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Background: Cardiac implantable electronic device (CIED) infection has a high mortality. Previous investigations showed reduced postoperative infections using skin preparation with chlorhexidine, preoperative intravenous antibiotics, and a TYRX-a antibacterial envelope. The additional benefit of antibiotic pocket wash and postoperative antibiotics has not been systematically studied. Methods: The ENVELOPE trial (A Randomized trial of Stand-Alone Use of the Antimicrobial Envelope in High-Risk Cardiac Device Patients) was a prospective, multicenter, randomized, controlled trial enrolling patients undergoing CIED procedures with ≥2 risk factors for infection. The control arm received standard chlorhexidine skin preparation, intravenous antibiotics, and the TYRX-a antibiotic envelope. The study arm received pocket wash (500 mL antibiotic solution) and postoperative antibiotics for 3 days along with the prophylactic control measures. The primary end point was CIED infection and system removal at 6 months. Results: One thousand ten subjects (505 per arm) were enrolled and randomized. Patients were seen in person for a wound check with digital photo 2 weeks postimplant and at 3 and 6 months. CIED infection rate was low in both groups (1.0% control arm and 1.2% study arm, P =0.74). In the 11 subjects with infection and system removal, the time to study end point was 107±92 days with a PADIT (Prevention of Arrhythmia Device Infection Trial) score of 7.4 and a 64% 1-year mortality. Prior history of CIED infection independently predicted CIED system removal at 6 months in all subjects (odds ratio, 9.77, P =0.004). Of 11 infections requiring system removal, 5 were in the setting of pocket hematoma. Conclusions: The use of antibiotic pocket irrigation and postoperative oral antibiotics provides no additional benefit to the prophylactic measures of chlorhexidine skin preparation, preoperative intravenous antibiotics, and an antibiotic envelope in reducing CIED infection. Postoperative hematoma is a major risk factor for infection, driven by the use of antiplatelet and anticoagulant medications. The strongest predictor of CIED removal at 6 months, regardless of intervention, was prior CIED infection. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02809131.

The COVID-19 pandemic poses a significant stress on health resources in Australia. The Heart Rhythm Council of the Cardiac Society of Australia and New Zealand aims to provide a framework for efficient resource utilisation balanced with competing risks when appropriately treating patients with cardiac arrhythmias. This document provides practical recommendations for the electrophysiology (EP) and cardiac implantable electronic devices (CIED) services in Australia. The document will be updated regularly as new evidence and knowledge is gained with time.

Background Implantable Cardiac Monitors (ICMs) are used for long-term monitoring of arrhythmias. BIOMONITOR III is a novel ICM with a miniaturized profile, long sensing vector due to a flexible antenna, simplified implantation with a dedicated insertion tool for pocket formation and ICM placement in a single step, and daily automatic Home Monitoring (HM) function. Methods In 47 patients undergoing BIOMONITOR III insertion for any ICM indication, 16 investigators at 10 Australian sites assessed handling characteristics of the insertion tool, R-wave amplitudes, noise burden, P-wave visibility, and HM transmission success. Patients were followed for 1 month. Results All 47 attempted insertions were successful. Median time from skin incision to removal of the insertion tool after ICM insertion was 39 s (IQR 19–65) and to wound closure and cleaning was 4.7 min (IQR 3.5–7.8). All aspects of the insertion tool were rated as “good” or “excellent” in ≥97.9% and “fair” in ≤2.1% of patients, except for “force needed for tunnelling” (91.5% good/excellent, 8.5% fair). Based on HM data, R-waves in the first month were stable at 0.70 ± 0.37 mV. Median noise burden (disabling automatic rhythm evaluation) was 0.19% (IQR 0.00–0.93), equivalent to 2.7 min (IQR 0.0–13.4) per day. In HM-transmitted ECG strips with regular sinus rhythm, P-waves were visible in 89 ± 24% of heart cycles. Patient-individual automatic Home Monitoring transmission success was 98.0% ± 5.5%. Conclusions The novel ICM performed well in all aspects studied, including fast insertion, reliable R-wave sensing, good P-wave visibility, and highly successful HM transmissions.

