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Voskoboinik A, Nehme Z, Kistler PM, Stub D, Smith K. First time use of manual pressure augmentation for ventricular fibrillation arrest in the community. Resuscitation 2022; 174:31-32. [PMID: 35331802 DOI: 10.1016/j.resuscitation.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
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52
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Chieng D, Canovas R, Sugumar H, Segan L, Ling LH, Voskoboinik A, Al-Kaisey A, Lee G, Prabhu S, Kaye DM, Morton JB, Kalman JM, Kistler PM. GROUND, INSTANT, OR DECAFFEINATED COFFEE? IMPACT OF DIFFERENT COFFEE SUBTYPES ON INCIDENT ARRHYTHMIA, CARDIOVASCULAR DISEASE AND MORTALITY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01017-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Paratz ED, Block TJ, Stub DA, La Gerche A, Kistler PM, Kalman JM, Strathmore N, Mond H, Woodford NWF, Burke M, Voskoboinik A. Postmortem Interrogation of Cardiac Implantable Electronic Devices: A 15-Year Experience. JACC Clin Electrophysiol 2022; 8:356-366. [PMID: 35331431 DOI: 10.1016/j.jacep.2021.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study sought to define the feasibility and utility of postmortem cardiac implantable electronic device (CIED) interrogation. BACKGROUND The diagnostic yield of routine postmortem interrogation of CIEDs including pacemakers, defibrillators, and implantable loop recorders has not been established. METHODS The study reviewed all CIED interrogations in deceased individuals undergoing medicolegal investigation of sudden or unexplained death by the Victorian Institute of Forensic Medicine between 2005 and 2020. RESULTS A total of 260 patients (68.8% male, median age 72.8 years [interquartile range: 62.7-82.2 years]) underwent CIED interrogation (202 pacemakers, 56 defibrillators, and 2 loop recorders) for investigation of sudden (n = 162) or unexplained (n = 98) death. CIEDs were implanted for median of 2.0 years (interquartile range: 0.7-5.0 years), with 19 devices at elective replacement indicator and 5 at end of life. Interrogation was successful in 256 (98.5%) cases. Potential CIED malfunction was identified in 20 (7.7%) cases, including untreated ventricular arrhythmias (n = 13) and lead failures (n = 3, 2 resulting in untreated ventricular arrhythmia). Interrogation directly informed cause of death in 131 (50.4%) cases. A total of 72 (27.7%) patients had abnormalities recorded in 30 days preceding death: nonsustained ventricular tachycardia (n = 26), rapid atrial fibrillation (n = 17), elective replacement indicator or end-of-life status (n = 22), intrathoracic impedance alarms (n = 3), lead issues (n = 3), or therapy delivered (n = 1). In 6 cases in which the patient was found deceased after a prolonged period, interrogation determined time of death. In 1 case, CIED interrogation was the primary means of patient identification. CONCLUSIONS Postmortem CIED interrogation frequently contributes important information regarding critical device malfunction, premortem abnormalities, mechanism, and time of death or patient identity. Device interrogation should be considered for select patients with CIEDs undergoing autopsy.
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Chieng D, Sugumar H, Segan L, Al-Kaisey A, Moore BM, Nam MCY, Prabhu S, Voskoboinik A, Ling LH, Kalman JM, Kistler PM. High power short duration (HPSD) versus lower power longer duration (LPLD) atrial fibrillation ablation: a multi-centre randomised controlled trial (HiLo-HEAT study). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Lower power (25W) longer duration (LPLD) radiofrequency (RF) ablation has conventionally been used on the posterior wall during pulmonary vein isolation (PVI) for atrial fibrillation (AF), to attenuate the risk of esophageal thermal injury (ETI). High power (40-50 W) short duration (HPSD) RF ablation results in shorter procedural times with no increase in ETI. However evidence had been limited by non-randomised studies.
Purpose
To compare HPSD versus LPLD ablation and the effects on esophageal thermal injury (ETI) and procedural outcomes.
Methods
In this multi-centre, prospective, randomised control trial, 88 patients with paroxysmal/persistent AF undergoing their first RF ablation procedure were randomised 1:1 to HPSD or LPLD ablation. Anterior wall ablation was done in both arms using 40-50 W, with ablation target of AI 500-500/ LSI 5-5.5. Posterior wall ablation was done using 40-50W (HPSD group) versus 25 W (LPLD group), with target AI 400/ LSI 4. Ablation involves wide antral circumferential PVI using contact force sensing ablation catheters, with additional ablation lines as per operator discretion. Circa multi-sensor esophageal temperature monitoring (ETM) probe was utilized. Endoscopy was performed within 24 hours to assess for ETI. The primary outcome was incidence of ETI, with secondary outcomes including acute procedural endpoints.
