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Bin Waleed K, Akhtar Z, Leung LW, Gallagher MM. Isolation of the superior vena cava by ultra-low temperature cryoablation. J Arrhythm 2024; 40:374-376. [PMID: 38586835 PMCID: PMC10995591 DOI: 10.1002/joa3.13010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/09/2024] [Accepted: 02/02/2024] [Indexed: 04/09/2024] Open
Abstract
A patient with shocks from his ICD related to AF underwent redo ablation. The only identifiable target was the superior vena cava. This was isolated using ultra-low cryotherapy, eliminating episodes of AF.
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Affiliation(s)
- Khalid Bin Waleed
- Department of Cardiology St. George's University Hospitals NHS Foundation Trust London UK
| | - Zaki Akhtar
- Department of Cardiology St. George's University Hospitals NHS Foundation Trust London UK
| | - Lisa Wm Leung
- Department of Cardiology St. George's University Hospitals NHS Foundation Trust London UK
| | - Mark M Gallagher
- Department of Cardiology St. George's University Hospitals NHS Foundation Trust London UK
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2
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Akhtar Z, Kontogiannis C, Elbatran AI, Leung LWM, Starck CT, Zuberi Z, Sohal M, Gallagher MM. Transvenous lead extraction: Experience of the Tandem approach. Europace 2023; 25:euad331. [PMID: 37936325 PMCID: PMC10903175 DOI: 10.1093/europace/euad331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/02/2023] [Indexed: 11/09/2023] Open
Abstract
AIMS Transvenous lead extraction (TLE) is important in the management of cardiac implantable electronic devices but carries risk. It is most commonly completed from the superior access, often with 'bail-out' support via the femoral approach. Superior and inferior access may be used in tandem, which has been proposed as an advance in safety and efficacy. The aim of this study is to evaluate the safety and efficacy of the Tandem approach. METHOD The 'Tandem' procedure entailed grasping of the targeted lead in the right atrium to provide countertraction as a rotational dissecting sheath was advanced over the lead from the subclavian access. Consecutive 'Tandem' procedures performed by a single operator between December 2020 and March 2023 in a single large-volume TLE centre were included and compared with the conventional superior approach (control) using 1:1 propensity score matching; patients were statistically matched for demographics. RESULTS The Tandem in comparison with the conventional approach extracted leads of much greater dwell time (148.9 ± 79 vs. 108.6 ± 77 months, P < 0.01) in a shorter procedure duration (96 ± 36 vs. 127 ± 67 min, P < 0.01) but requiring more fluoroscopy (16.4 ± 10.9 vs. 10.8 ± 14.9 min, P < 0.01). The Tandem and control groups had similar clinical (100% vs. 94.7%, P = 0.07) and complete (94.8% vs. 92.8%, P = 0.42) success, with comparable minor (4% vs. 6.7%, P = 0.72) and major (0% vs. 4%, P = 0.25) complications; procedural (0% vs. 1.3%, P = 1) and 30-day (1.3% vs. 4%, P = 0.62) mortality were also similar. CONCLUSION The Tandem procedure is as safe and effective as the conventional TLE. It can be applied to leads of a long dwell time with a potentially shorter procedure duration.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Christos Kontogiannis
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Ahmed I Elbatran
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
- Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Lisa W M Leung
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Christoph T Starck
- Department of Cardiothoracic Surgery, German Heart Centre, Berlin, Germany
| | - Zia Zuberi
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
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Akhtar Z, Kontogiannis C, Georgiopoulos G, Starck CT, Leung LWM, Lee SY, Lee BK, Seshasai SRK, Sohal M, Gallagher MM. Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis. Europace 2023; 25:euad316. [PMID: 37882609 PMCID: PMC10638006 DOI: 10.1093/europace/euad316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/07/2023] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
AIMS Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis. METHODS AND RESULTS We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01). CONCLUSION Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George’s University Hospital, London, UK
| | | | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Christoph T Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Lisa W M Leung
- Department of Cardiology, St George’s University Hospital, London, UK
| | - Sun Y Lee
- Department of Medicine, San Joaquin General Hospital, French Camp, CA, USA
| | - Byron K Lee
- Division of Cardiology, University of California, San Francisco, CA, USA
| | | | - Manav Sohal
- Department of Cardiology, St George’s University Hospital, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospital, London, UK
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Akhtar Z, Gallagher MM, Kontogiannis C, Leung LWM, Spartalis M, Jouhra F, Sohal M, Shanmugam N. Progress in Cardiac Resynchronisation Therapy and Optimisation. J Cardiovasc Dev Dis 2023; 10:428. [PMID: 37887875 PMCID: PMC10607614 DOI: 10.3390/jcdd10100428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Cardiac resynchronisation therapy (CRT) has become the cornerstone of heart failure (HF) treatment. Despite the obvious benefit from this therapy, an estimated 30% of CRT patients do not respond ("non-responders"). The cause of "non-response" is multi-factorial and includes suboptimal device settings. To optimise CRT settings, echocardiography has been considered the gold standard but has limitations: it is user dependent and consumes time and resources. CRT proprietary algorithms have been developed to perform device optimisation efficiently and with limited resources. In this review, we discuss CRT optimisation including the various adopted proprietary algorithms and conduction system pacing.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Mark M. Gallagher
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Christos Kontogiannis
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Lisa W. M. Leung
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Michael Spartalis
- Department of Cardiology, National and Kapodistrian University of Athens, 10679 Athens, Greece
| | - Fadi Jouhra
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Manav Sohal
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Nesan Shanmugam
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
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Akhtar Z, Sohal M, Gallagher MM. Comment on 'Leadless Pacemakers: Current Achievements and Future Perspectives'. Eur Cardiol 2023; 18:e50. [PMID: 37655135 PMCID: PMC10466268 DOI: 10.15420/ecr.2022.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 09/02/2023] Open
Affiliation(s)
- Zaki Akhtar
- Cardiology Academic Group, St George's University Hospital London, UK
| | - Manav Sohal
- Cardiology Academic Group, St George's University Hospital London, UK
| | - Mark M Gallagher
- Cardiology Academic Group, St George's University Hospital London, UK
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Abstract
Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
| | - Mary N Sheppard
- Cardiac Risk in the Young, Cardiovascular Pathology Unit, St George's University of LondonLondon, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
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7
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Leung LWM, Akhtar Z, Gallagher MM. Letter to the editor: oesophageal cooling for protection during left atrial ablations. Europace 2023; 25:euad153. [PMID: 37294672 PMCID: PMC10254069 DOI: 10.1093/europace/euad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023] Open
Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
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Leung LWM, Toor P, Akhtar Z, Bajpai A, Li A, Sohal M, Gallagher MM. Real-world results of oesophageal protection from a temperature control device during left atrial ablation. Europace 2023; 25:euad099. [PMID: 37096813 PMCID: PMC10228621 DOI: 10.1093/europace/euad099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/26/2023] [Indexed: 04/26/2023] Open
Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Pavandeep Toor
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Abhay Bajpai
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Anthony Li
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Manav Sohal
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
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9
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Leung LWM, Toor P, Akhtar Z, Gallagher MM. Delays in AF ablation cost lives. J Cardiovasc Electrophysiol 2023; 34:1092-1093. [PMID: 36861781 DOI: 10.1111/jce.15876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Affiliation(s)
| | | | - Zaki Akhtar
- St George's Hospital NHS Foundation Trust, London, UK
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10
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Waleed KB, Toor P, Akhtar Z, Aron J, Govewalla P, Gallagher MM. Stridor and dyspnoea after ablation for atrial fibrillation. Europace 2023; 25:129. [PMID: 36753479 PMCID: PMC9907543 DOI: 10.1093/europace/euac166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Indexed: 02/09/2023] Open
Affiliation(s)
- Khalid Bin Waleed
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, St George’s University of London, Blackshaw Road, SW17 0QT London, UK
| | - Pavandeep Toor
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, St George’s University of London, Blackshaw Road, SW17 0QT London, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, St George’s University of London, Blackshaw Road, SW17 0QT London, UK
| | - Jonathan Aron
- Department of Critical Care, St George’s University Hospitals NHS Foundation Trust, St George’s University of London, Blackshaw Road, SW17 0QT London, UK
| | - Paul Govewalla
- Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, St George's University of London, Blackshaw Road, SW17 0QT London, UK
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11
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Akhtar Z, Gallagher MM. Transvenous lead extraction: the Subclavian to Jugular pull-through technique. HeartRhythm Case Rep 2022; 9:160-164. [PMID: 36970377 PMCID: PMC10030300 DOI: 10.1016/j.hrcr.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Zaki Akhtar
- Address reprint requests and correspondence: Dr Zaki Akhtar, St George’s University Hospital, Blackshaw Rd, Tooting, London SW17 0RE, UK.