This article describes and compares the successes and challenges experienced by three social work programs in the United States working to infuse geriatric competencies into foundation Master of So...

Background Controversy exists regarding the optimal lead position for chronic right ventricular (RV) pacing. Placing a lead at the RV septum relies upon fluoroscopy assisted by a surface 12-lead electrocardiogram (ECG). We compared the postimplant lead position determined by ECG-gated multidetector contrast-enhanced computed tomography (MDCT) with the position derived from the surface 12-lead ECG. Methods Eighteen patients with permanent RV leads were prospectively enrolled. Leads were placed in the RV septum (RVS) in 10 and the RV apex (RVA) in eight using fluoroscopy with anteroposterior and left anterior oblique 30° views. All patients underwent MDCT imaging and paced ECG analysis. ECG criteria were: QRS duration; QRS axis; positive or negative net QRS amplitude in leads I, aVL, V1, and V6; presence of notching in the inferior leads; and transition point in precordial leads at or after V4. Results Of the 10 leads implanted in the RVS, computed tomography (CT) imaging revealed seven to be at the anterior RV wall, two at the anteroseptal junction, and one in the true septum. For the eight RVA leads, four were anterior, two septal, and two anteroseptal. All leads implanted in the RVS met at least one ECG criteria (median 3, range 1-6). However, no criteria were specific for septal position as judged by MDCT. Mean QRS duration was 160 ± 24 ms in the RVS group compared with 168 ± 14 ms for RVA pacing (P = 0.38). Conclusions We conclude that the surface ECG is not sufficiently accurate to determine RV septal lead tip position compared to cardiac CT.

The Pd-catalyzed Suzuki coupling reactions of a series of aryl chlorides and aryl bromides containing basic nitrogen centers with arylboronic acids in water in the absence of added base are reported. The reactions proceed either partially or entirely under acidic conditions. After surveying twenty-two phosphorus ligands, high yields of products were obtained with aryl chlorides only when a bulky ligand, 2-(di-tert-butyl-phosphino)-1-phenyl-1H-pyrrole (cataCXium®PtB) was used. In contrast, aryl bromides produced high yields of products in the absence of both added base and added ligand. In order to explore the Suzuki coupling process entirely under acidic conditions, a series of reactions were conducted in buffered acidic media using several model substrates. 4-Chlorobenzylamine, in the presence of cataCXium®PtB, produced high yields of product at buffered pH 6.0; the yields dropped off precipitously at buffered pH 5.0 and lower. The fall-off in yield was attributed to the decomposition of the Pd–ligand complex due to the protonation of the ligand in the more acidic aqueous media. In contrast, in the absence of an added ligand, 4-amino-2-chloropyridine produced quantitative yields at buffered pH 3.5 and 4.5 while 4-amino-2-bromopyridine produced quantitative yields in a series of buffered media ranging from pH 4.5 to 1.5. These substrates are only partially protonated in acidic media and can behave as active Pd ligands in the Suzuki catalytic cycle.

This study sought to investigate specific contact force (CF) parameters to guide cavotricuspid isthmus (CTI) ablation and compare the outcome with a historical control cohort. Patients (30) undergoing CTI ablation were enrolled prospectively in the Study cohort and compared with a retrospective Control cohort of 30 patients. Ablation in the Study cohort was performed using CF parameters >10 g and CTI ablation can be safely performed using CF parameters guiding ablation, with similar long-term results to a historical ablation control group. Potentially CF parameters may provide adjunctive information to enable a more efficient CTI ablation. Further research is required to confirm this.

BackgroundRight ventricular nonapical (RVNA) pacing may reduce the risk of heart failure. Fluoroscopy is the standard approach to determine lead tip position, but is inaccurate. We compared cardiac computed tomography (CT), magnetic resonance imaging (MRI), two-dimensional and three-dimensional transthoracic echocardiography (TTE), and chest x-ray (CXR) to assess which provides the optimal assessment of right ventricular (RV) lead tip position.