Results
Mean age of the cohort was 61+/-9 years, with 31% females. 36 (41%) had PAF. PVI was achieved in 100% of patients, with posterior wall isolation (PWI) added in 19 PsAF patients (21.6%). There were more hypertensive patients in HPSD (p = 0.02). Significant esophageal luminal temperature rises (≥ 38 c) were seen in 93.2% of patients, with no difference between groups (p = 0.69). First pass isolation rates for left and right PVs were 85% and 61% respectively, with similar rates in both groups (p = 0.37, p = 0.65 respectively). HPSD group had shorter RF time (1613 vs 2303 secs, p <0.04), and fluoroscopy times (11.4 vs 13.1 mins, p = 0.05). Procedural times were lower in HPSD, although not significant (133.7 vs 150.8 mins, p = 0.10). Post ablation endoscopy showed 4 cases of ETI (4.5%), with equal occurrence in HPSD and LPLD (p = 1.0). All ETIs were class 2a (superficial ulcer), and treated with PPI therapy. Esophageal injuries not attributable to RF ablation occurred in 9 (10%), with no difference between groups (p = 0.29). There was no difference in AF recurrence between the 2 groups (post 3 months blanking period) after a mean follow up of 6.3 months (p = 0.71).
Conclusion
HPSD ablation was associated with lower RF ablation and fluoroscopy times compared to LPSD, with comparably low rates of ETI on post ablation endoscopy. Our findings suggest that HPSD ablation is a safe and efficacious approach to PVI. However clinicians should be cognisant of the potential injury risk related to esophageal instrumentation from transesophageal echo/ ETM probes.
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Al-Kaisey A, Parameswaran R, Anderson R, Chieng D, Hawson J, Voskoboinik A, Sugumar H, Wong G, West D, Azzopardi S, Joseph S, McLellan A, Ling L, Bryant C, Finch S, Sanders P, Lee G, Kistler P, Kalman J. Randomised Evaluation of the Impact of Catheter Ablation on Cognitive Function in Atrial Fibrillation. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Segan L, Chieng D, Lee G, Sugumar H, Voskoboinik A, Ling L, Morton J, Kalman J, Kistler P, Prabhu S. The Impact of Atrial Scarring on AF Recurrence and LV Recovery in AF-Mediated Cardiomyopathy. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Chieng D, Segan L, Sugumar H, Al-Kaisey A, Hawson J, Moore B, Nam M, Voskoboinik A, Prabhu S, Ling L, Ng J, Brown G, Lee G, Morton J, Debinski H, Kalman J, Kistler P. High Power Short Duration (HPSD) is Safe and Improves Outcomes for Atrial Fibrillation Ablation vs Lower Power Longer Duration (LPLD): A Prospective Multi-Centre Randomised Controlled Study (Hi-Lo HEAT trial). Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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58
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Jumaah H, Kistler P, Mariani J, Patel H, Hare J, Kaye D, Taylor A, Voskoboinik A. Cardiac MRI Findings in Patients presenting With Advanced Conduction System Disease. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Chieng D, Canovas R, Segan L, Sugumar H, Voskoboinik A, Prabhu S, Ling L, Lee G, Morton J, Kaye D, Kalman J, Kistler P. Effects of Habitual Coffee Consumption on Incident Cardiovascular Disease, Arrhythmia, and Mortality: Long Term Outcomes From the UK Biobank. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Chieng D, Kistler P, Canovas R, Kaye D, Morton J, Lee G, Ling L, Prabhu S, Voskoboinik A, Sugumar H, Segan L, Kalman J. Regular Coffee Intake Is Safe and Associated With Improved Mortality in Prevalent Cardiovascular Disease and /or Arrhythmia. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Segan L, Canovas R, Nanayakkara S, Chieng D, Prabhu S, Sugumar H, Voskoboinik A, Ling L, Morton J, Lee G, Kalman J, Kistler P. Development and Validation of the HARMS2-AF Lifestyle Risk Score to Predict Incident AF. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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62
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Chieng D, Sugumar H, Segan L, Tan C, Vizi D, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Morton J, Lee G, Mariani J, Le Gerche A, Kistler P, Kalman J, Kaye D, Ling L. Catheter Ablation in Atrial Fibrillation and Heart Failure With Preserved Ejection Fraction Improves Peak Pulmonary Capillary Wedge Pressure, Exercise Capacity and Quality of Life. A Prospective Randomised Controlled Trial (RCT-STALL HFpEF). Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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63
