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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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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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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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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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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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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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10
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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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11
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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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12
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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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13
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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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14
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Gallagher MM, Yi G, Gonna H, Leung LWM, Harding I, Evranos B, Bastiaenen R, Sharma R, Wright S, Norman M, Zuberi Z, Camm AJ. Multi-catheter cryotherapy compared with radiofrequency ablation in long-standing persistent atrial fibrillation: a randomized clinical trial. Europace 2021; 23:370-379. [PMID: 33188692 DOI: 10.1093/europace/euaa289] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 06/01/2020] [Accepted: 09/04/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Restoring sinus rhythm (SR) by ablation alone is an endpoint used in radiofrequency (RF) ablation for long-standing persistent atrial fibrillation (AF) but not with cryotherapy. The simultaneous use of two cryotherapy catheters can improve ablation efficiency; we compared this with RF ablation in chronic persistent AF aiming for termination to SR by ablation alone. METHODS AND RESULTS Consecutive patients undergoing their first ablation for persistent AF of >6 months duration were screened. A total of 100 participants were randomized 1:1 to multi-catheter cryotherapy or RF. For cryotherapy, a 28-mm Arctic Front Advance was used in tandem with focal cryoablation catheters. Open-irrigated, non-force sensing catheters were used in the RF group with a 3D mapping system. Pulmonary vein (PV) isolation and non-PV triggers were targeted. Participants were followed up at 6 and 12 months, then yearly. Acute PVI was achieved in all cases. More patients in the multi-catheter cryotherapy group were restored to SR by ablation alone, with a shorter procedure duration. Sinus rhythm continued to the last available follow-up in 16/49 patients (33%) in the multi-catheter at 3.0 ± 1.6 years post-ablation and in 12/50 patients (24%) in the RF group at 4.0 ± 1.2 years post-ablation. The yearly rate of arrhythmia recurrence was similar. CONCLUSION Multi-catheter cryotherapy can restore SR by ablation alone in more cases and more quickly than RF ablation. Long-term success is difficult to achieve by either methods and is similar with both.
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Affiliation(s)
- Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Gang Yi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Hanney Gonna
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Idris Harding
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Banu Evranos
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Rachel Bastiaenen
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Rajan Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Sue Wright
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Mark Norman
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - A John Camm
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
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15
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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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16
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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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17
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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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18
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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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19
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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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20
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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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21
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Leung L, Bajpai A, Zuberi Z, Li A, Norman M, Kaba R, Akhtar Z, Evranos B, Gonna H, Harding I, Sohal M, Al-Subaie N, Louis-Auguste J, Hayat J, Gallagher M. Patient outcomes after AF ablation using Ablation Index technology with oesophageal protection: insight from the IMPACT study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0619] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Atrio-oesophageal fistula formation accounts for the majority of AF ablation-related morbidity and mortality. Thermal injury to the oesophagus can be significantly reduced by application of oesophageal cooling for protection during AF ablation. The effect of this method of oesophageal protection in patients receiving radiofrequency (RF) ablation guided by Ablation Index technology is currently unknown.
Objective
To investigate the ability of a temperature control device to protect the oesophagus from ablation-related thermal injury in patients receiving AF ablation guided by Ablation Index technology.
Methods
The IMPACT study is a single-centre, prospective, double-blind randomized controlled trial, which investigated the ability of a controlled method of oesophageal cooling to protect the oesophagus from ablation-related thermal injury. The EnsoETM device was used to deliver oesophageal cooling. This method was compared in a 1:1 randomization to a control group of standard practice utilizing a single-sensor temperature probe. In the study group, the device was used to keep the luminal temperature at 4°C during RF ablation. All participants received AF ablation using Ablation Index technology at posterior and anterior settings (30W at 350–400 and 40W at 450–500, respectively). Endoscopic examination was performed within 7 days post-ablation and oesophageal injury was graded. The patient and the endoscopist were blinded to the randomization. Structured clinical follow up occurred after 3 months post-ablation; both patient and follow up clinician were blinded.