The DF-4 is a new defibrillator lead technology. We present two cases of non-physiological transient ventricular over-sensing in patients who underwent implantation of an ICD for secondary prevention. Case 1 had ventricular over-sensing during pacing threshold evaluation post defibrillation testing while Case 2 had the lead integrity alert triggered immediately post discharge with transient over-sensing. No lead-connector issues were found. Case 1 was likely due to improper venting of the header and trapped air. Case 2 was hypothesized to be due to intermittent header pin non-contact secondary to blood in the header. These cases reveal that DF-4 leads are subject to both reported and potentially novel causes of transient acute ventricular over-sensing.

Primary cardiac tumors are rare malignancies. Patients may present with congestive cardiac failure due to intracavitary obstruction to blood flow, valvular dysfunction, embolic phenomena, local invasion resulting in arrhythmias, pericardial involvement, constitutional symptoms, or paraneoplastic syndromes. We describe the case of a previously fit 79-year-old woman who presented with acute pulmonary edema due to a large left atrial pleomorphic sarcoma causing severe functional mitral stenosis. She underwent palliative debulking surgery with good symptomatic relief.

Controversy exists regarding the optimal lead position for chronic right ventricular (RV) pacing. Placing a lead at the RV septum relies upon fluoroscopy assisted by a surface 12-lead electrocardiogram (ECG). We compared the postimplant lead position determined by ECG-gated multidetector contrast-enhanced computed tomography (MDCT) with the position derived from the surface 12-lead ECG.Eighteen patients with permanent RV leads were prospectively enrolled. Leads were placed in the RV septum (RVS) in 10 and the RV apex (RVA) in eight using fluoroscopy with anteroposterior and left anterior oblique 30° views. All patients underwent MDCT imaging and paced ECG analysis. ECG criteria were: QRS duration; QRS axis; positive or negative net QRS amplitude in leads I, aVL, V1, and V6; presence of notching in the inferior leads; and transition point in precordial leads at or after V4.Of the 10 leads implanted in the RVS, computed tomography (CT) imaging revealed seven to be at the anterior RV wall, two at the anteroseptal junction, and one in the true septum. For the eight RVA leads, four were anterior, two septal, and two anteroseptal. All leads implanted in the RVS met at least one ECG criteria (median 3, range 1-6). However, no criteria were specific for septal position as judged by MDCT. Mean QRS duration was 160 ± 24 ms in the RVS group compared with 168 ± 14 ms for RVA pacing (P = 0.38).We conclude that the surface ECG is not sufficiently accurate to determine RV septal lead tip position compared to cardiac CT.

Background Anticoagulation prior to elective external direct current cardioversion (EDCCV) is mandatory. The inability to monitor compliance with novel oral anticoagulants (NOACs) raises a potential safety issue. We aimed to evaluate whether a structured, nurse-led assessment of compliance prior to EDCCV ensures safety without the need for routine transoesophageal echocardiography (TOE).Methods Data was prospectively collected on consecutive patients undergoing EDCCV during 2014-2015. All procedures were supervised by an electrophysiology clinical nurse consultant (EPCNC). Drug compliance was verbally assessed using a standardised questionnaire by the EPCNC. Novel oral anticoagulants compliance was required for a continuous period of 3 weeks prior to EDCCV; otherwise a TOE-guided EDDCV was performed. All patients had follow-up 30 days post-procedure.Results Three hundred and eleven cardioversions were performed on 256 patients in whom 154 (49.5%) were prescribed a NOAC (rivaroxaban (n = 105; 68.2%), dabigatran (n = 38; 24.7%), apixaban (n = 11; 7.1%)). Median age was 63 years (24-94 yrs), mean CHADS(2) -Vasc score was 2.0 +/- 1.5 and 138 (89.6%) were outpatients. One hundred and twenty-nine (83.8%) EDCCV were for atrial fibrillation and 25 (16.2%) for atrial flutter. Sinus rhythm was achieved in 90.3% of cases. Fourteen patients (9%) assessed as non-compliant underwent TOE. 129 (83.8%) EDCCV were performed without prior TOE. No stroke or systemic embolism was identified in any patient treated with either warfarin or a NOAC.Conclusions A standardised, verbal questionnaire can be administered to detect NOAC non-compliance in patients undergoing EDCCV. With appropriate compliance assessment a nurse-led EDCCV without routine TOE did not significantly compromise safety in this study group.