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Segan L, Canovas R, Nanayakkara S, Chieng D, Prabhu S, Ling L, Voskoboinik A, Sugumar H, Lee G, Morton J, Kalman J, Kistler P. Development of an AF Lifestyle Score for Risk Prediction in Incident AF. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chieng D, Sugumar H, Ling LH, Segan L, Azzopardi S, Prabhu S, Al-Kaisey A, Voskoboinik A, Parameswaran R, Morton JB, Pathik B, McLellan AJ, Lee G, Wong M, Finch S, Pathak RK, Raja DC, Sanders P, Sterns L, Ginks M, Reid CM, Kalman JM, Kistler PM. Catheter ablation for persistent atrial fibrillation: A multicenter randomized trial of pulmonary vein isolation (PVI) versus PVI with posterior left atrial wall isolation (PWI) - The CAPLA study. Am Heart J 2022; 243:210-220. [PMID: 34619143 DOI: 10.1016/j.ahj.2021.09.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The success of pulmonary vein isolation (PVI) is reduced in persistent AF (PsAF) compared to paroxysmal AF. Adjunctive ablation strategies have failed to show consistent incremental benefit over PVI alone in randomized studies. The left atrial posterior wall is a potential source of non-PV triggers and atrial substrate which may promote the initiation and maintenance of PsAF. Adding posterior wall isolation (PWI) to PVI had shown conflicting outcomes, with earlier studies confounded by methodological limitations. OBJECTIVES To determine whether combining PWI with PVI significantly improves freedom from AF recurrence, compared to PVI alone, in patients with PsAF. METHODS This is a multi-center, prospective, international randomized clinical trial. 338 patients with symptomatic PsAF refractory to anti-arrhythmic therapy (AAD) will be randomized to either PVI alone or PVI with PWI in a 1:1 ratio. PVI involves wide antral circumferential pulmonary vein (PV) isolation, utilizing contact force sensing ablation catheters. PWI involves the creation of a floor line connecting the inferior aspect of the PVs, and a roof line connecting the superior aspect of the PVs. Follow up is for a minimum of 12 months with rhythm monitoring via implantable cardiac device and/or loop monitor, or frequent intermittent monitoring with an ECG device. The primary outcome is freedom from any documented atrial arrhythmia of > 30 seconds off AAD at 12 months, after a single ablation procedure. CONCLUSIONS This randomized study aims to determine the success and safety of adjunctive PWI to PVI in patients with persistent AF.
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Higuchi S, Tchou PJ, Voskoboinik A, Goldberger JJ, Nazer B, Dewland TA, Danon A, Belhassen B, Scheinman MM. Reply: Multiform Ventricular Tachycardia With Conduction System Participation: Is There a Fourth-Limb of the His. JACC Clin Electrophysiol 2021; 7:1626-1627. [PMID: 34949432 DOI: 10.1016/j.jacep.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022]
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66
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Wong GR, Nalliah CJ, Lee G, Voskoboinik A, Chieng D, Prabhu S, Parameswaran R, Sugumar H, Al-Kaisey A, McLellan A, Ling LH, Sanders P, Kistler PM, Kalman JM. Sex-Related Differences in Atrial Remodeling in Patients With Atrial Fibrillation: Relationship to Ablation Outcomes. Circ Arrhythm Electrophysiol 2021; 15:e009925. [PMID: 34937397 DOI: 10.1161/circep.121.009925] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Population studies have demonstrated a range of sex differences including a higher prevalence of atrial fibrillation (AF) in men and a higher risk of AF recurrence in women. However, the underlying reasons for this higher recurrence are unknown. This study evaluated whether sex-based electrophysiological substrate differences exist to account for worse AF ablation outcomes in women. METHODS High-density electroanatomic mapping of the left atrium was performed in 116 consecutive patients with AF. Regional analysis was performed across 6 left atrium segments. High-density maps were created using a multipolar catheter (Biosense Webster) during distal coronary sinus pacing at 600 and 300 ms. Mean voltage and conduction velocity was determined. Complex fractionated signals and double potentials were manually annotated. RESULTS Overall, 42 (36%) were female, mean age was 61±8 years and AF was persistent in 52%. Global mean voltage was significantly lower in females compared with males at 600 ms (1.46±0.17 versus 1.84±0.15 mV, P<0.001) and 300 ms (1.27±0.18 versus 1.57±0.18 mV, P=0.013) pacing. These differences were seen uniformly across the left atrium. Females demonstrated significant conduction velocity slowing (34.9±6.1 versus 44.1±6.9 cm/s, P=0.002) and greater proportion of complex fractionated signals (9.9±1.7% versus 6.0±1.7%, P=0.014). After a median follow-up of 22 months (Q1-Q3: 15-29), females had significantly lower single-procedure (22 [54%] versus 54 [75%], P=0.029) and multiprocedure (24 [59%] versus 60 [83%], P=0.005) arrhythmia-free survival. Female sex and persistent AF were independent predictors of single and multiprocedure arrhythmia recurrence. CONCLUSIONS Female patients demonstrated more advanced atrial remodeling on high-density electroanatomic mapping and greater post-AF ablation arrhythmia recurrence compared with males. These changes may contribute to sex-based differences in the clinical course of females with AF and in part explain the higher risk of recurrence.