Results
We recruited 188 patients, of whom 120 underwent endoscopic evaluation. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 versus 2/60; P=0.008). There was no difference between groups in RF time, lesion duration, force, power and combined ablation index (P value range= 0.2–0.9). Procedure and fluoroscopy duration were similar (P=0.97, P=0.91 respectively). The majority of those who passed through the 1st follow up evaluation (n=136) did not have gastrointestinal or chest pain symptoms post ablation and there was no difference between the randomized groups. Only 4.4% overall had severe symptoms and they were poorly correlated against those who sustained mucosal lesions. AF recurrence was similar in both groups (8% vs 8.8%). There were 2 cases of vascular trauma needing intervention in the control group and 1 case of conservatively managed pericardial effusion in the protected group only. Clinical and endoscopy findings did not report any EnsoETM device-related trauma.
Conclusion
Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared to standard care when ablation is performed using radiofrequency with Ablation Index technology. This method of oesophageal protection is safe and does not compromise the efficacy of the ablation procedure.
Endoscopy findings and patient symptoms.
Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): 1. Public hospital: St. George's NHS Foundation Trust; 2. Private company: Attune Medical (Chicago, IL)
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Affiliation(s)
- L Leung
- St. George's Hospital, London, United Kingdom
| | - A Bajpai
- St. George's Hospital, London, United Kingdom
| | - Z Zuberi
- St. George's Hospital, London, United Kingdom
| | - A Li
- St. George's Hospital, London, United Kingdom
| | - M Norman
- St. George's Hospital, London, United Kingdom
| | - R Kaba
- St. George's Hospital, London, United Kingdom
| | - Z Akhtar
- St. George's Hospital, London, United Kingdom
| | - B Evranos
- St. George's Hospital, London, United Kingdom
| | - H Gonna
- St. George's Hospital, London, United Kingdom
| | - I Harding
- St. George's Hospital, London, United Kingdom
| | - M Sohal
- St. George's Hospital, London, United Kingdom
| | - N Al-Subaie
- St. George's Hospital, London, United Kingdom
| | | | - J Hayat
- St. George's Hospital, London, United Kingdom
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22
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Akhtar Z, Montalbano N, Leung LWM, Gallagher MM, Zuberi Z. Drive-Through Pacing Clinic: A Popular Response to the COVID-19 Pandemic. JACC Clin Electrophysiol 2020; 7:128-130. [PMID: 33478706 PMCID: PMC7547579 DOI: 10.1016/j.jacep.2020.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 11/13/2022]
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23
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Harding I, Mannakkar N, Gonna H, Domenichini G, Leung LW, Zuberi Z, Bajpai A, Lalor J, Cox AT, Li A, Sohal M, Chen Z, Beeton I, Gallagher MM. Exclusively cephalic venous access for cardiac resynchronisation: A prospective multi-centre evaluation. Pacing Clin Electrophysiol 2020; 43:1515-1520. [PMID: 32860243 DOI: 10.1111/pace.14046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 08/14/2020] [Accepted: 08/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Small series has shown that cardiac resynchronisation therapy (CRT) can be achieved in a majority of patients using exclusively cephalic venous access. We sought to determine whether this method is suitable for widespread use. METHODS A group of 19 operators including 11 trainees in three pacing centres attempted to use cephalic access alone for all CRT device implants over a period of 8 years. The access route for each lead, the procedure outcome, duration, and complications were collected prospectively. Data were also collected for 105 consecutive CRT device implants performed by experienced operators not using the exclusively cephalic method. RESULTS A new implantation of a CRT device using exclusively cephalic venous access was attempted in 1091 patients (73.6% male, aged 73 ± 12 years). Implantation was achieved using cephalic venous access alone in 801 cases (73.4%) and using a combination of cephalic and other access in a further 180 (16.5%). Cephalic access was used for 2468 of 3132 leads implanted (78.8%). Compared to a non-cephalic reference group, complications occurred less frequently (69/1091 vs 12/105; P = .0468), and there were no pneumothoraces with cephalic implants. Procedure and fluoroscopy duration were shorter (procedure duration 118 ± 45 vs 144 ± 39 minutes, P < .0001; fluoroscopy duration 15.7 ± 12.9 vs 22.8 ± 12.2 minutes, P < .0001). CONCLUSIONS CRT devices can be implanted using cephalic access alone in a substantial majority of cases. This approach is safe and efficient.