Minimal-deviation endometrioid adenocarcinoma (MDEA) of the uterine cervix is a rare tumor that may be confused histologically with a number of benign lesions as well as other types of endocervical neoplasia. The histologic and immunohistochemical features of MDEA have been described in case reports and in small series, but correlation of these findings with ultrastructural examination has not been documented. Herein we report a 51-yr-old patient who underwent hysterectomy for menorrhagia and was found to have a clinically unsuspected, stage IB cervical MDEA. The light microscopic, immunohistochemical, and electron microscopic features of the tumor are described, with the most significant ultrastructural abnormality being the presence of abnormal cilia and ciliogenesis.

Cardiac implantable electronic devices (pacemakers and defibrillators) are increasingly common in modern cardiology practice, and health professionals from a variety of specialties will encounter patients with such devices on a frequent basis. This article will focus on the subset of patients who may request, or be appropriate for, device deactivation and discuss the issues surrounding end-of-life decisions, along with the ethical and legal implications of device deactivation.

A young woman with placement of a dual-chamber implantable cardioverter-defibrillator (ICD) and a history of prior cardiac arrest due to congenital long QT syndrome presented with defibrillation caused by a ventricular fibrillation arrest. Routine device interrogation revealed significant lead dysfunction. During device revision, breaches were detected in the insulation of both leads within the pre-pectoral pocket and an “arc mark” was observed on the ICD generator casing; these findings were consistent with a high-voltage discharge through a short circuit between the denuded right ventricular lead and the casing. In this case, system failure was unmasked only by interrogation after appropriate device activation, which highlights the importance of thorough evaluation after all ICD activations.

Background— Paroxysmal atrial fibrillation (PAF) is associated with elevated levels of brain natriuretic peptide (BNP). The exact cardiac source and implications of this are currently unknown, as are the effects of left atrial ablation on cardiac BNP release. We sought to investigate BNP levels at different cardiac sites in PAF patients before and after left atrial ablation and compare these with a non–atrial fibrillation control cohort. Methods and Results— Twenty PAF patients (52�10 years, 70% men; left ventricular ejection fraction, 55�3%) undergoing ablation were studied, BNP levels were measured at different cardiac sites before and after ablation and compared with a control cohort undergoing ablation for left lateral accessory pathways (10 patients, 41�11 years; left ventricular ejection fraction, 55�4%). In both cohorts, the coronary sinus BNP levels were the greatest. The PAF cohort had significantly greater BNP levels than the control cohort at all sites before and after ablation. Ablation of the left atrium was associated with a significant decrease in coronary sinus BNP levels ( P =0.05) and transcardiac BNP gradient ( P =0.03). This was not observed in the control cohort. Conclusions— BNP levels are elevated in PAF, with the highest levels in the coronary sinus. Ablation of the left atrium was associated with an immediate decrease of BNP levels, implicating this as the source.

Coronary vasospasm is an uncommon, but perhaps under-recognised, cause of cardiac arrest. We present a novel case of an exercise-induced out-of-hospital cardiac arrest due to coronary vasospasm, captured on a heartrate monitor, and discuss the management options for this condition.

