Transseptal puncture for left atrial ablation: risk factors for cardiac tamponade and a proposed causative classification system

Aims

Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the associations of TSP‐related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our center from 2016 to 2020.

Methods and Results

Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinized to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. A total of 3239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP‐related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above‐median age [odds ratio (OR): 2.4 (1.19–4.2), p = .006] and those undergoing re‐do procedures [OR: 1.95 (1.29–3.43, p = .042] were at higher risk of TRCT. Of the operator‐dependent variables, choice of transseptal needle (Endrys vs. Brockenbrough, p > .1) or puncture sheath (Swartz vs. Mullins vs. Agilis vs. Vizigo vs. Cryosheath, all p > .1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk [OR: 4.42 (2.45–8.2), p = .001], whilst top quartile operator experience [OR: 0.4 (0.17–0.85), p = .002], transoesophageal echocardiogram [TOE prevalence: 26%, OR: 0.51 (0.11–0.94), p = .023], and use of the SafeSept transseptal guidewire [OR: 0.22 (0.08–0.62), p = .001] reduced TRCT risk. An increase in transseptal guidewire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R² = 0.72, p < .001) and was associated with a relative risk reduction of 70%.

Conclusions

During left atrial ablation, the risk of TRCT was reduced by operator experience, TOE‐guidance, and use of a transseptal guidewire, and was increased by patient age, re‐do procedures, and failure to cross the septum first pass.

ProGlide venous closure device facilitates early ambulation following cryoablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Heart Foundation

Background

Same-day discharge following atrial fibrillation (AF) ablation is increasingly common. ProGlide device suture-mediated vascular closure (PD) offers a technique that may expedite mobilisation following large-bore (&gt;12F) venous access. The utility of PD closure following cryoablation of AF has not been reported.

Purpose

We sought to evaluate haemostasis and early ambulation outcomes in patients receiving the ProGlide compared with conventional techniques.

Methods

104 consecutive patients undergoing cryoballoon pulmonary vein isolation (PVI) for paroxysmal or persistent at a single high-volume institution were included. PVI was  performed via a standardised approach including sedation, ultrasound-guided vascular access for 14F Cryosheath and second 7F sheath, anticoagulation protocol, transeptal puncture, 28mm cryoballoon and nurse-led same-day discharge protocol. Haemostasis was achieved using the Perclose Proglide device (PD) in the 14F access point ("pre-closure" technique) plus 5 minutes manual pressure at the 7F sheath site. Alternatively, a figure-of-eight/Z-suture (ZS) was employed for closure according to operator preference. Protamine was used for heparin reversal in all patients. Safety outcomes of major bleeding, haematoma and minor bleeding were assessed. Time to ambulation (TTA), time to discharge (TTD), same-day discharge and complications at initial follow-up were measured.

Results

Overall, mean age was 64 ± 11 years, 65 (64%) were male and 52 (50%) of patients had paroxysmal AF, there were no significant differences between group demographics, with 31 patients (30%) in the PD group and 73 (70%) in the ZS group. All patients had uninterrupted oral anticoagulation throughout the periprocedural period. No major femoral bleeding complications requiring intervention occurred in either group. Haematomas occurred in none of the PD group compared with 2 (2.8%) in the ZS group. Incidence of minor bleeding was not significantly different between groups (PD: 3 [9.7%] vs ZS: 2 [2.7%], p = 0.155). Mean TTA was significantly shorter in the PD group (3.3 ± 1.1 vs 4.1 ± 1.7 hrs, p = 0.025). However, there was no significant difference in same-day discharge (PD: 25 [81%] vs ZS: 53 [73%], p = 0.386) and TTD (5.0 ± 3.6 vs 6.1 ± 4.2 hrs, p = 0.275) between groups. 1 patient complained of groin pain which delayed discharge in the ZS group not seen in the PD group. After a mean follow-up of 2.2 ± 1.4 months, there were no differences in major or minor complications.

Conclusion

Use of the Proglide closure device was associated with significant reductions in time to ambulation compared with Z-suture haemostasis following cryoablation of AF, and groin access complications were uncommon across groups.  PD closure may contribute to further streamlining patient pathways in day-case AF ablation.

