Usefulness of ‘figure-of-eight’ suture to achieve haemostasis after removal of 15-French calibre femoral venous sheath in patients undergoing cryoablation

Vascular Access and Closure Management for Electrophysiological Interventions: Small Interventions Big Impact

PURPOSE OF THE REVIEW

This review examines the role of vascular access and closure management in cardiac electrophysiology (EP) procedures, emphasising their impact on patient outcomes and safety. It synthesises current evidence and highlights advancements, challenges, and opportunities in this critical area of EP practice.

RECENT FINDINGS

Ultrasound-guided vascular access has significantly reduced complications and improved success rates compared to traditional methods. Vascular closure devices (VCDs) enable faster recovery and same-day discharge, becoming superior alternatives to manual compression. The "4P framework"- Plan, Prepare, Puncture, Protect- offers a structured approach to optimising vascular access. Alternative techniques, such as transhepatic and jugular access, are feasible in complex cases, though large-scale evidence is limited. Vascular access management is essential for EP procedures, demanding adequate planning and execution. While advancements in imaging and closure techniques enhance outcomes, further research is needed to standardise practices and evaluate long-term results. A personalised, systematic approach ensures optimal procedural success and patient care.

Purse string suture for rapid access hemostasis after removal of large-caliber femoral venous delivery sheaths in children with atrial septal defects

OBJECTIVES

To evaluate the efficacy and safety of purse-string sutures (PSS) compared with manual compression for access hemostasis in children with atrial septal defects (ASDs) after large-caliber venous delivery sheaths removal.

METHODS

We conducted a retrospective clinical data review of 271 children with ASDs who underwent transcatheter device closure through large-caliber venous delivery sheaths (≥ 8 Fr) at our institution from January 2018 to January 2023. The PSS group (n = 144) was compared to the control group (n = 127), which underwent manual compression for femoral venous hemostasis after sheath removal, focusing on hemostatic time, limb braking time, bed rest time, hospital stay, and vascular access complications. Two days post-catheterization, the sutures were taken out and a vascular ultrasound found the evidence of thrombosis, embolism, or venous narrowing.

RESULTS

Compared to the control group, the PSS group had significantly shorter average hemostatic time (4.63 ± 1.95 min vs. 19.69 ± 5.64 min), limb braking time (6.83 ± 2.25 h vs. 13.45 ± 2.87 h), and bed rest time (8.69 ± 1.43 h vs. 22.93 ± 2.24 h) (all, p < 0.001). There were no statistically significant differences in hospital stay and complications between the two groups.

CONCLUSIONS

The PSS is a simple, effective, and safe procedure that may play a valuable role in achieving rapid hemostasis after the removal of the large-caliber venous delivery sheaths in children. It allows earlier mobilization, reduces bed rest time, and alleviates discomfort compared to manual compression.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

[My patients can go home in the evening after pulmonary vein isolation : Pros and cons]

Given the background of optimizing financial and personnel resources while aligning with patient needs, the concept of same-day discharge following pulmonary vein isolation (PVI) appears attractive. However, a non-selective approach to different strategies is inappropriate, as is often the case in medicine. A "one size fits all" approach is therefore not advisable for outpatient PVI. Instead, the primary focus should be on identifying which patients can safely and effectively undergo PVI in an outpatient setting and which patients would benefit from inpatient care. Both procedural and patient-specific criteria should be considered in this context. In addition, structural prerequisites must also be met. Ultimately, the decision as to whether outpatient PVI is feasible should remain with the treating physician and the patient.

Efficacy and safety of the VASCADE® MVP venous vascular closure device in patients undergoing percutaneous left atrial appendage occlusion with WATCHMAN

BACKGROUND

The VASCADE MVP venous vascular closure system is commonly used for percutaneous venotomy closure in catheter-based procedures utilizing sheath sizes 6-12 French. However, its application with larger sheaths such as ones required in left atrial appendage occlusion (LAAO) has yet to be explored.

AIMS

This study compared the efficacy and safety of VASCADE MVP versus conventional Figure-of-8 sutures (Fo8) for femoral venotomy closure in patients undergoing Watchman LAAO.

METHODS

This single-center retrospective analysis included patients who underwent post-LAAO femoral venotomy closure with either VASCADE MVP or Fo8 sutures. The primary efficacy endpoint was time to hemostasis (TTH). Primary safety endpoints were 30-day access site-related readmissions and major complications. Minor access-site-related complications were also assessed.

RESULTS

107 patients underwent post-LAAO femoral venotomy closure with VASCADE MVP, of which 101 were successful (94.4%). 99 patients underwent conventional closure with Fo8 sutures and supplemental manual pressure. Baseline characteristics were similar between groups. TTH was significantly shorter with VASCADE MVP (152.9 vs. 335.8 s, p = 0.001). Major safety outcomes were comparable. However, the conventional group experienced a higher incidence of ecchymosis (16.2% vs 4.7%, p = 0.007) and 30-day all-cause readmission (18.2% vs 8.4%, p = 0.038).

CONCLUSIONS

VASCADE MVP significantly reduced TTH compared to Fo8 sutures after LAAO. While demonstrating a similar safety profile, VASCADE MVP may offer a more efficient approach to femoral vein closure in this patient population.

Suture-based techniques versus manual compression for femoral venous haemostasis after electrophysiology procedures

BACKGROUND AND AIMS

Methods for femoral venous haemostasis following electrophysiology (EP) procedures include manual compression (MC) and suture-based techniques such as a figure-of-eight suture secured with a hand-tied knot (Fo8HT) or a modified figure-of-eight suture secured with a 3-way stopcock (Fo8MOD). We hypothesised that short-term bleeding outcomes using the Fo8MOD approach would be superior to MC. We additionally compared outcomes between Fo8MOD and Fo8HT approaches.

METHODS

We studied consecutive patients undergoing EP procedures at our institution between March and December 2023. Patients were categorised into three haemostasis groups: MC, Fo8HT and Fo8MOD. Access site complications were classified as major (requiring intervention or blood transfusion, delaying discharge or resulting in death) or minor (bleeding/haematoma requiring additional compression).

