AF after CS would be lower in non-whites. Methods: We reviewed charts of all patients without a history of AF undergoing implantation of an ICM after CS at our hospital from July 2014 to December 2019. Incidence of AF was identified through review of ICM monitoring for each patient, including adjudication of AF episodes for accuracy. Kaplan Meier survival analysis was performed, and cumulative incidence of AF using adjusted Cox proportional hazards regression was compared by race. Results: We identified 417 patients who underwent ICM implant after CS during the study period, with a mean follow-up time of 1.5 ± 1.1 years. Mean age was 62 ± 12 years, and 46% (n=190) were male. The majority of patients were non-white (white, 15%, n=63; black, 59%, n=244; Hispanic, 26%, n=110). At baseline, blacks, Hispanics, and whites were of similar age (mean 62.2, 62.1, and 61.5 years, respectively), and blacks and Hispanics had more AF risk factors, including heart failure, hypertension, diabetes, chronic kidney disease, and higher BMI, than whites. Hispanics had more coronary artery disease than whites and blacks (25.5%, 17.5%, 9.1% respectively, p < 0.001). Among blacks, the cumulative incidence of newly detected AF at one, two, and three years was 13.0%, 18.9%, and 23%, which was similar to Hispanics (12.9%, 18.2%, and 20.9%). By comparison, the incidence in whites was significantly higher (20.8%, 34.3%, 40.3%; blacks p=0.02; Hispanics p=0.01) Conclusion: In patients undergoing ICM after CS, the incidence of newly detected AF is approximately double in whites compared to both blacks and Hispanics.

PURPOSE Non-white patients are underrepresented in left atrial appendage occlusion (LAAO) trials, and racial disparities in LAAO periprocedural management are unknown. METHODS We assessed sociodemographics and comorbidities of consecutive patients at our institution undergoing LAAO between 2015 and 2020, then in adjusted analyses, compared procedural wait time, procedural complications, and post-procedure oral anticoagulation (OAC) use in whites versus non-whites. RESULTS Among 109 patients undergoing LAAO (45% white), whites had lower CHA2 DS2 VASc scores, on average, than non-whites (4.0 vs. 4.8, p = .006). There was no difference in median time from index event (IE) or initial outpatient cardiology encounter to LAAO procedure (whites 10.5 vs. non-whites 13.7 months, p = .9; 1.9 vs. 1.8 months, p = .6, respectively), and there was no difference in procedural complications (whites 4% vs. non-whites 5%, p = .33). After adjusting for CHA2 DS2 VASc score, OAC use at discharge tended to be higher in whites (OR 2.4, 95% CI [0.9-6.0], p = .07). When restricting the analysis to those with prior gastrointestinal (GI) bleed, adjusting for CHA2 DS2 VASc score and GI bleed severity, whites had a nearly five-fold odds of being discharged on OAC (OR 4.6, 95% CI [1-21.8], p = 0.05). The association between race and discharge OAC was not mediated through income category (total mediation effect 19% 95% CI [-.04-0.11], p = .38). CONCLUSION Despite an increased prevalence of comorbidities amongst non-whites, wait time for LAAO and procedural complications were similar in whites versus non-whites. Among those with prior GI bleed, whites were nearly five-fold more likely to be discharged on OAC than non-whites, independent of income.

Presentation A 3.5-kg female infant is born preterm at 32 6/7 weeks of gestation via cesarean section to a 22-year-old gravida 2, para 0 woman because of breech presentation and preeclampsia. The pregnancy is complicated by limited prenatal care and hydrops (scalp edema, bilateral pleural effusions, and ascites). The mother’s blood type is O+, infant is O+, and Coombs test result is negative. Maternal serologies are negative. Maternal titers for toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex virus (HSV), and other organisms, including syphilis, parvovirus, and varicella zoster, are negative. At delivery the infant has significant respiratory distress requiring positive pressure ventilation, intubation, and multiple paracenteses. The infant’s Apgar scores are 1, 1, and 7 at 1, 5, and 10 minutes, respectively. ### Physical Examination Physical examination reveals frontal bossing, coarse facial features, large ears, hypotelorism, broad nasal bridge, anasarca, ascites, tapered fingers, bilateral feet inversion, right hand abduction, left wrist external rotation, and bilateral hip dislocation. Hepatosplenomegaly is appreciated after paracentesis. ### Laboratory Studies The patient is admitted to the NICU and evaluated for nonimmune hydrops. Echocardiography reveals normal anatomy for age, with the presence of a patent ductus arteriosus and normal function. Head ultrasonography findings are normal. A metabolic evaluation, including plasma amino acids, urine organic acids, and urine succinylacetone, has unremarkable findings. Her platelet count is less than 50×103 …