Long-term outcomes of index cryoballoon ablation or point-by-point radiofrequency ablation in patients with atrial fibrillation and systolic heart failure

Catheter ablation is an established effective approach for the treatment of atrial fibrillation (AF) in patients with heart failure, however, the role of cryoablation in this setting is unclear. Procedural success and left ventricular systolic dysfunction (LVEF) improvement in patients with LVEF ≤ 45% undergoing index catheter ablation with cryoablation were evaluated. Freedom from AF recurrence was seen in 43% rising to 59% following repeat procedure. There were significant improvements in LVEF and functional status at long-term follow-up. Results were comparable to a contemporaneous cohort of heart failure patients undergoing index ablation with radiofrequency ablation. Cryoablation is an effective first-line AF ablation approach in the setting of heart failure.

Outcome of ACHD patients with non-inducible versus inducible IART undergoing cavo-tricuspid isthmus ablation: the role of empiric ablation

PURPOSE

Catheter ablation for supraventricular tachycardia (SVT) in adults with congenital heart disease (ACHD) is an important therapeutic option. Cavo-tricuspid isthmus (CTI)-dependent intraatrial re-entrant tachycardia (IART) is common. However, induction of sustained tachycardia at the time of ablation is not always possible. We hypothesised that performing an empiric CTI line in case of non-inducibility leads to good outcomes. Long-term outcomes of empiric versus entrained CTI ablation in ACHD patients were examined.

METHODS

Retrospective, single-centre, case-control study over 7 years. Arrhythmia-free survival after empiric versus entrained CTI ablation was compared.

RESULTS

Eighty-seven CTI ablations were performed in 85 ACHD patients between 2010 and 2017. The mean age of the cohort was 43 years and 48% were male. Underlying aetiology included ASD (31%), VSD (11.4%), AVSD (9.1%), AVR (4.8%), Fallot's (18.4%), Ebstein's (2.3%), Fontan's palliation (9.2%) and atrial switch (13.8%). CTI-dependent IART was entrained in 59 patients whereas it was non-inducible in 28. The latter had an empiric CTI ablation. Forty-three percent of procedures were performed under general anaesthesia. There were no reported procedural complications. There was no significant difference in the mean procedure or fluoroscopy times between the groups (empiric vs entrained CTI; 169.1 vs 183.3 and 28.1 vs 19.9 min). Arrhythmia-free survival was 64.3% versus 72.8% (p value 0.44) in the empiric and entrained groups at 21 months follow-up.

CONCLUSIONS

Long-term outcomes after empiric and entrained CTI ablation for IART in ACHD patients are comparable. This is a safe and effective therapeutic option. In the case of non-inducibility of IART, an empiric CTI line should be considered in this cohort.

Impact of attributed audit on procedural performance in cardiac electrophysiology catheter laboratory

PURPOSE

Audit has played a key role in monitoring and improving clinical practice. However, audit often fails to drive change as summative institutional data alone may be insufficient to do so. We hypothesised that the practice of attributed audit, wherein each individual's procedural performance is presented will have a greater impact on clinical practice. This hypothesis was tested in an observational study evaluating improvement in fluoroscopy times for AF ablation.

METHODS

Retrospective analyses of fluoroscopy times in AF ablations at the Barts Heart Centre (BHC) from 2012-2017. Fluoroscopy times were compared pre- and post- the introduction of attributed audit in 2012 at St Bartholomew's Hospital (SBH). In order to test the hypothesis, this concept was introduced to a second group of experienced operators from the Heart Hospital (HH) as part of a merger of the two institutions in 2015 and change in fluoroscopy times recorded.

RESULTS

A significant drop in fluoroscopy times (33.3 ± 9.14 to 8.95 ± 2.50, p < 0.0001) from 2012-2014 was noted after the introduction of attributed audit. At the time of merger, a significant difference in fluoroscopy times between operators from the two centres was seen in 2015. Each operator's procedural performance was shared openly at the audit meeting. Subsequent audits showed a steady decrease in fluoroscopy times for each operator with the fluoroscopy time (min, mean±SD) decreasing from 13.29 ± 7.3 in 2015 to 8.84 ± 4.8 (p < 0.0001) in 2017 across the entire group.

CONCLUSIONS

Systematic improvement in fluoroscopy times for AF ablation procedures was noted byevaluating individual operators' performance. Attributing data to physicians in attributed audit can promptsignificant improvement and hence should be adopted in clinical practice.