RESULTS

1089 patients were included: MC 718 (65.9%); Fo8HT 105 (9.6%); Fo8MOD 266 (24.4%). Procedures were most commonly for atrial fibrillation (52.4%), atrial flutter (10.9%), and atrioventricular nodal re-entrant tachycardia (10.1%). In patients receiving periprocedural anticoagulation (865, 79.4%), Fo8MOD associated with fewer complications than MC or Fo8HT (major: MC 2.2%, Fo8HT 6.0%, Fo8MOD 0.8%, p = .01; minor: MC 16.5%, Fo8HT 12.0%, Fo8MOD 7.4%, p = .002). In patients not receiving periprocedural anticoagulation, complications did not differ between haemostasis methods (total major and minor complications 5.8%, p = .729 for between groups rates). On multivariable logistic regression, Fo8MOD was associated with a significantly lower risk of access site complications (OR 0.29 [95% CI 0.17-0.48], p < .001), whilst intraprocedural heparinisation (OR 5.25 [2.88-9.69], p < .001) and larger maximal sheath size (OR 1.06 [1.00-1.11], p = .04) were associated with a higher risk of complications.

CONCLUSION

Femoral haemostasis with Fo8MOD associates with fewer access site complications than MC and Fo8HT following EP procedures that need periprocedural anticoagulation.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Preclose Versus Postclose Using Suture-Mediated Vascular Closure System for Catheter Ablation With Femoral Vein Access

BACKGROUND

Differences in the efficacy and safety between the preclose and postclose suture-mediated vascular closure systems for femoral vein access have not been adequately studied.

OBJECTIVES

This study aimed to evaluate the efficacy and safety of these 2 suturing techniques in femoral vein access.

METHODS

Patients subjected to elective catheter ablation via the femoral vein using a sheath of 8- to 13-F inner diameter (n = 282) were randomized to the preclose or postclose groups for the single-suture technique using ProGlide/ProStyle (Abbott Vascular). Duplex ultrasound was performed on days 1 and 90 after the procedure to evaluate vascular complications. The primary efficacy endpoint was rebleeding requiring recompression, and the primary safety endpoint was any major complication occurring within 90 days. The secondary efficacy endpoints included time to hemostasis and time to ambulation, and the secondary safety endpoint was any minor complication occurring within 90 days.

RESULTS

The preclose group demonstrated a significantly lower rebleeding rate (5 of 141 [3.5%] vs 15 of 141 [10.6%]; P = 0.03) and shorter time to hemostasis (254.0 ± 120.4 seconds vs 299.8 ± 208.2 seconds; P = 0.02) compared with the postclose group. Five patients in each group were lost to follow-up at 90 days. Incidence of major complications were similar in both groups (1 of 136 [0.7%]; P = 1.00), whereas minor complications were observed in 18 of 136 (13.2%) and 21 of 136 (15.4%) patients in the preclose and postclose groups, respectively, without a significant difference (P = 0.73).

CONCLUSIONS

In femoral vein access using the single-suture technique with ProGlide/ProStyle, the preclose technique presented a higher hemostasis rate than the postclose technique, without compromising safety.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Venous vascular closure system vs. figure-of-eight suture following atrial fibrillation ablation: the STYLE-AF Study

AIMS

Simplified ablation technologies for pulmonary vein isolation (PVI) are increasingly performed worldwide. One of the most common complications following PVI are vascular access-related complications. Lately, venous closure systems (VCSs) were introduced into clinical practice, aiming to reduce the time of bed rest, to increase the patients' comfort, and to reduce vascular access-related complications. The aim of the present study is to compare the safety and efficacy of using a VCS to achieve haemostasis following single-shot PVI to the actual standard of care [figure-of-eight suture and manual compression (MC)].

METHODS AND RESULTS

This is a prospective, multicentre, randomized, controlled, open-label trial performed at three German centres. Patients were randomized 1:1 to undergo haemostasis either by means of VCS (VCS group) or of a figure-of-eight suture and MC (F8 group). The primary efficacy endpoint was the time to ambulation, while the primary safety endpoint was the incidence of major periprocedural adverse events until hospital discharge. A total of 125 patients were randomized. The baseline characteristics were similar between the groups. The VCS group showed a shorter time to ambulation [109.0 (82.0, 160.0) vs. 269.0 (243.8, 340.5) min; P < 0.001], shorter time to haemostasis [1 (1, 2) vs. 5 (2, 10) min; P < 0.001], and shorter time to discharge eligibility [270 (270, 270) vs. 340 (300, 458) min; P < 0.001]. No major vascular access-related complication was reported in either group. A trend towards a lower incidence of minor vascular access-related complications on the day of procedure was observed in the VCS group [7 (11.1%) vs. 15 (24.2%); P = 0.063] as compared to the control group.

CONCLUSION

Following AF ablation, the use of a VCS results in a significantly shorter time to ambulation, time to haemostasis, and time to discharge eligibility. No major vascular access-related complications were identified. The use of MC and a figure-of-eight suture showed a trend towards a higher incidence of minor vascular access-related complications.

Efficacy and safety of post-closure technique using Perclose ProGlide/ProStyle device for large-bore mechanical circulatory support access sites

PURPOSE

Mechanical circulatory support (MCS) using a venoarterial extracorporeal membrane oxygenation (VA-ECMO) device or a catheter-type heart pump (Impella) is critical for the rescue of patients with severe cardiogenic shock. However, these MCS devices require large-bore cannula access (14-Fr and larger) at the femoral artery or vein, which often requires surgical decannulation.

METHODS

In this retrospective study, we evaluated post-closure method using a percutaneous suture-mediated vascular closure system, Perclose ProGlide/ProStyle (Abbott Vascular, Lake Bluff, IL, Perclose), as an alternative procedure for MCS decannulation. Closure of 83 Impella access sites and 68 VA-ECMO access sites performed using Perclose or surgical method between January 2018 and March 2023 were evaluated.

RESULTS

MCS decannulation using Perclose was successfully completed in all access sites without surgical hemostasis. The procedure time of ProGlide was shorter than surgical decannulation for both Impella and VA-ECMO (13 min vs. 50 min; p < 0.001, 21 min vs. 65 min; p < 0.001, respectively). There were no significant differences in the 30-day survival rate and major adverse events by decannulation including arterial dissection requiring endovascular treatment, hemorrhage requiring a large amount of red blood cell transfusion, and access site infection.

CONCLUSION

Our results suggest that the post-closure technique using the percutaneous suture-mediated closure system appears to be a safe and effective method for large-bore MCS decannulation.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Anatomical variation of femoral vessels and ultrasound-guided femoral vein puncture for catheter ablation of arrhythmias

OBJECTIVE

This study aims to investigate the anatomical variations in femoral vasculature and evaluate the clinical value of ultrasound-guided femoral vein puncture in catheter ablation procedures.