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12
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Leung LWM, Akhtar Z, Elbatran AI, Bajpai A, Li A, Norman M, Kaba R, Sohal M, Zuberi Z, Gallagher MM. Effect of esophageal cooling on ablation lesion formation in the left atrium: Insights from Ablation Index data in the IMPACT trial and clinical outcomes. J Cardiovasc Electrophysiol 2022; 33:2546-2557. [PMID: 36284450 PMCID: PMC10091801 DOI: 10.1111/jce.15717] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/29/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The IMPACT study established the role of controlled esophageal cooling in preventing esophageal thermal injury during radiofrequency (RF) ablation for atrial fibrillation (AF). The effect of esophageal cooling on ablation lesion delivery and procedural and patient outcomes had not been previously studied. The objective was to determine the effect of esophageal cooling on the formation of RF lesions, the ability to achieve procedural endpoints, and clinical outcomes. METHODS Participants in the IMPACT trial underwent AF ablation guided by Ablation Index (30 W at 350-400 AI posteriorly, 40 W at ≥450 AI anteriorly). A blinded 1:1 randomization assigned patients to the use of the ensoETM® device to keep esophageal temperature at 4°C during ablation or standard practice using a single-sensor temperature probe. Ablation parameters and clinical outcomes were analyzed. RESULTS Procedural data from 188 patients were analyzed. Procedure and fluoroscopy times were similar, and all pulmonary veins were isolated. First-pass pulmonary vein isolation and reconnection at the end of the waiting period were similar in both randomized groups (51/64 vs. 51/68; p = 0.54 and 5/64 vs. 7/68; p = 0.76, respectively). Posterior wall isolation was also similar: 24/33 versus 27/38; p = 0.88. Ablation effect on tissue, measured in impedance drop, was no different between the two randomized groups: 8.6Ω (IQR: 6-11.8) versus 8.76Ω (IQR: 6-12.2; p = 0.25). Arrhythmia recurrence was similar after 12 months (21.1% vs. 24.1%; 95% CI: 0.38-1.84; HR: 0.83; p = 0.66). CONCLUSIONS Esophageal cooling has been shown to be effective in reducing ablation-related thermal injury during RF ablation. This protection does not compromise standard procedural endpoints or clinical success at 12 months.
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Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Ahmed I Elbatran
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK.,Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abhay Bajpai
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Anthony Li
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Mark Norman
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Riyaz Kaba
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Manav Sohal
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Zia Zuberi
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
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- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
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Leung LWM, Akhtar Z, Hayat J, Gallagher MM. Protecting Against Collateral Damage to Non-cardiac Structures During Endocardial Ablation for Persistent Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e15. [PMID: 35990104 PMCID: PMC9376833 DOI: 10.15420/aer.2021.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/13/2022] [Indexed: 11/04/2022] Open
Abstract
Injury to structures adjacent to the heart, particularly oesophageal injury, accounts for a large proportion of fatal and life-altering complications of ablation for persistent AF. Avoiding these complications dictates many aspects of the way ablation is performed. Because avoidance involves limiting energy delivery in areas of interest, fear of extracardiac injury can impede the ability of the operator to perform an effective procedure. New techniques are becoming available that may permit the operator to circumvent this dilemma and deliver effective ablation with less risk to adjacent structures. The authors review all methods available to avoid injury to extracardiac structures to put these developments in context.
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Affiliation(s)
- Lisa WM Leung
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Jamal Hayat
- Department of Gastroenterology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
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14
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Leung LWM, Akhtar Z, Kontogiannis C, Imhoff RJ, Taylor H, Gallagher MM. Economic Evaluation of Catheter Ablation Versus Medical Therapy for the Treatment of Atrial Fibrillation from the Perspective of the UK. Arrhythm Electrophysiol Rev 2022; 11:e13. [PMID: 35846425 PMCID: PMC9277614 DOI: 10.15420/aer.2021.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 03/14/2022] [Indexed: 12/17/2022] Open
Abstract
Randomised evidence supports an early rhythm control strategy as treatment for AF, and catheter ablation outperforms medical therapy in terms of effectiveness when studied as first- and second-line treatment. Despite evidence consistently showing that catheter ablation treatment is superior to medical therapy in most AF patients, only a small proportion receive ablation, in some cases after a prolonged trial of ineffective medical therapy. Health economics research in electrophysiology remains limited but is recognised as being important in influencing positive change to ensure early access to ablation services for all eligible patients. Such information has informed the updated recommendations from the recently published National Institute for Health and Care Excellence clinical guideline on the diagnosis and management of AF, but increased awareness is needed to drive real-world adoption and to ensure patients are quickly referred to specialists. In this article, economic evaluations of catheter ablation versus medical therapy are reviewed.
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Affiliation(s)
- Lisa WM Leung
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | | | - Ryan J Imhoff
- Real-World Evidence and Late Phase Research, CTI Clinical Trial and Consulting Services Inc, Covington, KY, US
| | | | - Mark M Gallagher
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
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Bin Waleed K, Leung LW, Akhtar Z, Sohal M, Zuberi Z, Gallagher MM. New approaches to achieving hemostasis after venous access in cardiovascular patients. Kardiol Pol 2022; 80:750-759. [PMID: 35724337 DOI: 10.33963/kp.a2022.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022]
Abstract
Recent decades have seen a series of advances in percutaneous transvenous procedures for cardiac arrhythmias, including the implantation of leadless pacemakers. Many of these procedures require the insertion of large caliber sheaths in large veins, usually the femoral vein. Securing hemostasis efficiently and reliably at the access site is a key step to improving a procedure's safety profile. Traditionally, hemostasis was achieved by manual compression of venous access sites, but the trend toward larger sheaths and the increased use of uninterrupted anticoagulation has pushed the limits of this method. Achieving hemostasis by compression alone in these circumstances requires more attention and longer duration, leading to greater patient discomfort and prolonged immobility. In turn, manual compression may be more time-consuming for medical professionals and increase the number of occupied hospital beds. New approaches have been developed to facilitate early ambulation, decrease patient discomfort, and address the risk of access site complications. These approaches include vascular closure devices and subcutaneous suture techniques including figureof- eight and purse-string sutures. This article reviews the new approaches applied to achieve venous access site hemostasis in patients undergoing transvenous procedures for cardiac arrhythmias.
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Affiliation(s)
- Khalid Bin Waleed
- Department of Cardiology, St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Lisa Wm Leung
- Department of Cardiology, St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Zaki Akhtar
- Department of Cardiology, St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Manav Sohal
- Department of Cardiology, St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Zia Zuberi
- Department of Cardiology, St. George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark M Gallagher
- Department of Cardiology, St. George's University Hospital NHS Foundation Trust, London, United Kingdom.
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Akhtar Z, Zaman KU, Leung LW, Zuberi Z, Sohal M, Gallagher MM. Triple access transvenous lead extraction: Pull-through of a lead from subclavian to jugular access to facilitate extraction. Pacing Clin Electrophysiol 2022; 45:1295-1298. [PMID: 35687737 DOI: 10.1111/pace.14547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/05/2022] [Indexed: 11/27/2022]
Abstract
A 39-years old ventricular lead of a right-sided single-chamber pacemaker required extraction for infection. Angulation at the right subclavian-superior vena cava junction coupled with calcified fibrotic encapsulating tissue prevented advancement of a rotational dissecting sheath. To straighten the lead, it was pulled from the subclavian and out of the right internal jugular vein, whilst the Needle's-Eye Snare via the femoral access provided counter-traction. A 13-french rotational dissecting sheath was successfully advanced over the lead via the jugular access to complete the lead extraction without any complication.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Khiast Ullah Zaman
- Department of Cardiology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Lisa Wm Leung
- Department of Cardiology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Zia Zuberi
- Department of Cardiology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital NHS Foundation Trust, London, UK
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17
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Akhtar Z, Sohal M, Kontogiannis C, Leung LWM, Harding I, Zuberi Z, Bajpai A, Norman M, Pearse S, Beeton I, Gallagher MM. Anatomical variations in coronary venous drainage: challenges and solutions in delivering cardiac resynchronisation therapy. Europace 2022. [DOI: 10.1093/europace/euac053.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Cardiac resynchronisation therapy (CRT) is the cornerstone of heart failure management. Delivery of a left ventricular lead can occur in a small proportion of patients undermining the benefits of this treatment. Abnormal coronary venous anatomy is a contributing factor to this failure. Although epicardial lead placement is available, this patient cohort requiring CRT is subject to higher peri-operative morbidity and mortality than the general population; a transvenous approach is preferable.
Purpose
To investigate the abnormalities of the coronary venous system in candidates for cardiac resynchronization therapy (CRT) and describe methods for circumventing the resulting difficulties.
Methods
From 4 implanting institutes, data of all CRT implants between October 2008-October 2020 were screened for abnormal cardiac venous anatomy, defined as an anatomical variation not conforming to the accepted ‘normal’ anatomy. Patient demographics, procedural detail and subsequent left ventricle (LV) lead pacing indices were collected.
Results
From a total of 3548 CRT implants, 15 (0.42%) patients (80% male) of 72.2±10.6 years in age with a LV ejection fraction of 34±10.3% were identified to have had an abnormal cardiac venous anatomy over the study period. There were 13 cases of persistent left side superior vena cava (pLSVC), 5 of which had coronary sinus ostium atresia (CSOA) including 2 with an ‘unroofed’ coronary sinus (CS); 1 patient had a unique anomalous origin of the CS and 1 patient had an isolated CSOA. In total 14 patients (60% repeat attempt) had successful percutaneous implant under general anaesthesia (46.7%) via the cephalic vein (59.1%), using the femoral approach (53.3%) for levophase venography and/or pull-through, including 1 case of endocardial LV implant. Pacing follow-up over 37.64±37.6 months demonstrated LV lead threshold between 0.62-2.9 volts (pulsewidth 0.4-1.5 milliseconds) in all cases; 5 patients died within 2.92±1.6 years of successful implant.
Conclusion
CRT devices can be implanted percutaneously even in the presence of substantial abnormalities of coronary venous anatomy. Alternative routes of venous access may be required.
