Safety of pacemaker implantation prior to radiofrequency ablation of atrioventricular junction in a single session procedure

Acute pacing threshold elevation during simultaneous Micra leadless pacemaker implantation and AV node ablation: Clinical cases, computer model and practical recommendations

BACKGROUND

In patients with refractory atrial fibrillation (AF), atrioventricular nodal (AVN) ablation and permanent pacemaker implantation is recommended. The Micra Transcatheter Pacing System (Micra) is a single chamber leadless pacemaker (LPM) and thus offers the possibility of AV node (AVN) ablation in the same procedure. Pacing threshold (PT) elevation after radiofrequency (RF) ablation is a potential complication.

METHODS

We conducted a single center retrospective cohort study. Patients implanted with a Micra (n = 84) and concomitant or delayed AVN ablation (n = 12) from 2014 to 2022 were included. Two cases of acute Micra PT elevation immediately following RF AVN ablation required device retrieval and implantation of a new Micra. Procedural characteristics and electrophysiological parameters were analyzed, and a computer model was performed to determine factors responsible for acute PT elevations.

RESULTS

A total of 84 patients were included. Mean age was 74 ± 10 and 48% were women. Twelve patients (14%) underwent AVN ablation. Two patients had acute PT elevation requiring device retrieval despite no direct contact of the ablation catheter with the Micra. Computer modeling shows that significant dissipated power due to electrical field coupling can occur at the tip or ring electrode if the catheter is not kept at a safe distance (≥35 mm) from the Micra when a maximum power of 100 W is delivered.

CONCLUSION

Concurrent AVN ablation and Micra implantation is safe in most patients. To prevent acute PT elevation, keeping a safe distance of ≥35 mm from the tip and ring electrodes of the Micra and using lower power output may prevent this complication.

EHRA White Paper: knowledge gaps in arrhythmia management—status 2019

Clinicians accept that there are many unknowns when we make diagnostic and therapeutic decisions. Acceptance of uncertainty is essential for the pursuit of the profession: bedside decisions must often be made on the basis of incomplete evidence. Over the years, physicians sometimes even do not realize anymore which the fundamental gaps in our knowledge are. As clinical scientists, however, we have to halt and consider what we do not know yet, and how we can move forward addressing those unknowns. The European Heart Rhythm Association (EHRA) believes that scanning the field of arrhythmia / cardiac electrophysiology to identify knowledge gaps which are not yet the subject of organized research, should be undertaken on a regular basis. Such a review (White Paper) should concentrate on research which is feasible, realistic, and clinically relevant, and should not deal with futuristic aspirations. It fits with the EHRA mission that these White Papers should be shared on a global basis in order to foster collaborative and needed research which will ultimately lead to better care for our patients. The present EHRA White Paper summarizes knowledge gaps in the management of atrial fibrillation, ventricular tachycardia/sudden death and heart failure.

The Effects of Catheter Ablation on Permanent Pacemakers and Implantable Cardiac Defibrillators

Catheter ablation is a procedure that is frequently performed in patients with cardiac implantable electronic devices. Here, we review all of the potential interactions that can occur among patients undergoing catheter ablation while having implantable cardiac electronic devices, and discuss the precautionary measures to minimize such interactions.

A review on atrioventricular junction ablation and pacing for heart rate control of atrial fibrillation

Atrioventricular junction ablation with permanent pacemaker implantation is a highly effective treatment approach in patients with atrial fibrillation and high ventricular rates resistant to other treatment modalities, especially in the elderly or those with severe comorbidities. Compared with pharmacological therapy alone, the so-called “ablate and pace” approach offers the potential for more robust control of ventricular rate. Atrioventricular junction ablation and pacing strategy is associated with improvement in symptoms, quality of life, and exercise capacity. Given the close relationship between atrial fibrillation and heart failure, there is a particular benefit of such a rate control in patients with atrial fibrillation and reduced systolic function. There is increasing evidence that cardiac resynchronization therapy devices may be beneficial in selected populations after atrioventricular junction ablation. The present review article focuses on the current recommendations for atrioventricular junction ablation and pacing for heart rate control in patients with atrial fibrillation. The technique, the optimal implantation time, and the proper device selection after atrioventricular junction ablation are also discussed.