METHODS

In this retrospective analysis conducted from January 2023 to March 2023, we examined data from patients who underwent catheter ablation with ultrasound-guided femoral venipuncture. We evaluated the anatomy of the femoral vasculature at both high and low inguinal levels. Based on the relationship between the femoral vein and artery, we classified the anatomy into four types: Type I (vein parallel to artery without overlap), Type II (vein medial to artery with lumen overlap ≤50%), Type III (vein posterior to artery with lumen overlap > 50%), and Type IV (vein lateral to artery). Additionally, we assessed procedure-related vascular complications that required interventions or prolonged hospital stays.

RESULTS

A total of 254 patients were included in this study. At the upper inguinal level, most cases (92.5%) exhibited Type II, followed by Type I (6.5%), while Type III (0.6%) and IV (0.4%) were less common. At the lower inguinal level, Type II accounted for 70.7%, there was a significantly higher proportion of Type III (23.4%) and Type IV (5.9%). The overall complication rate was 0.4%, no pseudoaneurysm or hematoma was observed in our study.

CONCLUSION

Our study revealed significant anatomical variations in the relationship between the femoral vein and femoral artery. Ultrasound-guided femoral venipuncture significantly reduced vascular complication rate, making it a valuable tool for guiding puncture procedures.

A Novel Hemostatic Belt Allowing Ambulation Soon After Atrial Fibrillation Ablation

We aimed to develop a hemostatic device with physiological evidence that allows ambulation soon after atrial fibrillation (AF) ablation. We measured right femoral vein pressure in 57 participants to clarify why groin post-venipuncture rebleeding often occurs during the transition from supine to sitting under compression bandage application and found that it increased more than threefold when raising the upper body (8.6 ± 4.1 to 27.6 ± 6.9 mmHg; P < 0.001). Based on that data, we created a novel hemostatic belt. Its capability test including 25 participants demonstrated that the belt gave much higher compression pressures on the right groin while sitting than the compression bandage (59.5 ± 14.9 vs. 8.1 ± 4 mmHg; P < 0.001), achieving pressures above the maximum femoral vein pressure in 92% of participants. A randomized trial comparing the belt with compression bandage in 74 AF patients demonstrated that the belt reduced time to ambulation without any rebleeding (340 [92.5-360] vs. 360 [360-360] min; P < 0.001) and satisfied more patients. The novel hemostatic belt provided a much higher compression pressure on the right groin during the sitting position than the conventional compression bandage, achieving a pressure above the maximum femoral vein pressure in 92% of the participants.

Comparison of pulsed-field ablation versus very high power short duration-ablation for pulmonary vein isolation

BACKGROUND

The newly introduced nonthermal pulsed field ablation (PFA) is a promising technology to achieve fast pulmonary vein isolation (PVI) with high acute success rates and good safety features. However, previous studies have shown that very high power short duration ablation (VHPSD) is also highly effective and fast to achieve PVI with potentially less arrhythmia recurrence compared to conventional radiofrequency ablation. Data comparing PFA to VHPSD-PVI is lacking.

OBJECTIVE

This study compared procedural and outcome data for PFA-PVI to VHPSD-PVI in patients with paroxysmal or persistent atrial fibrillation (PAF/persAF).

METHODS

Consecutive patients undergoing de novo PVI (PFA or VHPSD) were included in this analysis. For PFA-PVI a pentaspline 20 electrode catheter was used. For VHPSD-PVI an enhanced irrigated catheter with a power setting of 70 W/7 s (70 W/5 s at posterior wall) was employed in conjunction with electro-anatomical mapping. All procedures were performed in deep analgo-sedation.

RESULTS

A total of n = 114 patients (n = 57[50%] PFA, n = 17[30%] PAF; n = 40[70%] persAF) were included in this analysis. PVI was successful in all patients. The PFA group revealed a significantly shorter procedure duration (65 ± 17 min vs. 95 ± 23 min, p < 0.01) but longer fluoroscopy time (PFA 15 ± 5 min and VHPSD 12 ± 3 min; p < 0.001). At follow-up after median 125 days (interquartile range: 109-162) n = 46 PFA (80.7%) and n = 44 VHPSD pts (77.2%) were free from atrial arrhythmia after a single procedure (p = 0.819). Two tamponades occurred in the PFA while in VHPSD two pts suffered groin bleedings. One clinically nonsignificant PV stenosis occurred in the VHPSD group.

CONCLUSION

Pulsed-field ablation and VHPSD-PVI seem to be highly effective and safe to achieve PVI in the setting of PAF and persAF with comparable arrhythmia-free survival. However, procedure duration for PFA PVI is significantly shorter and therefore may be of potential benefit. Compared to PFA VHPSD-PVI might ensure information on left atrial substrate allowing to target concomitant secondary tachycardias.

Comparison of pulsed field ablation and cryoballoon ablation for pulmonary vein isolation

INTRODUCTION

Pulmonary vein isolation (PVI) remains the cornerstone in the treatment of atrial fibrillation (AF). PVI using cryoballoon (CB) technology has emerged as a standard procedure in many centers. Recently, pulsed field ablation (PFA) has been introduced and used to achieve PVI. First data show high acute and favorable long-term outcomes. So far, data comparing these new "single shot" devices are sparse. We sought to compare procedural and outcome data for first time PFA users versus CB in patients undergoing de novo PVI. Furthermore, potentially postprocedural discomfort and affection of autonomic ganglia were assessed.