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Affiliation(s)
- Z Akhtar
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - C Kontogiannis
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - LWM Leung
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - I Harding
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Bajpai
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Norman
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - S Pearse
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - I Beeton
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
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18
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Akhtar Z, Zuberi Z, Leung LWM, Kontogiannis C, Waleed K, Elbatran AI, Sohal M, Gallagher MM. Transvenous lead extraction: the Tandem approach. Europace 2022. [DOI: 10.1093/europace/euac053.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Transvenous lead extraction (TLE) has become an important strategy in the management of patients with cardiac implantable electronic devices (CIEDs). A rising population of patients with CIEDs coupled with an expanding indication for TLE, has fuelled demand. There are notable procedural risks however development of techniques and tools have contributed to an improvement in the safety and efficacy of TLE. The mechanical rotational dissecting sheath is safe and efficacious whilst the Needle’s Eye Snare (NES) is an additional ‘bail-out’ strategy contributing to procedural success.
Purpose
We sought to evaluate the outcomes of TLE performed from the superior access in conjunction with counter-traction provided by snaring of the targeted lead via the femoral access.
Method
The ‘Tandem’ procedure consisted of the rotational powered sheath performing dissection of the adhesions encapsulating the leads (at the superior access), in ‘Tandem’ with the Needle’s Eye Snare providing countertraction via the femoral vein. In brief: after deployment of the locking stylet in the lead lumen, the NES was used to grasp the lead in the right atrium and hold it tort while a rotational sheath was used to dissect through the veins. Once the sheath reached the right atrium, the lead was released from the snare and the sheath was used to continue dissection toward the lead tip. Data for all consecutive ‘Tandem’ procedures performed between 1/1/2021 – 1/1/2022 in our high-volume TLE institute were collected and evaluated for safety and efficacy.
Results
Forty patients aged 69.2±16.3 (70% male), underwent TLE of 75 leads (45 right ventricle, 25, right atrium, 5 left ventricle) with dwell time of 150.1±80.3 months for a non-infectious indication (65%). Of the 40 cases, 27 were hypertensives, 14 had ischaemic heart disease whilst 5 suffered diabetes with a left ventricle ejection fraction of 46.8±10.2%; 12 (30%) were pacing dependent. Procedures were performed by cardiologists in the cardiac catheterisation suite under general anaesthesia (95%) using a locking stylet (100%) with an Evolution RL (11-french 58.7%); a NES 13 millimetres curve (88%) was used to successfully snare 91% of the targeted leads. Complete procedural success was achieved in 92% of leads with 98.7% clinical success. Minor complications occurred in 2 cases (pneumothorax, pocket haematoma requiring intervention), in the absence of any major complications or peri-procedural mortality; there was no 30-day mortality.
Conclusion
The ‘Tandem’ procedure provides an additional strategy to improve the safety and efficacy of TLE, especially in leads of a long dwell time.
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Affiliation(s)
- Z Akhtar
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - LWM Leung
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - C Kontogiannis
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - K Waleed
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - AI Elbatran
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
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Leung L, Akhtar Z, Bajpai A, Li A, Sohal M, Norman M, Kaba R, Al-Subaie N, Louis-Auguste J, Hayat J, Zuberi Z, Gallagher M. Oesophageal protection during AF ablation: real world registry data and mechanisms behind the therapeutic effect of tissue cooling. Europace 2022. [DOI: 10.1093/europace/euac053.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Oesophageal protection using a dedicated device to provide controlled active thermal protection of the oesophagus during atrial fibrillation ablation has been shown to be effective at reducing endoscopically detected oesophageal lesions. Real world registry data of this device and established evidence on the effect of cooling on localized tissue after thermal injury have been under review.
Purpose
To determine the safety of an oesophageal temperature control device by a review of real-world registry data on its clinical use during catheter ablation procedures and to clarify basic mechanisms of its therapeutic action by a literature review of scientific studies on cooling in the context of thermal injury.
Methods
The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA) databases were reviewed for any device-related adverse events. A systematic literature review was conducted to clarify the findings from studies investigating the physiological processes behind the therapeutic effect of cooling after tissue thermal injury.
Results
Of over 20,000 oesophageal temperature control devices clinically used, 7976 were recorded as having been used for the purpose of oesophageal protection during left atrial catheter ablations. No adverse events occurred related to its use during left atrial catheter ablations. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device. 208 research articles retrieved from PubMed and MEDLINE that met the search criteria were reviewed. The common finding in all the studies was that cooling had an anti-inflammatory and restorative effect via modulation of several immune-mediated pathways, local cellular function and genetic expression.
Conclusions
There have been no adverse events reported to date in real world clinical use of an oesophageal temperature control device during left atrial catheter ablations, for the purpose of active thermal protection. Literature review data suggests that there are complex biophysical and cellular effects from cooling that leads to its therapeutic effect but further work is required to define the mechanisms of action of thermal protection in this specific context.
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Affiliation(s)
- L Leung
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - Z Akhtar
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - A Bajpai
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - A Li
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - M Norman
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - R Kaba
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - N Al-Subaie
- Ahmadi hospital, Anaesthetics, Kuwait, Kuwait
| | - J Louis-Auguste
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - J Hayat
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - M Gallagher
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
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Gallagher M, Akhtar Z, Gang Y, Gonna H, Li A, Bajpai A, Zuberi Z, Norman M, Sohal M, Leung LWM. Randomised comparison of achieve and traditional circular mapping catheters in cryoballoon ablation: results at up to a decade. Europace 2022. [DOI: 10.1093/europace/euac053.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
A single-centre trial randomised patients to the use of the Achieve mapping catheter or a traditional circular mapping catheter during cryoballoon procedures for paroxysmal atrial fibrillation (AF) in 2011-2014. Long-term outcomes from the cohort were determined in 2021.
Purpose
To evaluate the determinants of long-term outcome of ablation for paroxysmal AF.
Methods
Patient and study procedure characteristics and clinical outcomes were determined, including mapping catheter assignment, model of cryoballoon used, AF recurrence, repeat ablations required, findings at repeat ablation long term survival of the patient.
Results
Of 102 patients in the original study, 98 had long-term (4.11+/-2.82 years) follow up data available. 35 patients (35.7%) had AF recurrence, giving a long-term success rate at 64.3% after 1 ablation, increasing to 81.6% after repeat ablation. Of the study cohort n=8 (8.16%) died at a median of 4.9 years after ablation (IQR:1.7-5.7). 25/98 (25.5%) patients had a second ablation and 7 (7.1%) had a third or more ablations. Those who had AF recurrence were older, with a higher prevalence of prior ischaemic heart disease and cardiac device implantation (p=0.02-0.03). After multi-variate analysis, a prior implanted cardiac device was the only significant predictor of recurrence (p=0.03).
Conclusion
Long-term outcomes after a 1st time PAF cryoablation were similar regardless of the type of mapping catheter used, the generation of cryoballoon, and traditional procedure endpoints. AF recurrences were more often detected in older patients with a history of ischaemic heart disease and implanted cardiac devices.
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Affiliation(s)
- M Gallagher
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - Z Akhtar
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - Y Gang
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - H Gonna
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - A Li
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - A Bajpai
- Epsom and St Helier University Hospitals NHS Trust, Cardiology, Epsom, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- Royal Surrey County Hospital, Cardiology, Guildford, United Kingdom of Great Britain & Northern Ireland
| | - M Norman
- Frimley Park Hospital, Cardiology, Frimley, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - LWM Leung
- St George’s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
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21
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Akhtar Z, Gallagher MM, Leung LWM, Kontogiannis C, Elbatran AI, Zuberi Z, Sohal M. Tunnelled dialysis catheter extraction: a cardiology experience. Europace 2022. [DOI: 10.1093/europace/euac053.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Tunnelled dialysis catheters are integral to the management of patients with chronic kidney disease (CKD), providing a means to dialysis. They are prone to blockages necessitating removal. Most catheters are removed with manual traction without any sequalae by renal physicians whilst a small proportion require further intervention which may include interventional radiology or an ‘open’ surgical removal which carries additional risk. Cardiologists versed in transvenous lead extraction (TLE) provide an additional strategy.
Purpose
To evaluate the outcomes of tunnelled dialysis catheter ‘extractions’ performed by cardiologists at a high-volume TLE institute.
Method
All consecutive patients referred to cardiologists (1/10/2016 – 1/10/21) for extraction of tunnelled dialysis catheters following an unsuccessful attempt by the renal physicians and interventional radiology, were included in this series. Data of procedural outcomes was evaluated for safety and efficacy.
Results
Twelve patients (7 male) aged 64.15±15.04 years with a body mass index of 28.3 kg/m2 were referred for tunnelled catheter extraction for non-functioning lines (75%). Of these 12 CKD patients, the aetiology included focal segmental glomerulosclerosis (n=2), hypertension (n=2), diabetes (n=1) and sickle cell disease (n=1). In total, 12 tunnelled catheters (75%; n=9 right side) were completely removed (100%) using local anaesthesia (83.3%) in a procedure lasting 54.7±29.8 minutes and requiring 0.79±1.32 minutes of fluoroscopy. Eleven patients (91.7%) had their catheters successfully extracted with manual traction alone; 3 necessitated the use of a 0.035 stiff J-tip wire whilst one required the use of a rotational dissecting sheath Evolution (Cook Medical, USA). Of the 12 cases, 11 had a failed previous attempt including 1 patient who suffered a ventricular fibrillation cardiac arrest during the procedure and 1 was referred directly without an attempt as there was a concurrent pacemaker situated from the contralateral side; 4 patients had new lines placed and no significant complications occurred. There were no complications or procedural mortality.