Atrioventricular Junction Ablation In Atrial Fibrillation: Choosing The Right Patient And Pacing Device

Atrial fibrillation (AF) is the most common cardiac arrhythmia and despite advancements in rhythm control through direct catheter ablation, maintaining sinus rhythm is not possible in a large proportion of AF patients, who therefore are subject to a rate control strategy only. Nonetheless, in some of these patients pharmacological rate control may be ineffective, often leaving the patient highly symptomatic and at risk of developing tachycardia-induced cardiomyopathy and heart failure (HF). Catheter ablation of the atrioventricular junction (AVJ) with subsequent permanent pacemaker implantation provides definite rate control and represents an attractive therapeutic option when pharmacological rate control is not achieved. In patients with reduced ventricular function, cardiac resynchronization therapy (CRT) should be considered over right ventricular apical (RVA) pacing in order to avoid the deleterious effects associated with a high amount of chronic RVA pacing. Another group of patients that may also benefit from AVJ ablation are HF patients with concomitant AF receiving CRT. In this patient cohort AVJ ablation ensures near 100% biventricular pacing, thus allowing optimization of the therapeutic effects of CRT.

Comparison of different approaches to atrioventricular junction ablation and pacemaker implantation in patients with atrial fibrillation

BACKGROUND

To compare the feasibility and efficiency of atrioventricular junction (AVJ) ablation and device implantation in patients with drug-refractory atrial fibrillation using three different approaches.

METHODS

Sixty-nine patients (57% male; age 72 ± 10; ejection fraction 45 ± 15%) undergoing device implantation and AVJ ablation were retrospectively studied at a tertiary referral center. In 20 patients (29%) AVJ ablation was performed via the femoral vein immediately following device implantation (group 1), whereas 33 patients (48%) underwent a staged procedure with AVJ ablation via the femoral vein >3 weeks after device implantation (group 2). In a third group of 16 patients (23%), AVJ ablation was performed during device implantation through the pocket using the same axillary vein access site (group 3). The main outcome measures were: procedure time, fluoroscopy time, laboratory occupancy time, and success rate.

RESULTS

There was a significant difference in procedure time (118 ± 45 minutes. in group 1, 133 ± 32 minutes in group 2, and 87 ± 26 minutes in group 3, P < 0.001) and the laboratory occupancy time (175 ± 48 minutes in group 1, 200 ± 32 minutes in group 2, and 121 ± 27 minutes in group 3, P < 0.001). There was no difference in fluoroscopy time (group 1: 20 ± 15 minutes, group 2: 27 ± 22 minutes, and group 3: 24 ± 9 minutes P = 0.4). The procedure was successfully completed in all patients, but cross-over to a femoral approach was required in one patient in group 3.

CONCLUSION

The alternative approach of AVJ ablation during permanent pacemaker implantation from the same axillary vein access site is feasible and more efficient compared to the femoral approach.

Current role of atrioventricular junction (AVJ) ablation

Atrioventricular junction ablation with permanent pacemaker insertion is a highly effective treatment approach in patients with atrial fibrillation that is resistant to other treatment modalities, especially in the elderly or those with severe comorbidities. This effect likely reflects reversal of rapid ventricular rates and regularizing ventricular rates. There is increasing evidence that cardiac resynchronization therapy devices may be beneficial in selected populations after atrioventricular node ablation. The limitations of this approach include continued need for anticoagulation and lifelong pacemaker therapy.

Atrioventricular junction ablation and pacemaker implantation for heart failure associated with atrial fibrillation: potential issues and therapies in the setting of acute heart failure syndrome

Atrial fibrillation is the most common arrhythmia and is especially clinically important in patients with heart failure. Prolonged atrial fibrillation with high ventricular rate response may lead to development or worsening of left ventricular function. If adequate heart rate control cannot be obtained medically, often patients will undergo pacemaker implant and catheter ablation of the atrioventricular junction. This intervention can have profound effects on the course of heart failure. This article reviews the technique, complications, outcome data, and alternatives to this management strategy. The potential role of this therapeutic modality in those hospitalized with acute heart failure syndromes is discussed.

Outcome of magnetic resonance imaging (MRI) in selected patients with implantable cardioverter defibrillators (ICDs)

OBJECTIVE

To determine if simple strategies used to safely scan pacemaker patients could be applied to implantable cardioverter defibrillator (ICD), patients undergoing MRI allowing ICD patients to undergo MRI as well.

INTERVENTIONS

Screening, reprogramming, and monitoring strategies were used to facilitate MRI.

RESULTS

Seven patients underwent eight MRI scans at 1.5 T. Post-MRI, all devices demonstrated no change in pacing, sensing, impedances, charge times, or battery status. The patient undergoing a lumbar spine scan experienced a "power-on-reset" of his ICD without permanent impairment of his device.

CONCLUSION

Scanning of ICD patients might be performed if appropriate reprogramming and monitoring is implemented.