This study sought to investigate specific contact force (CF) parameters to guide cavotricuspid isthmus (CTI) ablation and compare the outcome with a historical control cohort.Patients (30) undergoing CTI ablation were enrolled prospectively in the Study cohort and compared with a retrospective Control cohort of 30 patients. Ablation in the Study cohort was performed using CF parameters10 g and40 g and a Force Time Integral (FTI) of 800 ± 10 g. The Control cohort underwent traditionally guided CTI ablation. Traditional parameters (electrogram and impedance change) were assessed in both cohorts. All ablations regardless of achieving targets were included in data analysis. Bidirectional CTI block was achieved in all of the Study and 27 of the Control cohort. Atrial flutter recurred in 3 (10%) patients (follow-up 564 ± 212 days) in the study cohort and in 3 (10%) patients (follow-up 804 ± 540 days) in the Control cohort. There were no major complications in either cohort. Traditional parameters correlated poorly with CF parameters. In the Study cohort, flutter recurrence was associated with significantly lower FTI and ablation duration, but was not associated with total average CF.CTI ablation can be safely performed using CF parameters guiding ablation, with similar long-term results to a historical ablation control group. Potentially CF parameters may provide adjunctive information to enable a more efficient CTI ablation. Further research is required to confirm this.

Advanced atrial remodeling predicts poor clinical outcomes in human atrial fibrillation (AF).The purpose of this study was to define the magnitude and predictors of change in left atrial (LA) structural remodeling over 12 months of AF.Thirty-eight patients with paroxysmal AF managed medically (group 1), 20 undergoing AF ablation (group 2), and 25 control patients with no AF history (group 3) prospectively underwent echocardiographic assessment of strain variables of LA reservoir function at baseline and at 4, 8, and 12 months. In addition, P-wave duration (Pmax,, Pmean) and dispersion (Pdis) were measured. AF burden was quantified by implanted recorders. Twenty patients undergoing ablation underwent electroanatomic mapping (mean 333 ± 40 points) for correlation with LA strain.Group 1 demonstrated significant deterioration in total LA strain (26.3% ± 1.2% to 21.7% ± 1.2%, P.05) and increases in Pmax (132 ± 3 ms to 138 ± 3 ms, P.05) and Pdis (37 ± 2 ms to 42 ± 2 ms, P.05). AF burden ≥10% was specifically associated with decline in strain and with P-wave prolongation. Conversely, group 2 manifest improvement in total LA strain (21.3% ± 1.7% to 28.6% ± 1.7%, P.05) and reductions in Pmax (136 ± 4 ms to 119 ± 4 ms, P.05) and Pdis (47 ± 3 ms to 32 ± 3 ms, P.05). Change was not significant in group 3. LA mean voltage (r = 0.71, P = .0005), percent low voltage electrograms (r = -0.59, P = .006), percent complex electrograms (r = -0.68, P = .0009), and LA activation time (r = -0.69, P = .001) correlated with total strain as a measure of LA reservoir function.High-burden AF is associated with progressive LA structural remodeling. In contrast, AF ablation results in significant reverse remodeling. These data may have implications for timing of ablative intervention.

Acute cardiac response to right ventricular pacing is unknown. We aimed to assess the acute haemodynamic, biochemical and hormonal response to asynchronous right ventricular pacing and investigate whether there is a difference between an apical and outflow tract site.In 21 patients with normal cardiac function, haemodynamics, brain natriuretic peptide and high sensitive troponin T were measured in response to 10minutes of pacing at each site in a randomised crossover fashion and compared.Pacing both sites there were significant increases in pulmonary capillary wedge pressures (p0.001) and QRS width (p0.01). In comparison to baseline, apical pacing demonstrated significant (p0.05) increases in arterial peptide and troponin levels and venous peptide levels. Outflow tract pacing compared to baseline demonstrated significant (p0.05) increases in arterial peptide and venous, arterial and coronary sinus troponin. There were no significant differences in responses between sites.Asynchronous right ventricular pacing demonstrated significant increases in filling pressures, cardiac hormonal and biochemical response above baseline with very short durations of pacing (10minutes). There was no difference in response between sites. These findings imply that even very short periods of right ventricular based pacing are potentially deleterious.