Conclusion
Extraction of tunnelled dialysis catheter lines performed by cardiologists is safe and efficacious; experience in TLE is vital. This may provide an additional strategy for removal of these catheters when other percutaneous attempts fail.
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Affiliation(s)
- Z Akhtar
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - LWM Leung
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - C Kontogiannis
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - AI Elbatran
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
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22
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Akhtar Z, Sohal M, Kontogiannis C, Harding I, Zuberi Z, Bajpai A, Norman M, Pearse S, Beeton I, Gallagher MM. Anatomical variations in Coronary Venous Drainage: Challenges and Solutions in Delivering Cardiac Resynchronisation Therapy. J Cardiovasc Electrophysiol 2022; 33:1262-1271. [PMID: 35524414 DOI: 10.1111/jce.15524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Abstract
AIMS To investigate the abnormalities of the coronary venous system in candidates for cardiac resynchronization therapy (CRT) and describe methods for circumventing the resulting difficulties. METHODS From 4 implanting institutes, data of all CRT implants between October 2008-October 2020 were screened for abnormal cardiac venous anatomy, defined as an anatomical variation not conforming to the accepted 'normal' anatomy. Patient demographics, procedural detail and subsequent left ventricle (LV) lead pacing indices were collected. RESULTS From a total of 3548 CRT implants, 15 (0.42%) patients (80% male) of 72.2±10.6 years in age with a LV ejection fraction of 34±10.3% were identified to have had an abnormal cardiac venous anatomy over the study period. There were 13 cases of persistent left side superior vena cava (pLSVC), 5 of which had coronary sinus ostium atresia (CSOA) including 2 with an 'unroofed' coronary sinus (CS); 1 patient had a unique anomalous origin of the CS and 1 patient had an isolated CSOA. In total 14 patients (60% repeat attempt) had successful percutaneous implant under general anaesthesia (46.7%) via the cephalic vein (59.1%), using the femoral approach (53.3%) for levophase venography and/or pull-through, including 1 case of endocardial LV implant. Pacing follow-up over 37.64±37.6 months demonstrated LV lead threshold between 0.62-2.9 volts (pulsewidth 0.4-1.5 milliseconds) in all cases; 5 patients died within 2.92±1.6 years of successful implant. CONCLUSION CRT devices can be implanted percutaneously even in the presence of substantial abnormalities of coronary venous anatomy. Alternative routes of venous access may be required. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Ashford and St Peter's Hospital, Surrey, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital, London, UK
| | | | - Idris Harding
- Department of Cardiology, St George's University Hospital, London, UK
| | - Zia Zuberi
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Royal Surrey County Hospital, Guildford, UK
| | - Abhay Bajpai
- Department of Cardiology, St George's University Hospital, London, UK
| | - Mark Norman
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Frimley Park Hospital, Surrey, UK
| | - Simon Pearse
- Department of Cardiology, St George's University Hospital, London, UK
| | - Ian Beeton
- Department of Cardiology, Ashford and St Peter's Hospital, Surrey, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Ashford and St Peter's Hospital, Surrey, UK
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23
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Leung LWM, Akhtar Z, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Sohal M, Gallagher MM. CA-528-03 A REGISTRY REVIEW UPDATE OF 7120 CATHETER ABLATIONS FOR ATRIAL FIBRILLATION USING A DEDICATED ESOPHAGEAL TEMPERATURE CONTROL DEVICE FOR PROTECTION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Akhtar Z, Gallagher MM, Elbatran AI, Starck CT, Gonzalez E, Al-Razzo O, Mazzone P, Delnoy PP, Breitenstein A, Steffel J, Eulert-Grehn J, Lanmüller P, Melillo F, Marzi A, Leung LW, Domenichini G, Sohal M. Patient Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: A comparison of two professions. Pacing Clin Electrophysiol 2022; 45:658-665. [PMID: 35417049 DOI: 10.1111/pace.14501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/09/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND With an increasing number of cardiac implantable electronic devices, there has been a paralleled increase in demand for transvenous lead extraction (TLE). Cardiac surgeons (CS) and cardiologists perform TLE; however, data comparing the two groups of operators is scarce. OBJECTIVE We compared the outcomes of TLE performed by cardiologists and CS from six European lead extraction units. METHOD Data was collected retrospectively of 2205 patients who had 3849 leads extracted (PROMET) between 2005-2018. Patient demographics and procedural outcomes were compared between the CS and cardiologist groups, using propensity score matching. A multivariate regression analysis was also performed for variables associated with 30-day mortality. RESULTS Cardiac surgeons performed the majority of extractions (59.8%), of leads with longer dwell times (90 [57-129 interquartile range (IQR)] vs 62 [31-102 IQR] months, CS vs cardiologists, p < 0.001) and with pre-dominantly non-infectious indications (57.4% vs 50.2%, CS vs cardiologists, p < 0.001). Cardiac surgeons achieved a higher complete success per lead than the cardiologists (98.1% vs 95.7%, respectively, p < 0.01), with a higher number of minor complications (5.51% vs 2.1%, p < 0.01) and similar number of major complications (0.47% vs 1.3%, p = 0.12). Thirty-day mortality was similarly low in the CS and cardiologist groups (1.76% vs 0.94%,p = 0.21). Unmatched data multivariate analysis revealed infection indication (OR 6.12 [1.9-20.3], p < 0.01), procedure duration (OR 1.01 [1.01-1.02], p < 0.01) and CS operator (OR 2.67, [1.12-6.37], p = 0.027) were associated with 30-day mortality. CONCLUSION Transvenous lead extraction by CS was performed with similar safety and higher efficacy compared to cardiologists in high and medium-volume lead extraction centres. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zaki Akhtar
- St. George's University Hospitals NHS Foundation Trust, London
| | | | - Ahmed I Elbatran
- St. George's University Hospitals NHS Foundation Trust, London.,Ain Shams University, Cairo, Egypt
| | - Christoph T Starck
- German Heart Center Berlin, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany.,German Center of Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | | | | | | | | | | | | | - Jürgen Eulert-Grehn
- German Heart Center Berlin, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany.,German Center of Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Pia Lanmüller
- German Heart Center Berlin, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany
| | | | | | - Lisa Wm Leung
- St. George's University Hospitals NHS Foundation Trust, London
| | | | - Manav Sohal
- St. George's University Hospitals NHS Foundation Trust, London
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25
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Akhtar Z, Kontogiannis C, Sharma S. Coronary Caverns: Spontaneous Recanalized Chronic Total Occlusion With Multiple Microchannels. J Invasive Cardiol 2022; 34:E347. [PMID: 35366232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Spontaneous chronic total occlusion recanalization is rare. It has scarcely been described previously and with minimal visual detail. Optical coherence tomography permitted comprehensive visualization of the microchannels in this case, seldom seen previously. With Thrombolysis in Myocardial Infarction 3 flow in the affected vessel via these patent channels, optimal medical therapy may be an appropriate strategy.
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Affiliation(s)
- Zaki Akhtar
- Ashford and St Peter's Hospital NHS trust, Guildford Road, Chertsey, Surrey, United Kingdom, KT16 0PZ.
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Akhtar Z, Leung LWM, Kontogiannis C, Chung I, Bin Waleed K, Gallagher MM. Arrhythmias in Chronic Kidney Disease. Eur Cardiol 2022; 17:e05. [PMID: 35321526 PMCID: PMC8924956 DOI: 10.15420/ecr.2021.52] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022] Open
Abstract
Arrhythmias cause disability and an increased risk of premature death in the general population but far more so in patients with renal failure. The association between the cardiac and renal systems is complex and derives in part from common causality of renal and myocardial injury from conditions including hypertension and diabetes. In many cases, there is a causal relationship, with renal dysfunction promoting arrhythmias and arrhythmias exacerbating renal dysfunction. In this review, the authors expand on the challenges faced by cardiologists in treating common and uncommon arrhythmias in patients with renal failure using pharmacological interventions, ablation and cardiac implantable device therapies. They explore the most important interactions between heart rhythm disorders and renal dysfunction while evaluating the ways in which the coexistence of renal dysfunction and cardiac arrhythmia influences the management of both.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Lisa WM Leung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Christos Kontogiannis
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Isaac Chung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Khalid Bin Waleed
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
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Akhtar Z, Beeton I, Marciniak A. A giant Sinus of Valsalva aneurysm presenting with ventricular tachycardia. Eur Heart J Cardiovasc Imaging 2022; 23:e166. [PMID: 35015826 DOI: 10.1093/ehjci/jeab296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/29/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford Street, Chertsey, Surrey, KT16 0PZ, UK.,Department of Cardiology, St George's University Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK
| | - Ian Beeton
- Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford Street, Chertsey, Surrey, KT16 0PZ, UK
| | - Anna Marciniak
- Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford Street, Chertsey, Surrey, KT16 0PZ, UK.,Department of Cardiology, St George's University Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK
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28
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Leung LWM, Akhtar Z, Sheppard MN, Louis-Auguste J, Hayat J, Gallagher MM. Preventing esophageal complications from atrial fibrillation ablation: A review. Heart Rhythm O2 2022; 2:651-664. [PMID: 34988511 PMCID: PMC8703125 DOI: 10.1016/j.hroo.2021.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review. Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed. The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation.