METHODS AND RESULTS

A retrospective analysis and comparison of all de novo PVIs with PFA and CB was performed. Furthermore, PFA PVI learning curve was evaluated. During follow-up, repeat outpatient visits and Holter electrocardiogram were performed to analyze arrhythmia-free survival. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI. Potential changes in heart rate (HR) between baseline and at 3-month follow-up were evaluated. A total of 108 patients (54 PFA and 54 CB; PFA; 33 (30%) female) with paroxysmal and persistent AF were analyzed. Type of AF was comparable (Patients suffering from PAF: PFA: 16 (30%), CB: 17 (31%), p = 1.0). In 107 (99%) patients, successful PVI was achieved. Transient phrenic palsy omitted complete PVI in one CB patient. A trend for a shorter overall procedure duration was observed in the PFA group (PFA: 64.5 ± 17.5 min; CB: 73.0 ± 24.8 min; p = 0.07). Excluding LA mapping time (first 14 cases), procedure time was significantly shorter using PFA (PFA: 58.0 ± 12.5 min, CB: 73.0 ± 24.8 min, p = 0.0001). Fluoroscopy time was significantly longer for PFA (PFA: 15.3 ± 4.7 min, CB: 12.3 ± 5.3 min; p = 0.001), but significantly less contrast medium was used (PFA: 12 ± 6 mL; CB: 51 ± 29 mL, p < 0.0001). Subgroup analysis of the PFA group revealed a significant shortening of procedure duration over time (first tertile: 72.7 ± 13.5 min, second tertile: 67.3 ± 21.7 min, third tertile: 53.4 ± 9.8 min, first vs. third tertile p < 0.0001). Two cardiac tamponades occurred in the PFA group (p = 0.495), of which one was most likely related to complex transseptal puncture. In the first 48 h after PVI, the number of prescribed analgesics due to postprocedural pain was equal between both groups (PFA: 7 (13%) patients, CB: 10 (19%) patients, p = 0.598). After a FU of 273 ± 129 days, 35 of 47 patients (74%) after PFA and 36 of 50 patients (72%) after CB PVI were free of any atrial arrhythmia (HR: 0.98, p = 0.88). Only in the PFA group, a significant increase in HR 3 months after PVI was observed (pre-PVI: 61 ± 8 beats/min, post-PVI: 65 ± 9 beats/min, p = 0.008).

CONCLUSION

The new PFA technology is equally effective and safe as compared to CB for complete PVI with potentially shorter procedure time and significantly less contrast medium. However, AF recurrence rates after PFA PVI seem to be comparable to CB PVI.

Clinical and economic outcomes of a systematic same-day discharge programme after pulmonary vein isolation: comparison between cryoballoon vs. radiofrequency ablation

AIMS

Same-day discharge (SDD) is feasible after pulmonary vein isolation (PVI). We aim to compare prospectively cryoballoon (CRYO) vs. radiofrequency (RF) ablation in a systematic SDD programme.

METHODS AND RESULTS

We prospectively analysed the 617 scheduled PVI performed consecutively at our institution (n = 377 CRYO, n = 240 RF) from 1 April 2019 to 31 December 2022 within a systematic programme of SDD. The feasibility of SDD, the 10-day incidence of urgent/unplanned medical care after discharge (UUC-10), and the cost per procedure due to hospital resource use were studied. The 100 procedures performed during the previous year, in which patients were systematically hospitalized, were used as a control group. Same-day discharge was achieved in 585/617 (95%) procedures, with a significant trend towards a higher monthly SDD rate from 2019 to 2022 (P = 0.03). The frequency of SDD was similar in CRYO (356/377; 94%) vs. RF (229/240; 95%). After SDD, the UUC-10 was 66/585 (11.3%), being similar for CRYO (41/356; 11.5%) and RF (25/229; 10.9%); P = 0.8 (log-rank test). Of these, 10 patients were re-hospitalized, with an identical rate in CRYO-treated (6/356; 1.7%) and RF-treated (4/229; 1.7%) patients and owing to similar causes (4 haematomas, 4 pericarditis, and 2 symptomatic sinus node dysfunction). Same-day discharge was associated with an average savings per procedure of 63% (P < 0.001), but no differences were found between the CRYO and RF (P = 0.8).

CONCLUSION

In a systematic SDD programme, feasibility (95%, increasing over time), safety (11% UUC-10, 1.7% re-hospitalizations), and savings (63% per procedure) were similar for CRYO and RF ablation procedures.

Left atrial appendage closure for stroke prevention in nonvalvular atrial fibrillation: A current overview

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and its prevalence increases with age. AF causes palpitations, heart failure, and cardiogenic embolism. Of them, the most critical and fatal complication is a cardio-embolic event. Oral anticoagulation plays a central role in reducing stroke risk in AF patients. Recently, when oral anticoagulation is considered in patients with non-valvular AF who are eligible for direct oral coagulations, they are preferred to vitamin K antagonist based on accumulating evidence. Although many patients can tolerate oral anticoagulation, there is a subset of patients who cannot tolerate long-term oral anticoagulation. Such a subset has a higher bleeding risk as indicated by the HAS-BLED score under oral anticoagulation. This subset of patients requires effective and safe non-pharmacological alternative therapies for stroke prevention. One of the promising non-pharmacological therapies is left atrial appendage closure. Three randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using WATCHMAN family to oral anticoagulation (Boston Scientific, Marlborough, MA, USA). WATCHMAN FLX, which was innovated following WATCHMAN 2.5, was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved issues remain, including device-related thrombosis, post-treatment antithrombotic therapy, and peri-device leakage. Left atrial appendage closure for patients with non-valvular AF may be an alternative therapy to avoid cardiac embolism for high bleeding risk patients with contraindications to long-term oral anticoagulation therapy.

Innovations in atrial fibrillation ablation

BACKGROUND

Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology.

METHODS

We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets.

RESULTS

Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation.

CONCLUSIONS

Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.

Vascular Closure: the ABC's

PURPOSE OF REVIEW

Vascular access and closure is a key part of endovascular procedures, and access site-related complications are an independent predictor of adverse procedural outcomes. The purpose of this review is to discuss the methods of vascular closure including manual compression, vascular closure devices (VCDs) for both arterial and venous arteriotomies, their mechanisms, and access site-related complications.

RECENT FINDINGS

Various VCDs have been approved over the last three decades. These devices have different mechanisms to achieve hemostasis and are generally categorized into active and passive approximators. Studies have largely found that they are non-inferior to manual compression. Uncomplicated vascular closure is pertinent to avoid adverse procedure-related outcomes. The emergence of VCDs has reduced time to hemostasis, facilitating early ambulation and discharge and reducing hospitalization cost with comparable complication rate to manual compression. Nonetheless, they should be used in favorable vascular anatomy and are not intended to reduce complications.

Intraoperative sensing increase predicts long-term pacing threshold in leadless pacemakers

PURPOSE

High pacing threshold (HPT) and very high pacing threshold (VHPT) are known to have a negative impact on leadless pacemaker battery longevity, representing the most common reason for device repositioning. In this study, we evaluated if intraoperative electrical parameters recorded during Micra™ VR implant would be able to predict device performance during follow-up (FU).