Moderate sedation in cardiac electrophysiology laboratory: a retrospective safety analysis

OBJECTIVE

Cardiac electrophysiology (EP) procedures can be performed under moderate sedation without the direct involvement of an anaesthetist. However, concerns have been raised over the safety of this approach. This study examines the use of a standardised nurse-led physician-directed sedation protocol for EP procedures to determine the safety of moderate sedation administered by non-anaesthesia personnel who have been trained in sedation techniques.

METHODS AND RESULTS

Consecutive EP procedures done under moderate sedation over 12 years at our institution were evaluated. Serious adverse events were defined as (i) procedural death related to sedation; (ii) intubation and ventilation; and (iii) hypotension requiring inotropic support. Reversal of sedation constituted a minor adverse event. Up to 7117 procedures were included. These comprised ablations (55%), devices (43%) and other procedures (2%). A majority of patients were men with a mean age of 61±10 years. 99.98% of procedures were completed successfully without sedation-related serious adverse events. Two patients (0.02%) required anaesthetic support for intubation. Sedation was reversed in 1.2% of procedures with less than 1% requiring reversal because of persistent drop in oxygen saturation, hypoventilation or markedly reduced level of consciousness. There was no significant difference in the patient characteristics, mean doses of sedative agents and procedure types in the group requiring reversal of sedation when compared with the whole cohort.

CONCLUSIONS

Our study demonstrates that nurse-led, physician-directed moderate sedation is safe. Anaesthesia services are not required routinely for invasive cardiac EP procedures and should be available on a need basis.

Percutaneous lead extraction and venous recanalisation using spectranetics tight rail: A single centre experience

Aims

Despite advances in lead extraction tools, percutaneous lead extraction remains a complex procedure associated with significant morbidity and mortality. Moreover, no standards or directives exist to guide physicians in the choice of their extraction tool or approach and all operators tend to have their own preferred method. The reporting of outcomes with existing and newly emerging extraction technology is therefore encouraged.

Methods and results

Four lead extraction procedures using the new spectranetics tight rail rotating dilator sheath are described here. All patients (n = 3) had chronically implanted leads (mean duration = 11.7 years) and the pre-procedure venogram showed occluded left subclavian and brachiocephalic veins with extensive collateralisation. All leads were extracted successfully using this newly designed rotating dilator sheath and vascular access was also retained by venous recanalisation using this kit. One patient required a second extraction procedure at four weeks due to diaphragmatic twitch without macroscopic coronary sinus (CS) lead displacement. This was replaced with a transseptal LV lead. There were no other procedure related complications and all patients remained well with good lead parameters at three months follow-up.

Conclusion

The use of this new tight rail extraction tool appears safe and effective in chronically implanted leads. Moreover, it helps to preserve the vascular access by recanalisation of long tortuous occlusions. Its use across various centres and larger number of patients will be required to confirm our results.

A randomized single-blind controlled trial of letrozole as a low-cost IVF protocol in women with poor ovarian response: a preliminary report

BACKGROUND

Use of letrozole, a selective inhibitor of aromatase, reduces the gonadotrophin dose required to induce follicular maturation. We evaluated whether incorporation of letrozole could be an effective low-cost IVF protocol for poor responders.

METHODS

A randomized, controlled, single-blind trial was conducted in the Assisted Reproduction Unit, Institute of Reproductive Medicine, Kolkata, India. Thirty-eight women with a history of poor ovarian response to gonadotrophins were recruited. Thirteen women (Let-FSH group) received letrozole 2.5 mg daily from day 3-7, and recombinant FSH (rFSH) 75 IU/day on days 3 and 8; and 25 women (GnRH-ag-FSH group) underwent long GnRH agonist protocol and stimulated with rFSH (300-450 IU/day). Ovulation was triggered by 10,000 IU of HCG followed by IVF-embryo transfer. The main outcome measures were total dose of rFSH (IU/cycle), terminal estradiol (E2) (pg/ml), numbers of follicles, oocytes retrieved and transferable embryo, endometrial thickness (mm), and pregnancy rate.

RESULTS

Compared with the GnRH-ag-FSH group (2865 +/- 228 IU), the Let-FSH group (150 +/- 0 IU) received a significantly (P < 0.001) lower total dose of FSH. Except for terminal E2, which was significantly higher (P < 0.001) in the GnRH-ag-FSH group (380 +/- 46 pg/ml) than the Let-FSH group (227 +/- 45 pg/ml), the treatment outcomes in all other respects, including pregnancy rate, were statistically comparable.

CONCLUSIONS

Adjunctive use of letrozole may form an effective means of low-cost IVF protocol in poorly responding women.