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Affiliation(s)
- Idris Harding
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Nilanka Mannakkar
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Hanney Gonna
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Giulia Domenichini
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Lisa Wm Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Zia Zuberi
- Department of Cardiology, Royal Surrey County Hospital, Guildford, UK
| | - Abhay Bajpai
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Joseph Lalor
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Andrew T Cox
- Department of Cardiology, Frimley Health NHS Foundation Trust, Camberley, UK
| | - Anthony Li
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Manav Sohal
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Zhong Chen
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Ian Beeton
- Department of Cardiology, St Peter's Hospital, Chertsey, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
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24
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Leung LW, Evranos B, Grimster A, Li A, Norman M, Bajpai A, Zuberi Z, Sohal M, Gallagher MM. Remanufactured circular mapping catheters: safety, effectiveness and cost. J Interv Card Electrophysiol 2018; 56:205-211. [PMID: 30588568 PMCID: PMC6848800 DOI: 10.1007/s10840-018-0497-x] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/10/2018] [Indexed: 12/02/2022]
Abstract
Background The use of remanufactured single-use devices (SUDs), including cardiac electrophysiology catheters, has become established in the USA and other health care systems but without much published scientific evaluation on the relative safety or efficacy of these devices. In the United Kingdom (UK), the use of remanufactured SUDs has not been routine. We performed a structured evaluation of the safety and efficacy of a remanufactured circular mapping catheter (Stryker® remanufactured Lasso NAV 2515) during its introduction in our centre. Methods We prospectively evaluated the performance of a remanufactured circular mapping catheter in 100 consecutive patients undergoing an AF ablation. Operator feedback was obtained, assessing the device appearance, ease of use and function. As an indirect measurement of efficacy, acute procedure metrics were compared to those in 100 propensity-matched cases performed by the same operators using a new device. Cost savings were calculated. Results No complication occurred in association with the remanufactured device. There was one reported failure of device malfunction—the flexion-extension mechanism of a remanufactured catheter and none in the matched-control group. There was satisfactory communication with the electro-anatomic mapping system. Ease of use of the remanufactured catheter was reported to be similar to a newly manufactured device. Procedural duration was similar with remanufactured devices and matched controls. With 100 cases using the remanufactured device, cost savings amounted to £30,444. Conclusions The use of remanufactured circular mapping catheters is safe, efficient and reliable. Widespread use of remanufactured SUDs offers the possibility of significant economic benefit.
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Affiliation(s)
- Lisa Wm Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK.
| | - Banu Evranos
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Alexander Grimster
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Anthony Li
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Mark Norman
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Abhay Bajpai
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Manav Sohal
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
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25
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Li A, Zuberi Z, Bradfield JS, Zarif JK, Ward DE, Anderson RH, Shivkumar K, Saba MM. Endocardial ablation of ventricular ectopic beats arising from the basal inferoseptal process of the left ventricle. Heart Rhythm 2018; 15:1356-1362. [PMID: 29709577 DOI: 10.1016/j.hrthm.2018.04.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [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: 01/06/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Idiopathic ventricular ectopy (VE) shows predilection to sites within the left ventricular (LV) base such as the outflow tract/aortic sinuses, LV summit, and areas adjacent to the aortomitral continuity. We characterize VE arising from the inferior septum of the LV base that was successfully managed by LV endocardial ablation from the inferoseptal recess of the LV. OBJECTIVE The purpose of this study was to determine the incidence, electrocardiographic (ECG) findings, electrophysiological findings, and anatomical features associated with VE arising from the basal inferoseptal process of the LV (ISP-LV) ablated using an LV endocardial approach via the inferoseptal recess of the LV. METHODS A total of 425 consecutive patients undergoing VE ablation between January 1, 2012 and December 31, 2016 at 3 centers were evaluated. Demographic characteristics, ECG findings, and procedural data were analyzed for patients with ISP-LV VEs. RESULTS Seven (1.5%) had a site of origin from the ISP-LV. Common ECG findings were a right bundle branch block concordant pattern or an atypical left bundle branch block early transition pattern, suggestive of a basal origin with a left superior axis, a biphasic QRS complex in lead aVR, and a small s wave in lead V6. Earliest activation was seen in an area below the outflow tract accessed from the inferoseptal recess inferior to the His bundle. In 3 cases, transient junctional rhythm was seen during ablation. All cases were ablated successfully with no complications. CONCLUSION VE arising from the ISP-LV represents a distinct subset of idiopathic arrhythmia and can be successfully treated by endocardial catheter ablation from the inferoseptal recess. They share common surface ECG and electrophysiological findings with special anatomical features that need recognition for successful catheter ablation.