METHODS

A total of 93 patients undergoing Micra™ VR implant were retrospectively considered. Patients were enrolled in the study if electrical assessment was performed at least twice at implant, at Micra™ final positioning and after removal of the delivery system. All patients received a FU visit at 1 and 12 month after discharge. R-wave sensing amplitude, pacing threshold (PT), and impedance were recorded at each visit.

RESULTS

When compared to the first assessment, R-wave sensing amplitude increased by 19.1% after 13 ± 4 min (+ 1.71 ± 0.2 mV, 95% CI 1.4 to 2.02; p < .001). Conversely, there was a significant PT decrease of 22.1% at 12-month FU (- 0.22 ± 0.03 V, 95% CI - 0.13 to - 0.31; p < .001). Among patients with HPT, acute increase of R-wave sensing of 1.5 mV after 14 ± 4 min predicted a significant reduction of PT below 1 V/0.24, at 12-month post-implant (R = 0.72, 95% CI 0.13 to 0.33, p < .001), with a sensitivity of 87.5% (95% CI 0.61-0.98) and a specificity of 88.8% (95% CI 0.51-0.99).

CONCLUSION

A 1.5-mV increase in R-wave amplitude at implant is predictive of PT normalization (< 1.0 V/0.24 ms) at 12-month FU. This finding may have practical implications for device repositioning in case of HPT recording at implant.

Efficacy and Safety of Nepcell STM in Achieving Hemostasis After Removal of a 15-Fr Femoral Venous Sheath in Patients Undergoing Cryoballoon Ablation for Atrial Fibrillation

Background: Hemostasis at the femoral venous access site after cryoballoon ablation (CA) for atrial fibrillation (AF) is often prolonged because of aggressive anticoagulation and the use of 15-Fr-caliber sheaths. The Nepcell S^TM (NC) is a newly developed hemostatic pad made of fibrosed calcium alginate extracted from natural seaweed. The calcium ions from the NC accelerate the clotting cascade. This single-center randomized clinical trial assessed the efficacy and safety of the NC in patients undergoing CA for AF.

Methods and Results: In all, 62 patients undergoing CA for non-valvular paroxysmal AF were randomly assigned to either the NC or control group. The primary endpoints of this study were time to hemostasis, internal hemorrhage, and rebleeding. Secondary endpoints were the length of hospital stay (LOS) and vascular complications at 1 month. The time to hemostasis was significantly shorter in NC than control group (mean [±SD] 377±216 vs. 505±241 s; P=0.031). The frequency of internal hemorrhaging (6% vs. 37%; P=0.003) and rebleeding (0% vs. 13%; P=0.033) was lower in the NC than control group, contributing to a decreased LOS in the NC group (3.56±0.67 vs. 4.23±0.73 days; P<0.001). There were no NC-related vascular complications at the 1-month echographic examination.

Conclusions: The use of NC was associated with a shorter hemostasis time and fewer bleeding complications in patients undergoing CA for AF, leading to a shorter LOS.

[Practical guide for safe and efficient cryoballoon ablation for atrial fibrillation : Practical procedure, tips and tricks]

In the current guidelines on treatment of atrial fibrillation, cryoballoon-based catheter ablation of atrial fibrillation is recommended in addition to radiofrequency ablation and has become established as a standard procedure in the clinical routine of many centers for index pulmonary vein isolation. A safe, simplified and often durable pulmonary vein isolation can be achieved by a systematic approach. This review article provides a practical guide for all steps of cryoballoon-based pulmonary vein isolation, including preprocedural preparation and postinterventional follow-up. Both cryoballoon systems currently available on the market are considered.

Femoral venous haemostasis in children and young adults using the 'figure-of-eight' suture technique

AIM

The aim of our study was to evaluate the safety and efficiency of the 'figure-of-eight' suture among children and young adults with congenital heart defects who underwent interventional procedures, in patients with structurally normal hearts who underwent electrophysiological study and in haemodynamically impaired children and newborns. We also reported a novel femoral haemostasis method in patients with a central catheter by modifying the 'figure-of-eight' suture around the catheter for haemorrhage control.

METHOD

Between 2015 and 2018, a total of 100 'figure-of-eight' sutures were performed in 90 patients (48 males, 42 females) where the median age was 12.5 years (minimum 3 days, maximum 22 years). The procedures were diagnostic angiography (n = 6), radiofrequency and/or cryoablation (n = 7) and interventional procedures (n = 87).

RESULT

Haemostasis was achieved in 89 of 90 patients. Haemostasis could not be achieved in one malnourished patient due to lack of subcutaneous tissue. There were no major complications. A bullous skin lesion and minor bleeding were the only complications seen in two patients. A central catheter was inserted in eight patients using the modified 'figure-of-eight' suture technique.

CONCLUSION

The 'figure-of-eight' suture is a safe and effective method for femoral venous haemostasis in patients who require large sheaths for procedures, in those using high-dose heparin and in haemodynamically unstable children who need cardiac catheterisation.

Comparative outcomes of vascular access closure methods following atrial fibrillation/flutter catheter ablation: insights from VAscular Closure for Cardiac Ablation Registry

PURPOSE

This registry compared the safety and efficacy of vascular closure device Perclose (PC) with figure-of-eight stitch (Fo8) and manual compression (MC) following catheter ablation of atrial fibrillation/flutter.

METHODS

VAscular Closure for Cardiac Ablation Registry (VACCAR) is a prospective, observational registry that assessed the time to hemostasis (TTH), time to ambulation (TTA), length of stay (LOS), complications, patient-reported outcomes, and pain medication use.

RESULTS

A total of 434 patients (mean age 64.0±11.0 years; 38% female; 94.9% white) were enrolled between October 2017 and May 2019: 156 in MC, 203 in Fo8, and 75 in the PC group. Median TTH was significantly reduced in the PC and Fo8 group at 7 and 9 min respectively vs. the MC group at 20 min (p<0.001). Median TTA was significantly reduced in both the PC and Fo8 group at 2.2 h vs. the MC group at 6.5 h (p<0.001 for both). Median LOS for the PC group was significantly reduced at 27.5 h compared to the MC and Fo8 group at 29 h (p<0.01). A higher proportion of same-day discharges were noted in the PC and Fo8 groups at 14 (18.7%) and 25 (12.3%), respectively, compared to 5 (3.2%) in the MC group (p<0.01 for all). There was no significant difference in complications between the three groups.