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Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Zaki Akhtar
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Mary N Sheppard
- Cardiac Pathology Unit, St. George's University of London, London, United Kingdom
| | - John Louis-Auguste
- Department of Gastroenterology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Jamal Hayat
- Department of Gastroenterology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark M Gallagher
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
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29
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Ball A, Mansfield A, Taylor B, Sheerin F, Wickins J, Akhtar Z, Bhangu A, Karandikar S. COVID-19 opens the door for right iliac fossa pain treatment pathway. Ann R Coll Surg Engl 2021; 104:302-307. [PMID: 34882012 DOI: 10.1308/rcsann.2021.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR. METHODS A retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups. RESULTS The mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16-45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%. CONCLUSIONS Greater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.
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Affiliation(s)
- A Ball
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - A Mansfield
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - B Taylor
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - F Sheerin
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - J Wickins
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - Z Akhtar
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - A Bhangu
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - S Karandikar
- University Hospitals Birmingham NHS Foundation Trust, UK
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Leung LWM, Akhtar Z, Seshasai SRK, Gallagher MM. First-line management of paroxysmal atrial fibrillation: is it time for a 'pill in the bin' approach? A discussion on the STOP AF First, EARLY AF, Cryo-FIRST, and EAST-AF NET 4 clinical trials. Europace 2021; 24:533-537. [PMID: 34850953 DOI: 10.1093/europace/euab259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | - Zaki Akhtar
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| | | | - Mark M Gallagher
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
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31
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Akhtar Z, Sohal M, Starck CT, Mazzone P, Melillo F, Gonzalez E, Al-Razzo O, Richter S, Breitenstein A, Steffel J, Rinaldi CA, Mehta V, Zuberi Z, Zaidi A, Gallagher MM. Persistent left superior vena cava transvenous lead extraction: A European experience. J Cardiovasc Electrophysiol 2021; 33:102-108. [PMID: 34783107 DOI: 10.1111/jce.15290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/22/2021] [Accepted: 11/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transvenous lead extraction (TLE) is rising in parallel to cardiac implantable electronic device implantations. Persistent left side superior vena cava (PLSVC) is a relatively common anatomical variant in the healthy population; TLE in patients with a PLSVC is rare. METHOD Data were collated from 6 European TLE institutes of 10 patients who had undergone lead extraction with a PLSVC. Patient demographics, procedural challenges and outcomes were reported. RESULTS Ten patients aged 73.4 ± 7.8 years (60% male) underwent TLE of 20 leads (3 left ventricle, 10 right ventricle, 7 right atrium) with dwell time of 82.95 ± 39.1 months. Of the 10 cases, 4 had an infection indication and 5 were biventricular system extractions; 25% of the extracted leads were defibrillator leads. The majority of the procedures were completed in the cardiac catheterization suite (80%) under general anaesthesia (60%) by cardiologists (80%) using a rotational powered sheath (65%). The Tandem approach was used successfully in 3 cases. Complete procedural success was obtained in 100% of cases in the absence of complications within 127.4 ± 74.7 min. There was no 30-day mortality. CONCLUSION TLE in PLSVC is feasible albeit rare. Standard extraction techniques in experienced hands are associated with favorable outcomes; the Tandem procedure may be an additional technique to improve the safety and efficacy of TLE in PLSVC.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital, London, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital, London, UK
| | - Christoph T Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | | | | | - Elkin Gonzalez
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | - Omar Al-Razzo
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | - Sergio Richter
- Department of Electrophysiology, HELIOS Heart Center-University of Leipzig, Leipzig, Germany
| | | | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, Zürich, Switzerland
| | | | - Vishal Mehta
- Department of Cardiology, Guy's and St Thomas's Hospital, London, UK
| | - Zia Zuberi
- Department of Cardiology, St George's University Hospital, London, UK
| | - Amir Zaidi
- Department of Cardiology, Manchester University Hospitals, Manchester, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital, London, UK
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33
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Akhtar Z, Kontogiannis C, Sharma S, Gallagher MM. The 12-Lead ECG in COVID-19: QT Prolongation Predicts Outcome. JACC Clin Electrophysiol 2021; 7:1072-1073. [PMID: 34412874 PMCID: PMC8366575 DOI: 10.1016/j.jacep.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 11/30/2022]
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34
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Leung LWM, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Akhtar Z, Evranos B, Gonna H, Harding I, Sohal M, Al-Subaie N, Louis-Auguste J, Hayat J, Gallagher MM. Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study. Europace 2021; 23:205-215. [PMID: 33205201 PMCID: PMC7868886 DOI: 10.1093/europace/euaa276] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/13/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023] Open
Abstract
Aims Thermal injury to the oesophagus is an important cause of life-threatening complication after ablation for atrial fibrillation (AF). Thermal protection of the oesophageal lumen by infusing cold liquid reduces thermal injury to a limited extent. We tested the ability of a more powerful method of oesophageal temperature control to reduce the incidence of thermal injury. Methods and results A single-centre, prospective, double-blinded randomized trial was used to investigate the ability of the ensoETM device to protect the oesophagus from thermal injury. This device was compared in a 1:1 randomization with a control group of standard practice utilizing a single-point temperature probe. In the protected group, the device maintained the luminal temperature at 4°C during radiofrequency (RF) ablation for AF under general anaesthesia. Endoscopic examination was performed at 7 days post-ablation and oesophageal injury was scored. The patient and the endoscopist were blinded to the randomization. We recruited 188 patients, of whom 120 underwent endoscopy. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 vs. 2/60; P = 0.008), with a trend toward reduction in gastroparesis (6/60 vs. 2/60, P = 0.27). There was no difference between groups in the duration of RF or in the force applied (P value range= 0.2–0.9). Procedure duration and fluoroscopy duration were similar (P = 0.97, P = 0.91, respectively). Conclusion Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared with standard care. This method of oesophageal protection is safe and does not compromise the efficacy or efficiency of the ablation procedure.
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Affiliation(s)
- Lisa W M Leung
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Abhay Bajpai
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Anthony Li
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Mark Norman
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Riyaz A Kaba
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Zaki Akhtar
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Banu Evranos
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Hanney Gonna
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Idris Harding
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Manav Sohal
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Nawaf Al-Subaie
- Anesthetic Department, Anesthesia and Intensive Care Medicine, Kuwait Oil Company Ahmadi Hospital, Kuwait
| | - John Louis-Auguste
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, St. George's, London, UK
| | - Jamal Hayat
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, St. George's, London, UK
| | - Mark M Gallagher
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
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35
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital, Blackshaw Road, London SW17 0RE, UK
| | - Lisa W M Leung
- Department of Cardiology, St George's University Hospital, Blackshaw Road, London SW17 0RE, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital, Blackshaw Road, London SW17 0RE, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital, Blackshaw Road, London SW17 0RE, UK
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36
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Akhtar Z, Leung LWM, Gallagher MM, Zuberi Z. Subcutaneous implantable cardioverter-defibrillator: the impedance of air. Europace 2021; 24:30-31. [PMID: 34339485 DOI: 10.1093/europace/euab149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, Royal Surrey County Hospital NHS Trust, Surrey, UK.,Department of Cardiology, St George's University Hospital NHS Trust, Blackshaw Road, Tooting, London SW17 0RE, UK
| | - Lisa W M Leung
- Department of Cardiology, Royal Surrey County Hospital NHS Trust, Surrey, UK
| | - Mark M Gallagher
- Department of Cardiology, Royal Surrey County Hospital NHS Trust, Surrey, UK
| | - Zia Zuberi
- Department of Cardiology, Royal Surrey County Hospital NHS Trust, Surrey, UK.,Department of Cardiology, St George's University Hospital NHS Trust, Blackshaw Road, Tooting, London SW17 0RE, UK
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37
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Akhtar Z, Leung LW, Kontogiannis C, Zuberi Z, Bajpai A, Sharma S, Chen Z, Beeton I, Sohal M, Gallagher MM. Prevalence of bradyarrhythmias needing pacing in COVID-19. Pacing Clin Electrophysiol 2021; 44:1340-1346. [PMID: 34240439 PMCID: PMC8447422 DOI: 10.1111/pace.14313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/19/2021] [Accepted: 07/04/2021] [Indexed: 12/15/2022]
Abstract
Background The Sars‐Cov‐2 infection is a multisystem illness that can affect the cardiovascular system. Tachyarrhythmias have been reported but the prevalence of bradyarrhythmia is unclear. Cases have been described of transient high‐degree atrioventricular (AV) block in COVID‐19 that were managed conservatively. Method A database of all patients requiring temporary or permanent pacing in two linked cardiac centers was used to compare the number of procedures required during the first year of the pandemic compared to the corresponding period a year earlier. The database was cross‐referenced with a database of all patients testing positive for Sars‐Cov‐2 infection in both institutions to identify patients who required temporary or permanent pacing during COVID‐19. Results The number of novel pacemaker implants was lower during the COVID‐19 pandemic than the same period the previous year (540 vs. 629, respectively), with a similar proportion of high‐degree AV block (38.3% vs. 33.2%, respectively, p = .069). Four patients with the Sars‐Cov‐2 infection had a pacemaker implanted for high‐degree AV block, two for sinus node dysfunction. Of this cohort of six patients, two succumbed to the COVID‐19 illness and one from non‐COVID sepsis. Device interrogation demonstrated a sustained pacing requirement in all cases. Conclusion High‐degree AV block remained unaltered in prevalence during the COVID‐19 pandemic. There was no evidence of transient high‐degree AV block in patients with the Sars‐Cov‐2 infection. Our experience suggests that all clinically significant bradyarrhythmia should be treated by pacing according to usual protocols regardless of the COVID status.