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Navani RV, Koh Y, Voskoboinik A. Syncope in a young male. Eur Heart J Case Rep 2021; 5:ytab458. [PMID: 34870089 PMCID: PMC8634506 DOI: 10.1093/ehjcr/ytab458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/27/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022]
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Shirwaiker A, William J, Mariani J, Kistler P, Patel H, Voskoboinik A. Long-term implications of pacemaker insertion in younger adults: a single centre experience. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The long-term implications of pacemaker insertion in younger adults are poorly described in the literature.
Methods
We performed a retrospective analysis of consecutive younger adult patients (18–50 years) undergoing pacemaker implantation at a quaternary hospital between 1986–2020. Defibrillators and cardiac resynchronisation therapy devices were excluded. All clinical records, pacemaker checks and echocardiograms were reviewed.
Results
81 patients (39.5±9.6 years, 53% male) underwent pacemaker implantation. Indications were complete heart block (41%), sinus node dysfunction (33%), high grade AV block (11%) and tachycardia-bradycardia syndrome (7%). During a median 7.6 (IQR=0.6–14.8) years follow-up, 9 patients (11%) developed 13 late device-related complications (generator or lead malfunction requiring reoperation (n=11), device infection (n=1) and pocket revision (n=1)). Five of these patients were <40 years old at time of pacemaker insertion. At long-term follow-up, a further 9 patients (11%) experienced significant symptoms from inadequate lead performance managed with device reprogramming. Sustained ventricular tachycardia was detected in 2 patients (2%). Deterioration in ventricular function (LVEF decline >10%) was observed in 14 patients (17%) and 7 of these patients required subsequent biventricular upgrade. Furthermore, 4 patients (5%) developed new tricuspid regurgitation (≥ moderate-severe). Of 69 patients with available long-term pacing data, minimal pacemaker utilisation (pacing <5% at all checks) was observed in 13 (19%) patients.
Conclusions
Pacemaker insertion in younger adults has significant long-term implications. Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.
Funding Acknowledgement
Type of funding sources: None.
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Block T, Paratz E, La Gerche A, Stub D, Strathmore N, Mond H, Kistler P, Kalman J, Burke M, Voskoboinik A. Unearthing the evidence: post-mortem interrogation of cardiac implantable electronic devices. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The diagnostic yield of post-mortem interrogation of cardiac implantable electronic devices (CIEDs) including pacemakers, defibrillators and implantable loop recorders has not been well described.
Methods
We reviewed all post-mortem CIED interrogations performed by our statewide Institute of Forensic Medicine between 2005–2020 for investigation of sudden or unexplained death.
Results
260 patients (68.8% male, median age 72.8 years [IQR 62.7–82.2]) underwent post-mortem CIED interrogation (202 pacemakers, 56 defibrillators and 2 loop recorders). CIEDs were implanted for a median of 2.0 [IQR 0.75–5] years, with 19 devices requiring replacement (and 5 end of life). Post-mortem interrogation was successful in 256 (98.5%) cases. Potential CIED malfunction was identified in 21 (8.1%) cases: untreated ventricular arrhythmias (n=13), lead failures (n=3) and battery depletion (n=5). CIED interrogation directly informed cause of death in 130 (50.0%) cases, with fatal ventricular arrhythmias identified in 121 patients (46.5%). In retrospect, 72 (27.7%) patients had abnormalities recorded by their device in the 30 days preceding death: non-sustained ventricular tachycardia (n=26), rapid atrial fibrillation (n=17), longevity concerns (n=22), intrathoracic impedance alarms (n=3), lead issues (n=3) or therapy delivered (n=1). In 6 cases where the patient was found deceased after a prolonged time, CIED interrogation accurately determined time of death. In one case, CIED interrogation was the primary method of patient identification.