CONCLUSIONS

Both PC and Fo8 are safe with improved TTH, TTA, LOS, and a higher number of same-day discharges compared to MC.

First experience of POLARx™ versus Arctic Front Advance™: An early technology comparison

INTRODUCTION

Cryoballoon ablation is an established technique to achieve pulmonary vein isolation in patients with atrial fibrillation (AF). Recently, a new manufacturer of cryoballoon achieved regulatory CE marking (POLARx™; Boston Scientific). We describe our early experience of using this new market entrant of the technology and describe procedural aspects in comparison to the incumbent Medtronic Arctic Front Advance™.

METHODS

We assessed the first 40 AF ablations performed with the POLARx catheter at the Barts Heart Centre. These patients were compared with a contemporaneous series of patients undergoing ablation by the same operators using the Arctic Front Advance. Procedural metrics were prospectively recorded.

RESULTS

A total of four operators undertook 40 cases using the POLARx catheter, compared with 40 cases using the Arctic Front Advance. Procedure times (60.0 vs. 60.0 min) were similar between the two technologies, however left atrial dwell time (35.0 vs 39.0 min) and fluoroscopy times (3.3 vs. 5.2 min) were higher with the POLARx. Measured nadir and isolation balloon temperatures were significantly lower with POLARx. Almost all veins were isolated with a median freezing time of 16.0 (POLARx) versus 15.0 (Arctic Front Advance) min. The rate of procedural complications was low in both groups.

CONCLUSION

The POLARx cryoballoon is effective for pulmonary vein isolation. Measured isolation and nadir temperatures are lower compared with the predicate Arctic Front Advance catheter. The technology appears similar in acute efficacy and has a short learning curve, but formal dosing studies may be required to prove equivalence of efficacy.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Long-term outcomes of cryoballoon-based left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation

AIMS

Pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (AF) is not as successful as in paroxysmal AF, and recent data indicate the key role of non-PV triggers. We aimed to assess the long-term safety and efficacy of left atrial appendage isolation (LAAi) as an adjunct to PVI using cryoballoon (CB) in persistent AF.

METHODS AND RESULTS

We compared 144 persistent AF patients (59 ± 10 years, 51% females) who underwent PVI combined with LAAi with a propensity-score matched cohort of 138 persistent AF patients (59 ± 6 years, 52% female) in whom PVI-only was performed. Baseline and follow-up data including electrocardiography (ECG), 24-h Holter ECG's, and echocardiography were recorded for all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of AF, atrial flutter, or atrial tachycardia (≥30 s) after a 3-month blanking period. At a mean of 30.5 ± 5.6 months follow-up, 85 (61.6%) patients in the PVI-only group and 109 (75.7%) patients in the PVI+LAAi group were free of ATa after the index procedure (P = 0.008). Ischaemic stroke/transient ischaemic attack was detected in 4 (2.9%) patients in PVI-only group and in 5 (3.5%) patients in the PVI+LAAi group (P = 0.784). Cox regression analysis revealed that the PVI-only strategy was found as a significant predictor for recurrence (hazard ratio 3.01, 95% confidence interval 1.81-5.03; P < 0.001).

CONCLUSIONS

Our findings indicated that CB-based LAAi+PVI was associated with a favourable efficacy compared to PVI-only strategy in patients with persistent AF. Although ischaemic event rates were similar between the groups, rigorous adherence to anticoagulation regime is paramount in order to prevent thrombo-embolic complications.

Venous access-site closure with vascular closure device vs. manual compression in patients undergoing catheter ablation or left atrial appendage occlusion under uninterrupted anticoagulation: a multicentre experience on efficacy and complications

AIMS

Manual compression (MC), widely used to achieve venous access haemostasis, needs prolonged immobilization and extended time-to-haemostasis. Vascular closure devices (VCD) have been reported to have significantly shorter time to haemostasis and ambulation in arterial access-site management. The current study aimed to evaluate the safety and efficacy as well as rate of urinary tract complications in patients receiving MC vs. VCD for venous access-site closure.

METHODS AND RESULTS

A total of 803 consecutive patients undergoing catheter ablation or left atrial appendage closure were classified into the VCD (n = 304) and the MC (n = 499) group, based on the methods used for haemostasis at the venous access site. Foley catheter was used for bladder-emptying in all MC cases and 15 VCD patients. At one site, VCD group patients with experience of MC in prior ablations were asked to describe their overall satisfaction level after comparing the past experience with the present. Haemostasis was achieved effectively in both populations. No VCD cases required >2 h bed rest, whereas 7 (1.4%) patients in the MC group needed prolonged immobilization (P = 0.04). Significantly higher incidence of access-site haematoma (P = 0.004) and urinary complications (P < 0.05) were observed in the MC group. Majority of VCD patients (68%) with prior experience of MC for haemostasis expressed satisfaction over the early ambulation and ability to void urine without bladder catheterization.

CONCLUSION

Vascular closure devices provided effective haemostasis, while reducing the access-site complications, ambulation time, and urinary complications.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Safety and cost-effectiveness of same-day complex left atrial ablation

Background

Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.

Method

Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.

Results

A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.

Conclusions

Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

•

We have previously reported same-day standard catheter ablation is safe, feasible and cost-effective. Data on same-day complex left-atrial ablation are limited.

•

Our multi-centre cohort study of 967 consecutive elective complex left-atrial ablation procedures between January 2011 and December 2019 revealed same-day ablations using conscious sedation were safe and associated with very few complications and could have significant benefits to patients and cost-savings for healthcare providers worldwide.

•

Same-day complex left-atrial ablation procedures can be performed safely without the need for overnight-stay. This has major implications for both patients and healthcare providers, especially given the current financial challenges and Covid-19 pandemic.

Percutaneous transseptal transcatheter mitral valve-in-valve replacement for degenerated mitral bioprosthesis: The first experience in Japan

A 76-year-old woman had received surgical mitral valve replacement with Magna Mitral Ease (Edwards Lifesciences, Irvine, CA, USA) 25 mm for functional severe mitral regurgitation 6 years previously. She presented recurrence of heart failure due to severe stenotic and moderate regurgitant degeneration of the implanted mitral bioprosthesis. Considering her comorbidities and left ventricular systolic dysfunction, our heart valve team eventually decided to perform percutaneous transseptal transcatheter mitral valve-in-valve replacement instead of surgical redo mitral valve replacement, using a 26 mm SAPIEN 3 valve (Edwards Lifesciences) via trans-femoral approach. Post-procedural course was uneventful and she was discharged on post-procedural day 2. This is, to the best of our knowledge, the first case of successful percutaneous transseptal transcatheter mitral valve-in-valve replacement in Japan. Further large-scale prospective studies are warranted to validate its long-term safety and efficacy, particularly by comparing with the redo surgery.