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Affiliation(s)
- Zaki Akhtar
- Cardiology, St George's University Hospital NHS trust, London, UK.,Cardiology, Ashford and St Peter's Hospitals NHS trust, Surrey, UK
| | - Lisa Wm Leung
- Cardiology, St George's University Hospital NHS trust, London, UK
| | | | - Zia Zuberi
- Cardiology, St George's University Hospital NHS trust, London, UK.,Cardiology, Royal Surrey County Hospital, Surrey, UK
| | - Abhay Bajpai
- Cardiology, St George's University Hospital NHS trust, London, UK.,Cardiology, Epsom and St Heliers University Hospitals, London, UK
| | - Sumeet Sharma
- Cardiology, St George's University Hospital NHS trust, London, UK
| | - Zhong Chen
- Cardiology, Ashford and St Peter's Hospitals NHS trust, Surrey, UK
| | - Ian Beeton
- Cardiology, Ashford and St Peter's Hospitals NHS trust, Surrey, UK
| | - Manav Sohal
- Cardiology, St George's University Hospital NHS trust, London, UK
| | - Mark M Gallagher
- Cardiology, St George's University Hospital NHS trust, London, UK.,Cardiology, Ashford and St Peter's Hospitals NHS trust, Surrey, UK.,Cardiology, Epsom and St Heliers University Hospitals, London, UK
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38
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Akhtar Z, Elbatran AI, Starck CT, Gonzalez E, Al-Razzo O, Mazzone P, Delnoy PP, Breitenstein A, Steffel J, Eulert-Grehn J, Lanmüller P, Melillo F, Marzi A, Leung LWM, Domenichini G, Sohal M, Gallagher MM. Transvenous lead extraction: The influence of age on patient outcomes in the PROMET study cohort. Pacing Clin Electrophysiol 2021; 44:1540-1548. [PMID: 34235772 DOI: 10.1111/pace.14310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/25/2021] [Accepted: 06/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac implantable electronic device (CIED) therapy contributes to an improvement in morbidity and mortality across all patient demographics. Patient age is a recognized risk factor for unfavorable outcomes in invasive procedures. This is the largest series of non-laser transvenous lead extraction (TLE) evaluating the association between patient age and procedure outcomes. METHODS Data of 2205 (3849 leads) patients was collected retrospectively from six European TLE centers between January 2005-December 2018 in the PROMET study. Of these, 153 patients with 319 leads were excluded for incomplete data. A comparison of outcomes was performed between the age groups young [< 50 years], young intermediate [50-69 years], older intermediate [70-79 years], and octogenarian [≥80 years]. RESULTS Infection was most common indication for TLE in the octogenarian cohort, less common in the younger population (60.1% vs. 33.2%, respectively, p < .01). High-voltage leads were extracted most frequently from young patients, less frequently from octogenarians (31.6% vs. 10%, p < .001), while the opposite was evident for pacemaker leads (p < .001). Rotational sheath use was equally prevalent across all patient groups (p = .79). Minor and major complications across all the age groups were statistically similar, as was procedural success; the 30-day mortality was most significant in the octogenarian and least in the young patients (4.9% vs. 0.4%, p = .005). Propensity matching multivariate analysis found systemic infection, lead dwell time, and patient age (p = .013, OR 1.064 [1.013-1.116]) increased risk of 30-day mortality. CONCLUSION TLE is safe and effective across all age groups. 30-day mortality risk is significantly higher in the older patients.
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Affiliation(s)
- Zaki Akhtar
- Cardiology, St. George's University Hospitals, London, UK
| | - Ahmed I Elbatran
- Cardiology, St. George's University Hospitals, London, UK.,Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Christoph T Starck
- German Heart Centre, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany.,German Centre of Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Steinbeis University Berlin, Institute (STI) of Cardiovascular Perfusion, Berlin, Germany
| | | | | | | | | | | | - Jan Steffel
- University Hospital Zurich, Zurich, Switzerland
| | - Jürgen Eulert-Grehn
- German Heart Centre, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany.,German Centre of Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Pia Lanmüller
- German Heart Centre, Department of Cardiothoracic & Vascular Surgery, Berlin, Germany
| | | | | | - Lisa W M Leung
- Cardiology, St. George's University Hospitals, London, UK
| | | | - Manav Sohal
- Cardiology, St. George's University Hospitals, London, UK
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39
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Akhtar Z, Leung LWM, Chen Z, Beeton I, Gallagher MM. 'Close' cardiac monitoring: life-threatening complication of a loop recorder implant. Europace 2021; 23:1492. [PMID: 34097037 DOI: 10.1093/europace/euab086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zaki Akhtar
- Cardiology department, Ashford and St Peter's Hospital NHS trust, Surrey, KT16 0PZ, UK.,Cardiology department, St George's University Hospital, Blackshaw Road, London, SW17 0RE, UK
| | - Lisa W M Leung
- Cardiology department, St George's University Hospital, Blackshaw Road, London, SW17 0RE, UK
| | - Zhong Chen
- Cardiology department, Ashford and St Peter's Hospital NHS trust, Surrey, KT16 0PZ, UK
| | - Ian Beeton
- Cardiology department, Ashford and St Peter's Hospital NHS trust, Surrey, KT16 0PZ, UK
| | - Mark M Gallagher
- Cardiology department, Ashford and St Peter's Hospital NHS trust, Surrey, KT16 0PZ, UK.,Cardiology department, St George's University Hospital, Blackshaw Road, London, SW17 0RE, UK
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40
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Akhtar Z, Leung LWM, Gallagher MM, Sharma S. Subacute left main stem thrombus in COVID-19: a case report. Eur Heart J Case Rep 2021; 5:ytab222. [PMID: 34263123 PMCID: PMC8274640 DOI: 10.1093/ehjcr/ytab222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/22/2021] [Accepted: 05/18/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford road, Surrey, KT16 0PZ, UK
- Department of Cardiology, St George's University Hospital, Blackshaw road, London, SW17 0RE, UK
| | - Lisa W M Leung
- Department of Cardiology, St George's University Hospital, Blackshaw road, London, SW17 0RE, UK
| | - Mark M Gallagher
- Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford road, Surrey, KT16 0PZ, UK
- Department of Cardiology, St George's University Hospital, Blackshaw road, London, SW17 0RE, UK
| | - Sumeet Sharma
- Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford road, Surrey, KT16 0PZ, UK
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Akhtar Z, Gallagher MM, Elbatran A, Starck CT, Leung LWM, Sohal M. PROMET: The effect of operator profession on non-laser transvenous lead extraction. Europace 2021. [DOI: 10.1093/europace/euab116.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
OnBehalf
PROMET group
Background
As implantation of cardiac implantable devices (CIED) rises globally, there is a paralleled need for extraction of these devices. Indications for transvenous lead extraction (TLE) is expanding, fuelling demand. This lifesaving procedure is performed by cardiologists and cardiac surgeons (CS). Cardiologists are familiar with transvenous methods whilst cardiac surgeons possess the skillset to address the significant complications associated with this procedure.
We compared non-laser TLE outcomes performed by cardiologists and cardiac surgeons from six high-volume extraction centres across Europe.
Methods
Data was collected retrospectively from six major European TLE centres of 2205 patients and 3849 leads (PROMET). Propensity 1:1 score matching (PSM) was performed to account for confounding variables. PSM model with variables: lead dwell time, infection indication, biventricular system and defibrillator device, was best matched. This dataset was analysed to compare outcomes of TLE performed by the cardiologists and CS. Predictors of 30-day mortality and complications were identified using a multivariate regression analysis.
Results
Patients treated by CS and cardiologists were similar in age (64.7 vs 66.7 years, p = NS) and equally male (70.3% vs 72.3%, p = 0.39) with a parallel infectious indication (51.7% vs 47.6%, p = 0.1). Surgeons achieved a significantly higher proportion of clinical success than cardiologists (98.9% vs 96.4%, p = 0.001) and complete lead extraction (98% vs 95.9%, p < 0.01) with a higher rate of minor complications (4.1% vs 2.2%, p = 0.024); major complications were similar (0.9% vs 1.2%, respectively, p = 0.46) as was 30-day mortality (3.2% vs 2%, respectively, p = 0.28). Multivariate regression analysis revealed systemic infection (p < 0.001, OR 7.2 [CI 2.3-20.1]) and defibrillator system extraction (p = 0.025, OR 3.4 [CI 1.2-10.2]) increased the odds of 30-day mortality, whilst Evolution™ sheath use reduced the odds (p = 0.025, OR 0.34 [CI 0.13-0.88]); lead dwell time (p = 0.02, OR 1.005 [1-1.009] and Evolution™ sheath use (p = 0.023, OR 2.15[1.1-4.15]) increased the odds of complications.
Conclusion
Cardiac surgeons and cardiologists achieved a high rate of TLE procedural success and with a similar safety profile, replicating standards seen across Europe.
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Affiliation(s)
- Z Akhtar
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Elbatran
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - CT Starck
- German Heart Center Berlin, Berlin, Germany
| | - L WM Leung
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
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42
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Akhtar Z, Elbatran A, Starck CT, Leung LWM, Sohal M, Gallagher MM. PROMET: the effect of age on patient outcomes in non-laser transvenous lead extraction. Europace 2021. [DOI: 10.1093/europace/euab116.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
OnBehalf
PROMET group
Background
Cardiac implantable electronic devices (CIEDs) improve morbidity and mortality. This has fuelled an upsurge in implantation of these devices across all patient cohorts, simultaneously increasing the need for transvenous lead extractions (TLE). As the global population expands and life-expectancy extends, TLE will play a significant role in CIED management. Advancing patient age is a recognised risk factor for poor outcomes however the association between patient age and TLE outcomes remains unclear.