Conclusion
Post-mortem CIED interrogation frequently contributes important information regarding critical device malfunction, pre-mortem abnormalities, cause and time of death or patient identity. Device interrogation should be considered for select patients with CIEDs undergoing autopsy.
Funding Acknowledgement
Type of funding sources: None.
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Nalliah CJ, Wong GR, Lee G, Voskoboinik A, Kee K, Goldin J, Watts T, Linz D, Wirth D, Parameswaran R, Sugumar H, Prabhu S, McLellan A, Ling H, Joseph S, Morton JB, Kistler P, Sanders P, Kalman JM. Sleep apnoea has a dose-dependent effect on atrial remodelling in paroxysmal but not persistent atrial fibrillation: a high-density mapping study. Europace 2021; 23:691-700. [PMID: 33447844 DOI: 10.1093/europace/euaa275] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022] Open
Abstract
AIMS Obstructive sleep apnoea (OSA) associates with atrial fibrillation (AF), but the relationship of OSA severity and AF phenotype with the atrial substrate remains poorly defined. We sought to define the atrial substrate across the spectrum of OSA severity utilizing high-density mapping. METHODS AND RESULTS Sixty-six consecutive patients (male 71%, age 61 ± 9) having AF ablation (paroxysmal AF 36, persistent AF 30) were recruited. All patents underwent formal overnight polysomnography and high-density left atrial (LA) mapping (mean 2351 ± 1244 points) in paced rhythm. Apnoea-hypopnoea index (AHI) (mean 21 ± 18) associated with lower voltage (-0.34, P = 0.005), increased complex points (r = 0.43, P < 0.001), more low-voltage areas (r = 0.42, P < 0.001), and greater voltage heterogeneity (r = 0.39, P = 0.001), and persisted after multivariable adjustment. Atrial conduction heterogeneity (r = 0.24, P = 0.025) but not conduction velocity (r = -0.09, P = 0.50) associated with AHI. Patchy regions of low voltage that co-localized with slowed conduction defined the atrial substrate in paroxysmal AF, while a diffuse atrial substrate predominated in persistent AF. The association of AHI with remodelling was most apparent among paroxysmal AF [LA voltage: paroxysmal AF -0.015 (-0.025, -0.005), P = 0.004 vs. persistent AF -0.006 (-0.017, 0.005), P = 0.30]. Furthermore, in paroxysmal AF an AHI ≥ 30 defined a threshold at which atrial remodelling became most evident (nil-mild vs. moderate vs. severe: 1.92 ± 0.42 mV vs. 1.84 ± 0.28 mV vs. 1.34 ± 0.41 mV, P = 0.006). In contrast, significant remodelling was observed across all OSA categories in persistent AF (1.67 ± 0.55 mV vs. 1.50 ± 0.66 mV vs. 1.55 ± 0.67 mV, P = 0.82). CONCLUSION High-density mapping observed that OSA associates with marked atrial remodelling, predominantly among paroxysmal AF cohorts with severe OSA. This may facilitate the identification of AF patients that stand to derive the greatest benefit from OSA management.