<Learning objective: We experienced an off-label transseptal mitral valve-in-valve replacement using SAPIEN 3 to treat degenerative mitral bioprosthesis for the first time in Japan. Although further large-scale prospective studies are warranted, this procedure should be a promising therapeutic alternative to conventional redo-surgery, particularly for elderly patients with multiple comorbidities.>

Risk factors for venous bleeding complication at the femoral puncture site after catheter ablation of atrial fibrillation

BACKGROUND

Venous bleeding complication is often observed after catheter ablation of atrial fibrillation (AF), but the risk factors remain unclear.

METHODS

We retrospectively evaluated 570 consecutive patients who underwent catheter ablation of AF from April 2012 to March 2017. After the procedure, the sheaths were removed, and hemostasis was obtained by manual compression followed by application of rolled gauze with elastic bandage and continuous pressure to the puncture site. We evaluated the risk factors for venous bleeding complications defined as hemorrhage from the puncture site that needed recompression after removal of the elastic bandage and rolled gauze.

RESULTS

After excluding 11 patients because of missing data, 559 patients (395 [70.7%] men, mean age: 65.6 ± 8.7 years) were included for analysis. Venous bleeding complication was observed in 213 patients (38.1%). In the multivariate logistic regression analysis, low body mass index (BMI; odds ratio [OR] 0.95, 95% CI 0.90-1.00, P = .04), short compression time (OR 0.77, 95% CI 0.68-0.88, P < .001), and antiplatelet therapy (OR 1.86, 95% CI 1.09-3.16, P = .02) were independent risk factors for venous bleeding complication.

CONCLUSIONS

Low BMI, short compression time, and antiplatelet therapy were independent risk factors for venous bleeding complication after catheter ablation of AF. Longer compression time may be needed for patients with low BMI and/or those receiving antiplatelet therapy.

A comparison of figure-of-8-suture versus manual compression for venous access closure after cardiac procedures: An updated meta-analysis

BACKGROUND

Manual compression (MC) is the current standard to achieve postprocedural hemostasis in patients who need venous vascular access closure after cardiovascular procedures. Figure-of-8 (F8) suture for venous access closure has been reported to be a safe and efficacious alternative to MC.

METHODS

A systematic search was done using PubMed, Google Scholar, EMBASE, SCOPUS, and ClinicalTrials.gov without language restriction up until April 15, 2020 for studies comparing F8 suture versus MC. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated using a random effects model.

RESULTS

Time to achieve hemostasis was significantly reduced in the F8 arm [MD -21.04 min (95% CI: -35.66 to -6.42; P = .005)]. Access site bleeding was significantly lower in the F8 group [RR 0.35 (95% CI: 0.18 to 0.66; P = .001)] along with a lower incidence of hematoma formation [RR 0.42 (95% CI: 0.26 to 0.67; P = .0003)]. There was no significant difference in rates of fistula or pseudoaneurysm formation between the two groups. Overall access site complications were lower in the F8 arm [RR 0.38 (95% CI: 0.26 to 0.55; P < .00001)] and the effect was more pronounced for sheaths ≥10 Fr [RR 0.33 (95% CI: 0.18 to 0.60; P = .0003)]. There was lower postprocedural protamine use in the F8 group [RR 0.07 (95% CI: 0.01 to 0.36; P = .001)].

CONCLUSION

For large-bore venous access closure, the F8 suture results in a shortened time to achieve hemostasis along with a lower overall risk of access site complications and postprocedural protamine use.

Use of figure of eight suture for groin closure with no heparin reversal in patients undergoing cryoballoon ablation for atrial fibrillation

PURPOSE

We aimed to demonstrate the feasibility of figure of eight (FoE) suture for groin access closure in cryoballoon (CB) ablation and its impact on the lab workflow.

METHODS

We retrospectively analyzed all patients who underwent CB ablation in our institution from June 2018. From June 2019, we have been consistently using FoE suture for hemostasis (FoE+ group), and before that conventional manual compression was utilized (FoE- group). Ablations were performed under uninterrupted oral anticoagulant strategy. Both femoral veins were punctured, and a single introducer was placed in each vein. In the FoE- group, after ablation, protamine was administered, and manual compression was applied. In the FoE+ group, the suture was placed in both groins without protamine administration and manual compression. All patients were in decubitus position until the next morning.

RESULTS

A total of 190 consecutive patients (73.2% male, 59.7 ± 11.0 years old) were evaluated, 90 being in the FoE+ group. There was no difference in the mean procedure duration between two groups (72.7 ± 23.1 min vs 73.7 ± 27.1 min, p = 0.784). However, the total lab time was significantly longer in FoE- group (132.9 ± 35.3 min vs 109.9 ± 32.6 min, p < 0.0001). There was no difference in complication rates. No major vascular complications were found in our cohort.

CONCLUSIONS

Utilization of FoE sutures for hemostasis seems to be a safe and effective after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious adverse events. As manual compression is unrequired, EP lab workflow improves due to significantly shortened total lab time per patient.

Feasibility of the Figure-of-8-Suture as Venous Closure in Interventional Electrophysiology: One Strategy for All?

Background: Venous vascular access with higher sheath size is common in interventional electrophysiology. In contrast to arterial vascular access, no dedicated closure devices exist for closure after venous access with higher sheath sizes. The Figure-of-8-Suture, an easy to apply suture, may be as a feasible approach for closure venous puncture. Our aim was to evaluate the feasibility of closure of femoral venous access. Methods: From November 2016 to February 2018, patients undergoing electrophysiological procedures, closure of left atrial appendage or patent foramen ovale were included. Until May 2017, manual compression was performed to achieve haemostasis at venous access site (control group). From May 2017, patients were treated with a Figure-of-8-Suture (treatment group, Figure 1). Turnaround time and incidence of vascular complications were compared between the two groups. Results: In total, 290 patients were included, 132 in the control group and 158 in the Figure-of-8-Suture group. Hemostasis after sheath removal was achieved in 100% of the cases in the control group by manual compression and in 98.7% of the cases with the Figure-of-8-Suture (p=0.2). Vascular complications were more common in the control group (6.8 vs. 1.3 %, p=0.01). Turnaround time was significantly lower in the Figure-of-8-Suture group (58.6 ± 14 vs. 77 ± 33.9 min, p=0.004). In a sub-analysis in obese patients with body mass index (BMI) ≥30 kg/m² (Figure-of-8 n=45, controls n=35), vascular complications were significantly more common in the control group (9.4 vs 0%, p=0.045). Conclusion: The Figure-of-8-Suture is an easy-to-apply, effective approach for venous closure after electrophysiological procedures.