Electrolyte abnormalities are a known trigger for ventricular arrhythmia, and patients with heart disease on diuretic therapy may be at higher risk for electrolyte depletion. Our aim was to determine the prevalence of electrolyte depletion in patients presenting to the hospital with sustained ventricular tachycardia or ventricular fibrillation (VT/VF) versus heart failure, and identify risk factors for electrolyte depletion. Consecutive admissions to a tertiary care hospital for VT/VF were identified between July 2016 and October 2018 using the electronic medical record and compared with an equal number of consecutive admissions for heart failure (CHF). The study included 280 patients (140 patients in each group; mean age 63, 60% male, 59% African American). Average EF in the VT/VF and CHF groups was 30% and 33%, respectively. Hypokalemia (K3.5 mmol/L) and severe hypokalemia (K3.0 mmol/L) were present in 35.7% and 13.6%, respectively, of patients with VT/VF, compared to 12.9% and 2.7% of patients with CHF (p0.001 and p = 0.001, respectively, between groups). Hypomagnesemia was found in 7.8% and 5.8% of VT/VF and CHF patients, respectively (p = 0.46). Gastrointestinal illness and recent increases in diuretic dose were strongly associated with severe hypokalemia in VT/VF patients (odds ratio: 11.1 and 21.9, respectively; p0.001). In conclusion, hypokalemia is extremely common in patients presenting with VT/VF, much more so than in patients with CHF alone. Preceding gastrointestinal illness and increase in diuretic dose were strongly associated with severe hypokalemia in the VT/VF population, revealing a potential opportunity for early intervention and arrhythmia risk reduction.

It is inspirational to read the description from George Ralph Mines, >100 years ago, of his accidental observation of a “reciprocating rhythm” in the hearts of 3 electric rays and 1 frog ([1][1]). With timed electrical stimulus delivery, knowledge of myocardial physiology, and impeccable logic

A patient presented with typical atrial flutter; however, during ablation, a change in cycle length prompted recognition of a change in the arrhythmia mechanism. Entrainment maneuvers proved critical in identifying the rhythm mechanism and appropriate subsequent ablation strategy.

A woman with paroxysmal atrial fibrillation, managed on dofetilide, suffered recurrent pre-syncope. Tracings from an implantable loop recorder provided recognition of torsades de pointes, and with cessation of dofetilide, her episodes of presyncope resolved. In the right context, as in use of a QT prolonging drug, acquired long QT syndrome and torsades de pointes may be an etiology of presyncope or syncope.

Background Transvenous lead extraction (TLE) carries a significant risk of intraprocedural complications. Phased-array intracardiac echocardiography (ICE) is widely used during cardiac procedures; however, its utility during TLE has not been well described. Objective We sought to define the utility of ICE imaging during TLE. Methods Fifty patients referred for TLE were included. Patients underwent ICE imaging before and throughout TLE. Clinical characteristics of the patients, ICE findings, and procedural outcomes were collected and analyzed. Results Of the 50 patients, 18 (36%) were found to have visible binding sites in the ICE field of view; 13 (26%) had intracardiac binding sites only, and 5 (10%) had both superior vena cava (SVC) and intracardiac binding sites. Lead-adherent echodensities (LAEs) were found in 36 patients (72%), of whom 7 (14%) had bacteremia. Patients with SVC and/or intracardiac binding sites were more likely to have a complex extraction, defined as that requiring the use of internal jugular or femoral venous access, advancement of extraction apparatus beyond the SVC, disruption of lead structure during the procedure, or resulting in major complications (56% vs 0%; P ≤ .0001). Conclusion ICE imaging during TLE can be used to assess the presence of lead binding sites, LAEs, and procedural complications. LAEs were found in the majority of patients, mostly in the absence of bacteremia. The presence of ICE-detected lead binding sites is predictive of a more complex extraction procedure.

Background Device reimplantation after extraction because of cardiac implantable electronic device (CIED) infection in pacemaker-dependent patients can be challenging in individuals with limited access options. Objective The purpose of this study was to describe a straightforward, low lateral thoracic implantation technique for patients with a patent axillary vein but unavailable bilateral pectoral sites. Methods Nine pacemaker-dependent patients (mean age 70 ± 13 years, 7 male) who underwent CIED extraction and low lateral thoracic reimplantation in whom bilateral pectoral sites were unavailable were included in the study. Results Extraction was performed a median of 10 (interquartile range [IQR] 8–13) days before CIED reimplantation (4 dual-chamber, 3 single-chamber, 2 cardiac resynchronization therapy). The new generator was implanted in the low lateral thoracic region ipsilateral to the extracted generator in 7 patients (78%) and contralateral in 2 patients (22%), via a subcutaneous pocket in 6 (67%) and submuscular pocket in 3 (33%). Median procedure duration was 85 (IQR 61–116) minutes, median fluoroscopy time was 7.2 (IQR 5.7–10.9), minutes and median fluoroscopy exposure was 26.0 (IQR 10.0–110.5) mGy. No acute complications occurred. Over median follow-up of 92 (IQR 31–131) days, 1 patient experienced right atrial lead dislodgment (122 days postimplantation) requiring lead revision. No patients experienced recurrent device infection. Conclusion In pacemaker-dependent patients with limited prepectoral and vascular access options, a low lateral thoracic implantation site is a viable alternative to surgical epicardial or femoral pacing systems. This simple implantation technique is a safe and effective option in selected patients who require a single-chamber, dual-chamber, or biventricular pacemaker or implantable cardioverter–defibrillator.