We sought to evaluate the relationship between patient age and non-laser TLE outcomes.
Method
Data of 2205 patients (3849 leads) was collected retrospectively from six high-volume TLE institutes across Europe (PROMET) between January 2005-December 2018. Propensity 1:1 score matching was performed to limit the effects of confounding variables, pairing 353 patients in the >80 years of age category with 353 patients in <80 years of age group. Procedural outcomes were compared between the two age groups and multivariate regression analysis was used for predictors of 30-day mortality.
Results
In the <80 and >80 years-of-age cohorts, there was a similar proportion of male patients (65.3% vs 67.9%, p = 0.47) treated under general anaesthesia (96.5% vs 93.4%, p = 0.078) for a pre-dominant infectious indication (56.7% vs 60.3%, p = 0.52) but with a higher requirement of the EvolutionTM sheath in the octogenarians (39.4% vs 48.4%, p = 0.015). A similar clinical success per lead was achieved between the two age groups (96.6% vs 98%, <80 vs >80 years, p = 0.245) as was complete lead extraction (95.5% vs 96.6%, <80 vs >80 years, p = 0.44) with a comparable minor complication rate (2.3% vs 3.1%, <80 vs >80 years, p = 0.29) and major complications (1.1% vs 1.4%, <80 vs >80 years, p = 0.74). Thirty-day mortality was higher in the octogenarian cohort than the <80-year-olds without reaching statistical significance (5.4% vs 2.6%, p = 0.08); peri-procedural mortality was similar in both age groups (0.3% vs 0.6%, respectively, p = 0.56). Multivariate regression analysis revealed age (p = 0.013, OR 1.06 [1.01-1.12]), systemic infection (p = 0.026, OR 3.4 [1.16-10.35]) and lead dwell time (p = 0.007, OR 1.01 [1.003-1.017]) increased the odds of 30-day mortality.
Conclusion
Transvenous lead extraction is similar in efficacy and safety across all age groups. Thirty-day mortality is higher in the advanced age group, signifying the importance of post-procedural management in this cohort.
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Affiliation(s)
- Z Akhtar
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Elbatran
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - CT Starck
- German Heart Center Berlin, Berlin, Germany
| | - L WM Leung
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
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43
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Elbatran A, Akhtar Z, Bajpai A, Leung LWM, Li A, Pearse S, Zuberi Z, Kaba R, Saba M, Norman M, Grimster A, Gallagher MM, Sohal M. Transvenous lead revision for cardiac perforation: a single centre experience. Europace 2021. [DOI: 10.1093/europace/euab116.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Cardiac perforation is an uncommon but life-threatening complication of cardiac implantable electronic device (CIED) implantation. Management strategy commonly relies on diagnostic Computed Tomography (CT) imaging and cardiac surgery. Emerging evidence has indicated a diversion from this approach. Transvenous culprit lead revision has been shown to be safe and efficacious in limited series.
We sought to evaluate the outcomes of transvenous lead revision in patients with cardiac perforation.
Method
Data was collected retrospectively of patients admitted to a single tertiary centre with CIED-related cardiac perforation between December 2013 – October 2019. Transvenous lead revision was performed as standard with cardiac surgery on standby. Patient demographics, use of CT imaging, method of removal and 30-day outcomes were recorded.
Results
Of the 46 recorded CIED-related cardiac perforations, the majority occurred in female patients (63%) and hypertensives (61%), whilst a proportion had cancer (20%) and ischaemic heart disease (30%). The culprit in most cases was a standard pacing lead (92%) of an active fixation (98%) in the right ventricle (80%) positioned at the ventricular apex (65%). The median time to presentation from implant was 14 days [IQR 4-50 days] with chest pain (44%); abnormal pacing indices was highly prevalent (95%) whilst a pericardial effusion was noted in the majority of cases (57%). CT scanning was performed in 19 cases (41%) for various indications but deemed essential in only 4, all of which had non-diagnostic pacing indices and imaging. Chest X-ray (CXR) found clear perforation, lead displacement or pleural effusion in 74% of cases, whilst an echocardiogram found these in 64% of cases. The culprit lead was replaced in the majority of cases (87%) under local anaesthesia (76%) with surgical backup. The median hospital stay was 7 days [IQR 3-10 days] with zero procedural and 30-day mortality.
Conclusion
Transvenous lead revision for CIED-related cardiac perforation is safe and efficacious. CT modality for diagnostic purposes is useful in providing incremental value in a minority of cases; patients with non-diagnostic pacing parameters and non-CT imaging benefit most from this.
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Affiliation(s)
- A Elbatran
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - Z Akhtar
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Bajpai
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - L WM Leung
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Li
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - S Pearse
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - R Kaba
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Saba
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Norman
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - A Grimster
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George"s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
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Leung L, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Sohal M, Akhtar Z, Evranos B, Gonna H, Harding I, Al Subaie N, Louis-Auguste J, Hayat J, Gallagher MM. A registry review of 2532 catheter ablations for atrial fibrillation using active thermal protection. Europace 2021. [DOI: 10.1093/europace/euab116.250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Dr Leung has received research support from Attune Medical (Chicago, IL). Dr Gallagher has received research funding from Attune Medical (Chicago, IL).
Background
Thermal injury to the oesophagus causes a spectrum of adverse effects after ablation for atrial fibrillation (AF); at the most severe end, atrio-oesophageal fistula carries a high mortality rate. Controlled active thermal protection in the oesophagus during ablation is the most promising method of oesophageal protection. Randomized evidence from the IMPACT trial (NCT03819946) showed an 83.4% reduction in endoscopically detected oesophageal lesions compared to standard care when an oesophageal temperature control device was used to control the local temperature. The IMPACT patients who were randomized to the use of the device had no adverse event related to its use. Real world registry data on applications of this device have not previously been available.
Purpose
To determine the safety of an oesophageal temperature control device by review of real-world registry data on its clinical use and any reported device-related adverse events.
Methods
We reviewed the following databases for any reported oesophageal temperature control device-related complications: The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA). An internal registry (post-marketing follow up) database maintained by the manufacturer of the device was used to quantify the number used for each indication. Reported events were reviewed and catalogued for description and identification of any events related to its use in the cardiac electrophysiology lab. The IMPACT study patients were reviewed for any device-related events.
Results
Of the 13, 284 oesophageal temperature control devices used, 2532 were recorded as having been used for the purpose of oesophageal protection during catheter ablation for AF. A total of 5 events associated with the device were identified, all from the MAUDE database. Three were from 2017, one from 2018, and one from 2019. All involved its use in critical care or trauma patients and were related to user error or contraindicated patient selection; none resulted in serious harm to the patient. No adverse events occurred related to its use in the cardiac electrophysiology lab. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device.