Heparin reversal with protamine sulfate is not required in atrial fibrillation ablation with suture hemostasis

BACKGROUND

The utility of protamine sulfate for heparin reversal in catheter-based atrial fibrillation (AF) ablation is unclear when using the suture closure technique for vascular hemostasis.

OBJECTIVE

This study sought to address if protamine sulfate use for heparin reversal reduces vascular access complications in AF catheter ablation when suture techniques are used for postprocedural vascular hemostasis.

METHODS

This is a retrospective multicenter observational study of 294 consecutive patients who underwent catheter ablation for AF with subsequent vascular access hemostasis by means of a figure-of-eight suture or stopcock technique. A total of 156 patients received protamine for heparin reversal before sheath removal while 138 patients did not receive protamine. The two groups were compared for procedural activated clotting time (ACT), access site complications, and duration of hospital stay.

RESULTS

Baseline demographic characteristics were comparable in both groups. Despite higher ACT before venous sheath removal in patients not receiving protamine (288.0 ± 44.3 vs 153.9 ± 32.0 seconds; P < .001), there was no significant difference in groin complications, postoperative thromboembolic events, or duration of hospital stay between the two groups. Suture failure requiring manual compression was rarely observed in this cohort (0.34%).

CONCLUSION

With modern vascular access and sheath management techniques, for patients undergoing catheter ablation for AF, simple suture closure techniques can obviate the need for protamine administration to safely achieve hemostasis after removal of vascular sheaths.

Venous Vascular Closure System Versus Manual Compression Following Multiple Access Electrophysiology Procedures: The AMBULATE Trial

OBJECTIVES

This study compared the efficacy and safety of the VASCADE MVP Venous Vascular Closure System (VVCS) device (Cardiva Medical, Santa Clara, California) to manual compression (MC) for closing multiple access sites after catheter-based electrophysiology procedures.

BACKGROUND

The VASCADE MVP VVCS is designed to provide earlier ambulatory hemostasis than MC after catheter-based procedures.

METHODS

The AMBULATE (A Randomized, Multi-center Trial to Compare Cardiva Mid-Bore [VASCADE MVP] VVCS to Manual Compression in Closure of Multiple Femoral Venous Access Sites in 6 - 12 Fr Sheath Sizes) trial was a multicenter, randomized trial of device closure versus MC in patients who underwent ablation. Outcomes included time to ambulation (TTA), total post-procedure time (TPPT), time to discharge eligibility (TTDe), time to hemostasis (TTH), 30-day major and minor complications, pain medication usage, and patient-reported outcomes.

RESULTS

A total of 204 patients at 13 sites were randomized to the device arm (n = 100; 369 access sites) or the MC arm (n = 104; 382 access sites). Baseline characteristics were similar between groups. Mean TTA, TPPT, TTDe, and TTH were substantially lower in the device arm (respective decreases of 54%, 54%, 52%, and 55%; all p < 0.0001). Opioid use was reduced by 58% (p = 0.001). There were no major access site complications. Incidence of minor complications was 1.0% for the device arm and 2.4% for the MC arm (p = 0.45). Patient satisfaction scores with duration of and comfort during bedrest were 63% and 36% higher in device group (both p < 0.0001). Satisfaction with bedrest pain was 25% higher (p = 0.001) for the device overall, and 40% higher (p = 0.002) for patients with a previous ablation.

CONCLUSIONS

Use of the closure device for multiple access ablation procedures resulted in significant reductions in TTA, TPPT, TTH, TTDe, and opioid use, with increased patient satisfaction and no increase in complications. (A Randomized, Multi-center Trial to Compare Cardiva Mid-Bore VVCS to Manual Compression in Closure of Multiple Femoral Venous Access Sites in 6 - 12 Fr Sheath Sizes [AMBULATE]; NCT03193021).

Comparison of standard vs modified "figure-of-eight" suture to achieve femoral venous hemostasis after cryoballoon based atrial fibrillation ablation

BACKGROUND

Immediate hemostasis following removal of sheaths is essential to prevent access site complications after atrial fibrillation (AF) ablation. Despite various precautions to achieve complete hemostasis in a safe and effective manner, no standard approach is present yet.

OBJECTIVE

We aimed to compare the efficacy and safety of standard vs modified figure-of-eight (sFoE vs mFoE) suture for immediate venous hemostasis after cryoballoon (CB) AF ablation.

METHODS

A total of 150 patients who underwent CB catheter ablation were sequentially allocated to either sFoE (n = 75) or mFoE (n = 75) suture to achieve immediate venous hemostasis at right femoral access site after 15 Fr sheath removal. A "three-way stopcock" was used in the mFoE group rather than tying the knot as in a sFoE group. Demographics, clinical and procedural data, and access site complications were recorded.

RESULTS

Immediate haemostasis was achieved in all patients (n = 75) with mFoE suture as compared to 90.7% (n = 68) of sFoE suture group (P < .001). Light manual pressure of ≤1 min was required in five patients (6.7%) due to looseness and conventional manual compression because of the snapped silk suture during knotting was required in two patients (2.6%) in the sFoE group. Time to hemostasis was shorter in the mFoE group (P < .001), but time to ambulation and time to discharge were similar in both groups (P > .05). Although no minor or major access site complication has occurred in the mFoE group, in-hospital rebleeding (n = 2, 2.7%) and early local access site infection (n = 2, 2.7%) were observed in the sFoE group.

CONCLUSION

The mFoE suture using three-way stopcock is an available, effective, maybe safe, and time- and cost-saving alternative technique to achieve immediate hemostasis after removal of 15 Fr right femoral venous sheath in patients undergoing cryoablation.