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

SANS FLUORO Too Big to Fail

We present the first ever reported case of a super morbidly obese patient (BMI > 60) with drug refractory, symptomatic persistent atrial fibrillation who underwent an uncomplicated, but unsuccessful PVI ablation procedure and subsequently underwent AV node ablation and cardiac resynchronization therapy - pacemaker (CRT-P) insertion using a zero fluoroscopy technique. This case demonstrates the following two critical points: (1) difficulties in the treatment of massively obese patients with arrhythmias1; (2) increased use of fluoroless procedures2-4.

Strategy of pacemaker and electrode replacement for superior vena cava stenosis

Cardiac implantable devices are commonly used for superior vena cava stenosis, but there have been few reports of electrode replacement in the stenosed superior vena cava. A 73-year-old man was diagnosed with second-degree type II atrioventricular block and a permanent dual-chamber, rate-modulated pacing pacemaker was implanted 10 years previously. Because of depletion of the pacemaker battery and an increase in the ventricular pacing threshold, replacement of the pacemaker and ventricular electrode was required. During the operation, we found that the patient had severe superior vena cava stenosis on angiography, and this caused obstruction when a common guidewire was used to pass through the superior vena cava. After attempting various methods, we successfully passed through the vascular stenosis with a super slide guidewire and a long sheath, and completed replacement of the pacemaker and ventricular electrode. We summarize the related literature of superior vena cava stenosis related to a cardiac implantable device, and discuss the replacement strategy of this complication and other treatment options.

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.

Acute and long-term outcomes of simultaneous atrioventricular node ablation and leadless pacemaker implantation

AIMS

Leadless pacemaker (LDP) allows implantation using a femoral approach. This access could be utilized for conventional atrioventricular nodal ablation (AVNA). It could facilitate unifying the two procedural components. Data regarding its feasibility and long-term outcomes remain lacking. We aim to evaluate the feasibility and long-term outcomes of sequential LDP and AVNA.

METHODS

Prospective, observational multicenter study including consecutive patients with indication for single-chamber pacemaker placement. In those with additional indication for AVNA, ablation was performed immediately after the LPD through the same sheath.

RESULTS

A total of 137 patients were included. Mean age was 77.9 ± 10.5 years; 74 (54%) were men. Immediately following LDP implantation, 27 patients (19.7%) underwent concurrent AVNA. There were six (5.5%) complications in patients referred for LDP procedures and three (11%) in those who underwent a combined approach. None of these complications were solely attributable to the added AVNA component. No mechanical dislodgement, electrical damage to any device, or electromagnetic interference ever took place. During a mean follow-up period of 123 ± 48 days, three patients (3.6%) died of noncardiovascular causes. The remaining population stayed alive without significant arrhythmias. There were no relevant differences with regard to sensing and pacing thresholds between patients in the two groups.

CONCLUSIONS

AVNA can safely be performed immediately following LDP. A combined approach obviates the need for additional vascular access and optimizes feasibility and comfort for patients and healthcare providers. It offers an acceptable safety and efficacy profile, both acutely and upon intermediate-term follow-up.