Conclusions
Real world registry data has shown no adverse events reported to date in over 2500 uses of an oesophageal temperature control device in the cardiac electrophysiology lab, for the purpose of active thermal protection. This data supports the randomized trial evidence of its clinical effectiveness. Abstract Figure. Oesophageal active thermal protection
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Affiliation(s)
- L Leung
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - A Bajpai
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - Z Zuberi
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - A Li
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - M Norman
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - RA Kaba
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - M Sohal
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - Z Akhtar
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - B Evranos
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - H Gonna
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - I Harding
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - N Al Subaie
- Ahmadi hospital, Anaesthetics , Kuwait, Kuwait
| | - J Louis-Auguste
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - J Hayat
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George"s Hospital (London), London, United Kingdom of Great Britain & Northern Ireland
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45
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Akhtar Z, Gallagher MM, Yap YG, Leung LWM, Elbatran AI, Madden B, Ewasiuk V, Gregory L, Breathnach A, Chen Z, Fluck DS, Sharma S. Prolonged QT predicts prognosis in COVID-19. Pacing Clin Electrophysiol 2021; 44:875-882. [PMID: 33792080 PMCID: PMC8251438 DOI: 10.1111/pace.14232] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 01/03/2023]
Abstract
Background Coronavirus disease‐2019 (COVID‐19) causes severe illness and multi‐organ dysfunction. An abnormal electrocardiogram is associated with poor outcome, and QT prolongation during the illness has been linked to pharmacological effects. This study sought to investigate the effects of the COVID‐19 illness on the corrected QT interval (QTc). Method For 293 consecutive patients admitted to our hospital via the emergency department for COVID‐19 between 01/03/20 ‐18/05/20, demographic data, laboratory findings, admission electrocardiograph and clinical observations were compared in those who survived and those who died within 6 weeks. Hospital records were reviewed for prior electrocardiograms for comparison with those recorded on presentation with COVID‐19. Results Patients who died were older than survivors (82 vs 69.8 years, p < 0.001), more likely to have cancer (22.3% vs 13.1%, p = 0.034), dementia (25.6% vs 10.7%, p = 0.034) and ischemic heart disease (27.8% vs 10.7%, p < 0.001). Deceased patients exhibited higher levels of C‐reactive protein (244.6 mg/L vs 146.5 mg/L, p < 0.01), troponin (1982.4 ng/L vs 413.4 ng/L, p = 0.017), with a significantly longer QTc interval (461.1 ms vs 449.3 ms, p = 0.007). Pre‐COVID electrocardiograms were located for 172 patients; the QTc recorded on presentation with COVID‐19 was longer than the prior measurement in both groups, but was more prolonged in the deceased group (448.4 ms vs 472.9 ms, pre‐COVID vs COVID, p < 0.01). Multivariate Cox‐regression analysis revealed age, C‐reactive protein and prolonged QTc of >455 ms (males) and >465 ms (females) (p = 0.028, HR 1.49 [1.04‐2.13]), as predictors of mortality. QTc prolongation beyond these dichotomy limits was associated with increased mortality risk (p = 0.0027, HR 1.78 [1.2‐2.6]). Conclusion QTc prolongation occurs in COVID‐19 illness and is associated with poor outcome.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK.,Department of Cardiology, St George's University Hospital, London, UK
| | - Mark M Gallagher
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK.,Department of Cardiology, St George's University Hospital, London, UK
| | - Yee Guan Yap
- Department of Cardiology, Sunway Medical Centre, Sunway City, Selangor, Malaysia
| | - Lisa W M Leung
- Department of Cardiology, St George's University Hospital, London, UK
| | - Ahmed I Elbatran
- Department of Cardiology, St George's University Hospital, London, UK
| | - Brendan Madden
- Department of Cardiology, St George's University Hospital, London, UK
| | - Victoria Ewasiuk
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK
| | - Louise Gregory
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK
| | - Aodhan Breathnach
- Department of Cardiology, St George's University Hospital, London, UK
| | - Zhong Chen
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK
| | - David S Fluck
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK
| | - Sumeet Sharma
- Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK.,Department of Biological Sciences, Royal Holloway University of London, Egham, UK
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46
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Elbatran AI, Akhtar Z, Bajpai A, Leung LWM, Li A, Pearse S, Zuberi Z, Kaba R, Saba MM, Norman M, Grimster A, Gallagher MM, Sohal M. Percutaneous management of lead-related cardiac perforation with limited use of computed tomography and cardiac surgery. Pacing Clin Electrophysiol 2021; 44:614-624. [PMID: 33624296 DOI: 10.1111/pace.14204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/28/2021] [Accepted: 02/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac implantable electronic device (CIED)-related perforation is uncommon but potentially lethal. Management typically includes the use of computed tomography (CT) scanning and often involves cardiac surgery. METHODS Patients presenting to a single referral centre with CIED-related cardiac perforation between 2013 and 2019 were identified. Demographics, diagnostic modalities, the method of lead revision, and 30-day complications were examined. RESULTS A total of 46 cases were identified; median time from implantation to diagnosis was 14 days (interquartile range = 4-50). Most were females (29/46, 63%), 9/46 (20%) had cancer, 18 patients (39%) used oral anticoagulants, and no patients had prior cardiac surgery. Active fixation was involved in 98% of cases; 9% involved an implantable cardioverter defibrillator lead. Thirty-seven leads perforated the right ventricle (apex: 24) and 9 punctured the right atrium (lateral wall: 5). Abnormal electrical parameters were noted in 95% of interrogated cases. Perforation was visualized in 41% and 6% of cases with chest X-ray (CXR) and transthoracic echocardiography, respectively. CXR revealed a perforation, gross lead displacement, or left-sided pleural effusion in 74% of cases. Pericardial effusion occurred in 26 patients (57%) of whom 11 (24%) developed tamponade, successfully drained percutaneously. Pre-extraction CT scan was performed in 19 patients but was essential in four cases. Transvenous lead revision (TLR) was successfully performed in all cases with original leads repositioned in six patients, without recourse to surgery. Thirty-day mortality and complications were low (0% and 26%, respectively). CONCLUSION CT scanning provides incremental diagnostic value in a minority of CIED-related perforations. TLR is a safe and effective strategy.
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Affiliation(s)
- Ahmed I Elbatran
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.,Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Zaki Akhtar
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Abhay Bajpai
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Anthony Li
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Simon Pearse
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Riyaz Kaba
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Magdi M Saba
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Mark Norman
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Alexander Grimster
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Manav Sohal
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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47
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Akhtar Z, Chen Z, Leung LWM, Beeton I, Gallagher MM. Innovative Cardiac Resynchronization: Deployable Lead as an Anchor to Facilitate Guidewire Advancement. JACC Case Rep 2021; 3:594-596. [PMID: 34317584 PMCID: PMC8302769 DOI: 10.1016/j.jaccas.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/08/2021] [Indexed: 12/01/2022]
Abstract
An acutely angulated coronary sinus ostium coupled with a dilated right atrium presents technical challenges for cardiac resynchronization therapy (CRT) implantation. Innovative use of a deployable left ventricle lead as an anchor to support guidewire navigation within the cardiac venous system permits optimal CRT deployment. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Zaki Akhtar
- St. George's University Hospital, London, United Kingdom.,Ashford and St. Peter's Hospitals NHS Trust, Surrey, United Kingdom
| | - Zhong Chen
- Ashford and St. Peter's Hospitals NHS Trust, Surrey, United Kingdom
| | - Lisa W M Leung
- St. George's University Hospital, London, United Kingdom
| | - Ian Beeton
- Ashford and St. Peter's Hospitals NHS Trust, Surrey, United Kingdom
| | - Mark M Gallagher
- St. George's University Hospital, London, United Kingdom.,Ashford and St. Peter's Hospitals NHS Trust, Surrey, United Kingdom
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48
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Leung LWM, Akhtar Z, Hayat J, Gallagher MM. Mechanical deviation of the esophagus: Not an easy concept to swallow. J Cardiovasc Electrophysiol 2021; 32:1209-1210. [PMID: 33651482 DOI: 10.1111/jce.14960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK.,Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK.,Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Jamal Hayat
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK.,Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK.,Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
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49
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Leung LW, Akhtar Z, Gallagher MM. Finding the heart of the problem: A letter to the editor on 'Detection of oesophageal course during left atrial ablation' by Santoro et al. Indian Pacing Electrophysiol J 2021; 21:137. [PMID: 33577968 PMCID: PMC7952889 DOI: 10.1016/j.ipej.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 11/08/2022] Open
Affiliation(s)
- Lisa Wm Leung
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, UK.
| | - Zaki Akhtar
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, UK
| | - Mark M Gallagher
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, UK
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Akhtar Z, Harding I, Elbatran AI, Gonna H, Mannakkara NN, Leung LWM, Zuberi Z, Bajpai A, Pearse S, Cox AT, Li A, Jouhra F, Valencia O, Chen Z, Sohal M, Beeton I, Gallagher MM. Multi-lead cephalic venous access and long-term performance of high-voltage leads. J Cardiovasc Electrophysiol 2021; 32:1131-1139. [PMID: 33565195 DOI: 10.1111/jce.14939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy-defibrillator (CRT-D) implantation via the cephalic vein is feasible and safe. Recent evidence has suggested a higher implantable cardioverter-defibrillator (ICD) lead failure in multi-lead defibrillator therapy via the cephalic route. We evaluated the relationship between CRT-D implantation via the cephalic and ICD lead failure. METHODS Data was collected from three CRT-D implanting centers between October 2008 and September 2017. In total 633 patients were included. Patient and lead characteristics with ICD lead failure were recorded. Comparison of "cephalic" (ICD lead via cephalic) versus "non-cephalic" (ICD lead via non-cephalic route) cohorts was performed. Kaplan-Meier survival and a Cox-regression analysis were applied to assess variables associated with lead failure. RESULTS The cephalic and non-cephalic cohorts were equally male (81.9% vs. 78%; p = .26), similar in age (69.7 ± 11.5 vs. 68.7 ± 11.9; p = .33) and body mass index (BMI) (27.7 ± 5.1 vs. 27.1 ± 5.7; p = .33). Most ICD leads were implanted via the cephalic vein (73.5%) and patients had a mean of 2.9 ± 0.28 leads implanted via this route. The rate of ICD lead failure was low and statistically similar between both groups (0.36%/year vs. 0.13%/year; p = .12). Female gender was more common in the lead failure cohort than non-failure (55.6% vs. 17.9%, respectively; p = .004) as was hypertension (88.9% vs. 54.2%, respectively, p = .038). On multivariate Cox-regression, female sex (p = .008; HR, 7.12 [1.7-30.2]), and BMI (p = .047; HR, 1.12 [1.001-1.24]) were significantly associated with ICD lead failure. CONCLUSION CRT-D implantation via the cephalic route is not significantly associated with premature ICD lead failure. Female gender and BMI are predictors of lead failure.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Ashford and St Peter's Hospitals NHS Trust, Surrey, UK
| | - Idris Harding
- Department of Cardiology, St George's University Hospital, London, UK
| | - Ahmed I Elbatran
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Ains Sham University, Cairo, Egypt
| | - Hanney Gonna
- Department of Cardiology, St George's University Hospital, London, UK
| | | | - Lisa W M Leung
- Department of Cardiology, St George's University Hospital, London, UK
| | - Zia Zuberi
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Abhay Bajpai
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Epsom and St Helier NHS Trust, Surrey, UK
| | - Simon Pearse
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Kingston Hospital NHS Trust, London, UK
| | - Andrew T Cox
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Frimley Park NHS Foundation Trust, UK
| | - Anthony Li
- Department of Cardiology, St George's University Hospital, London, UK
| | - Fadi Jouhra
- Department of Cardiology, St George's University Hospital, London, UK
| | - Oswaldo Valencia
- Department of Cardiology, St George's University Hospital, London, UK
| | - Zhong Chen
- Department of Cardiology, Ashford and St Peter's Hospitals NHS Trust, Surrey, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital, London, UK
| | - Ian Beeton
- Department of Cardiology, Ashford and St Peter's Hospitals NHS Trust, Surrey, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital, London, UK.,Department of Cardiology, Ashford and St Peter's Hospitals NHS Trust, Surrey, UK.,Department of Cardiology, Epsom and St Helier NHS Trust, Surrey, UK
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