Scintigraphy using iodine-123-metaiodobenzylguanidine (I-123-MIBG) has been used to demonstrate that >50% of orthotopically transplanted hearts undergo partial cardiac sympathetic re-innervation and that this occurs no earlier than 1 year post-transplant. This study used planar and singe-photon emission computed tomography (SPECT) I-123 MIBG scintigraphy to show that cardiac re-innervation was not detectable in any of the 8 patients studied 1.1 to 6.3 years post-heterotopic transplantation. Thus, potential for cardiac re-innervation varies according to the type of procedure performed.

This review focuses on recent literature on the cardiovascular investigation of syncope.Syncope is a common and complex clinical entity with many varied etiologies, the diagnosis of which can often be elusive. Recent advances in the area of investigation in syncope include improvements in technologies for arrhythmia event monitoring and an increase in applicability and efficacy of traditional investigations. These advances have increased our ability to manage syncope.A better understanding of the etiology of syncope in certain cohorts has allowed tailoring of investigations and management of syncope. This is evident when syncope occurs in the presence of structural heart disease, which is associated with a higher incidence of arrhythmias and an increased 1-year mortality. Patients with left-ventricular dysfunction should be considered candidates for an implantable cardioverter defibrillator based on heart function and syncopal presentation. In the absence of significant heart disease, investigations need to be tailored to diagnose neurally mediated causes for syncope and detection of intermittent bradycardia. The improved understanding of syncope has arisen from studies using improved investigational tools for syncope, in particular loop recorders, which are able to monitor cardiac rhythm over long periods. In those without structural heart disease and undifferentiated syncope, neurally mediated causes should be pursed initially. Tilt testing and loop recorders are employed most often in this cohort. Electrophysiological studies have largely been supplanted by implantable cardioverter defibrillator use in structural heart disease, with a low yield in patients with preserved heart function.

Biventricular pacing has been an exciting recent advance in the management of drug-refractory heart failure. This new therapy has evolved as much from necessity as scientific observation, since benefits derived from pharmacotherapy currently appear to have reached their peak. Clinical trials of biventricular pacing are establishing morbidity and mortality benefits in heart failure. New challenges in the use of these pacemakers are now arising. These include the accurate diagnosis of ventricular dyssynchrony and, hence, potential responders to the refinement of implantation of the left ventricular lead to the appropriate dyssynchronous ventricular area and optimization of pacemaker programming. This review gives a general overview of the principles and the current evidence for the use of biventricular pacemakers in the treatment of heart failure. In addition, a discussion of current research and future projects is included.

In this study we sought to assess the influence of atrial fibrillation (AF) on sympathetic nervous system overactivity in congestive heart failure (CHF) patients.We studied 133 consecutive patients with moderate to severe CHF. Subjects underwent haemodynamic assessment (right heart catheterization) and assessment of total systemic and cardiac sympathetic activity by the norepinephrine (NE) spillover method. The study population included 108 patients in sinus rhythm (SR) and 25 in AF. While AF patients had a lower cardiac output (CO) (SR vs AF: 4.2+/-0.1 vs 3.7+/-0.2l/min, P0.05), the groups were otherwise matched for systemic blood pressure (BP), heart rate and filling pressures. In conjunction, total body NE spillover (SR vs AF: 5.8+/-0.4 vs 4.9+/-0.5 nmol/min, P0.05) and cardiac NE spillover (SR vs AF: 339+/-21 vs 393+/-49 pmol/min, P0.05) were not significantly different between the two groups, while the systemic clearance rate for NE was lower in the AF group (SR vs AF: 2.2+/-0.1 vs 1.6+/-0.1l/min, P0.05).Congestive heart failure patients in AF do not appear to have heightened sympathetic tone compared to CHF patients in SR.