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Voskoboinik A, Im SI, Higuchi S, Lee AC, Rahmutula D, Marcus GM, Olgin JE, Vittinghoff E, Bibby D, Abraham T, Gerstenfeld EP. B-AB04-02 FREQUENT PREMATURE ATRIAL CONTRACTIONS LEAD TO ADVERSE ATRIAL REMODELING AND ATRIAL FIBRILLATION IN A SWINE MODEL. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Higuchi S, Voskoboinik A, Goldberger JJ, Nazer B, Dewland TA, Danon A, Belhassen B, Tchou PJ, Scheinman MM. B-PO01-085 ARRHYTHMIAS UTILIZING VENTRICULAR-NODAL OR VENTRICULAR-HISIAN PATHWAYS: A STRUCTURED APPROACH TO DIAGNOSIS AND MANAGEMENT. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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73
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Higuchi S, Il Im S, Voskoboinik A, Lee A, Marcus GM, Olgin J, Bibby D, Abraham T, Gerstenfeld EP. B-PO02-140 EFFECT OF ATRIAL ECTOPY COUPLING INTERVAL ON ATRIAL STRUCTURAL REMODELLING AND ATRIAL FIBRILLATION IN A SWINE MODEL. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Higuchi S, Voskoboinik A, Goldberger JJ, Nazer B, Dewland TA, Danon A, Belhassen B, Tchou PJ, Scheinman MM. Arrhythmias Utilizing Concealed Nodoventricular or His-Ventricular Pathways: A Structured Approach to Diagnosis and Management. JACC Clin Electrophysiol 2021; 7:1588-1599. [PMID: 34332874 DOI: 10.1016/j.jacep.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to describe the electrophysiologic characteristics, diagnostic maneuvers, and treatment of a series of arrhythmias using concealed nodoventricular (cNV) or His-ventricular (cHV) pathways. BACKGROUND Confirming the presence and participation of cNV or cHV pathways in tachyarrhythmias is challenging. METHODS We present 4 cases of tachycardias with a participatory cNV or cHV pathway. RESULTS The first patient had a narrow complex tachycardia with ventriculoatrial dissociation. Findings of an entrainment pacing from the right ventricle and fused premature ventricular complexes suggested cNV pathway involvement. The second patient had nonsustained narrow complex tachycardia with more ventricular than atrial complexes. The tachycardia exhibited an anterograde His-right bundle (RB) activation sequence and normal His-ventricular (HV) interval and consistently terminated with fused ventricular extra stimuli, suggesting cNV pathway participation. The third patient had a wide complex tachycardia (WCT) with either a right or left bundle branch block pattern. The WCT showed an eccentric His-RB activation sequence and short HV interval and terminated with fused premature ventricular complexes, suggesting a cHV (or concealed fasciculoventricular) pathway involvement. The fourth patient had a WCT with alternating bundle branch block morphologies with a short HV interval. Entrainment from the basal right ventricle demonstrated fusion and a short postpacing interval, suggesting cHV (or fasciculoventricular) pathway involvement. Ablation at the proximal RB rendered the tachycardia noninducible. CONCLUSIONS A structured approach can help diagnose and treat cNV or cHV pathways. We emphasize the importance of evaluating both the His-RB activation pattern and HV interval during sinus rhythm and tachycardia as well as the ventricular pacing study.
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Chieng D, Sugumar H, Kaye D, Azzopardi S, Vizi D, Rossi E, Voskoboinik A, Prabhu S, Ling LH, Lee G, Kalman JM, Kistler PM. Prone and Supine 12-Lead ECG Comparisons: Implications for Cardiac Assessment During Prone Ventilation for COVID-19. JACC Clin Electrophysiol 2021; 7:1348-1357. [PMID: 34217662 PMCID: PMC8245052 DOI: 10.1016/j.jacep.2021.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 12/29/2022]
Abstract
Objectives This study sought to describe expected changes in a mirror-image prone electrocardiogram (ECG) compared with normal supine, including a range of cardiac conditions. Background Unwell COVID-19 patients are at risk of cardiac complications. Prone ventilation is recommended but poses practical challenges to acquisition of a 12-lead ECG. The effects of prone positioning on the ECG remain unknown. Methods 100 patients each underwent 3 ECGs: standard supine front (SF); prone position with precordial leads attached to front (PF); and prone with precordial leads attached to back in a mirror image to front (PB). Results Prone positioning was associated with QTc prolongation (PF 437 ± 32 ms vs. SF 432 ± 31 ms; p < 0.01; PB 436 ± 34 ms vs. SF 432 ± 31 ms; p = 0.02). In leads V1 to V3 on PB ECG, a qR morphology was present in 90% and changes in T-wave polarity in 84%. In patients with anterior ischemia, ST-segment changes in V1 to V3 on supine ECG were no longer visible on PB in 100% and replaced by an R-wave in V1. Bundle branch block (BBB) remained detectable in 100% on PB, with left BBB appearing as right BBB on PB in 71% and QRS narrowing with qR in V1 for right BBB. ST-segment/T-wave changes in limb leads and arrhythmia detection were largely unaffected in PB. Conclusions As expected, the PB ECG is unreliable for the detection of anterior myocardial injury but remains useful for ST-segment/T-wave abnormalities in limb leads, BBB detection, and rhythm monitoring. The prone ECG is a useful screening tool with diagnostic utility in COVID-19 patients who require prone ventilation.
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