Introduction: Brain Natriuretic Peptide (BNP) is secreted from cardiac myocytes in response to the wall stress. BNP is eliminated via Natriuretic Peptide Receptor C (NPR-C) and degradation by extracellular proteases including neprilysin (NEP). Obesity and insulin resistance predispose to lower circulating natriuretic peptide levels. Raised NEP activity and an elevated NPR-C gene expression have been described in obese individuals with insulin resistance and lower circulating levels of natriuretic peptide. Methods: We assessed the relationship between markers of peptide production and pulmonary clearance with indices of insulin resistance and body weight. The cardiac, peripheral and pulmonary Extraction Ratio (ER) has been quantified to assess BNP synthesis and clearance. Twenty one individuals admitted for EP study were consented. Simultaneous sampling of serum BNP level was performed from femoral artery and vein, coronary sinus and femoral artery and pulmonary artery and pulmonary wedge position. Results: The mean serum BNP level was 37 ng/L. The mean cardiac ER was 1.20, pulmonary and peripheral ER was 0.13. There was a tendency for lower cardiac and pulmonary ER in males. Pulmonary ER correlated with age (r=0.495, p=0.023) and systolic BP (r=0.58, p=0.006) only. However there was no correlation between cardiac and pulmonary ER with BMI, waist circumference and HOMA-IR. Conclusions: We found no correlation between the marker of BNP pulmonary clearance with body size and insulin resistance. Induction of the adipose tissue specific NPR-C pathway (rather than NEP clearance) is more likely the cause of the lower level of BNP in patients with obesity and insulin resistance.

Background Implantable cardioverter defibrillator (ICD) leads have traditionally been placed at the right ventricular apex (RVA). An important minority of patients with an ICD may develop a future requirement for bradycardia support. Pacing from the RVA may be detrimental, promoting heart failure and mortality. Increasingly non-apical right ventricular (RVNA) lead positions have been suggested as an alternative pacing site. Methods A retrospective review of 512 patients who received an ICD at our institution between 1999 and 2011 was conducted. A comparison of lead performance characteristics was performed between RVNA sites and those at RVA. Data were collated from chart review and the pacing database. Results The mean follow-up period in the RVNA cohort was 40.4 ± 25.9 months and in the RVA cohort it was 38 ± 31.8 months (p = 0.43). The RVNA cohort consisted of 144 leads and 368 leads in the RVA cohort. The groups had similar baseline clinical characteristics. No significant difference was detected in the proportion of patients receiving an appropriate ICD defibrillation (RVNA 10.4% vs. RVA 16.8%; p = 0.07), inappropriate defibrillation (RVNA 7.6% vs. RVA 7.6%; p = 0.99) or an unsuccessful defibrillation (RVNA 0% vs. RVA 1.7%; p = 0.12). There was also no significant difference in the proportion of patients receiving successful anti-tachycardia pacing (ATP) (RVNA 13.2% vs. RVA 17.4%; p = 0.49) or failed ATP (RVNA 2.7% vs. RVA 4.1%; p = 0.25). There was no significant difference in lead impedance (p = 0.99), sensing (p = 0.59) and pacing threshold (p = 0.34). Conclusion In this large retrospective study, RVNA ICD lead had similar stability and therapy efficacy compared to the traditional RVA position. This potentially has important implications for the suitability of RVNA as an alternative site for ICD leads.

Background Traditionally the provision of elective external direct current cardioversion (EDCCV) for patients with atrial arrhythmias has been doctor-led. Increasing demands on hospital beds and time pressures for doctors has driven the desire for an alternative approach. We established a nurse-led cardioversion service in 2006 and present our experience. Methods A prospective database of patients undergoing elective EDCCV between July 2006 and July 2013 was collected. Demographic data, arrhythmia, success and immediate complications of cardioversion were recorded. Results A total of 974 EDCCV were performed on 772 patients. The mean patient age was 62.7 years, 564 (73.1%) were male. In 530 patients (69.0%) AF was the primary arrhythmia, in 242 (31.0%) atrial flutter. All EDCCVs were performed in a high dependency unit. Sinus rhythm was obtained in 692 patients (89.6%). Of 640 outpatients, 629 (98.3%) were discharged on the same day of their procedure. Eleven patients (1.7%) required admission to hospital. No patients required urgent temporary transvenous or permanent pacing, and there were no deaths in association with this procedure. Conclusions Nurse-led elective EDCCV is a safe and effective way of restoring sinus rhythm in patients with AF or atrial flutter, with additional benefits to resource provision.