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Affiliation(s)
- Anthony Li
- Cardiology Clinical Academic Group, St. George's University of London, London, United Kingdom
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University of London, London, United Kingdom
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John K Zarif
- Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - David E Ward
- Cardiology Clinical Academic Group, St. George's University of London, London, United Kingdom
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Magdi M Saba
- Cardiology Clinical Academic Group, St. George's University of London, London, United Kingdom.
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26
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Leung L, Evranos B, Gonna H, Gomes J, Harding I, Raju H, Angelozzi A, Domenichini G, Zuberi Z, Norman M, Gallagher M. 220Simultaneous multi-catheter cryotherapy for the treatment of accessory pathways refractory to radiofrequency catheter ablation. Europace 2018. [DOI: 10.1093/europace/euy015.069] [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: 11/15/2022] Open
Affiliation(s)
- L Leung
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - B Evranos
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - H Gonna
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - J Gomes
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - I Harding
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - H Raju
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - A Angelozzi
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - G Domenichini
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - Z Zuberi
- Royal Surrey County Hospital, Cardiology Department, Guildford, United Kingdom
| | - M Norman
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
| | - M Gallagher
- St George's University of London, Cardiology Clinical Academic Group, London, United Kingdom
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27
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Gonna H, Domenichini G, Zuberi Z, Norman M, Kaba R, Grimster A, Gallagher MM. Initial clinical results with the ThermoCool® SmartTouch® Surround Flow catheter. Europace 2016; 19:1317-1321. [DOI: 10.1093/europace/euw177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 05/22/2016] [Indexed: 11/13/2022] Open
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28
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Gonna H, Domenichini G, Zuberi Z, Adhya S, Sharma R, Anderson LJ, Beeton I, Dhillon PS, Gallagher MM. Femoral implantation and pull through as an adjunct to traditional methods in cardiac resynchronization therapy. Heart Rhythm 2016; 13:1260-5. [PMID: 26820509 DOI: 10.1016/j.hrthm.2016.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 12/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND We have described the use of femoral access followed by pull through of the lead to a pectoral position to circumvent difficulty in implanting a left ventricular (LV) lead by standard methods. OBJECTIVE The purpose of this study was to establish the effect of femoral implantation and pull through on the overall rate of success in percutaneous implantation of LV leads. METHODS We collected data prospectively in all attempts at LV lead implantation from the time that we envisioned the femoral pull-through approach. RESULTS In the 6 years to September 30, 2014, our group attempted to implant a new LV lead in 736 patients, including 16 who previously had failed attempts by other groups. A standard superior approach was successful in 726 of 731 patients (99.3%) in whom it was attempted. In 5 patients (0.7%), we failed to deliver a lead from a superior approach; in 5 of 16 patients, with previous failed attemtps (31%), we judged that those attempts had been exhaustive. In all 10 cases, LV lead placement was achieved from a femoral approach, with the procedure time being 186 ± 65 minutes. In the first case attempted, the pull through failed; the lead was tunneled to the pectoral generator. In 1 case, the coronary sinus was found to be occluded at the ostium: a transseptal approach was used with the subsequent pull through. No complication occurred. At 22.3 ± 18.5 months after the implantation, all systems implanted by a femoral approach continued to function. CONCLUSION Used as an adjunct to standard methods, the femoral access and pull through method allows percutaneous LV lead placement in virtually all cases.
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Affiliation(s)
- Hanney Gonna
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Giulia Domenichini
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Zia Zuberi
- Department of Cardiology, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Shaumik Adhya
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Rajan Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Lisa J Anderson
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Ian Beeton
- Department of Cardiology, St Peter's Hospital, Chertsey, United Kingdom
| | - Paramdeep S Dhillon
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom; Department of Cardiology, St Peter's Hospital, Chertsey, United Kingdom
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom; Department of Cardiology, St Peter's Hospital, Chertsey, United Kingdom.
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Gang Y, Gonna H, Domenichini G, Sampson M, Aryan N, Norman M, Behr ER, Zuberi Z, Dhillon P, Gallagher MM. Evaluation of the Achieve Mapping Catheter in cryoablation for atrial fibrillation: a prospective randomized trial. J Interv Card Electrophysiol 2015; 45:179-87. [DOI: 10.1007/s10840-015-0092-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 12/14/2015] [Indexed: 11/25/2022]
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Zuberi Z, Gill J, O'Neill M. Dyspnoea post pulmonary vein isolation: Occam's razor blunted. Int J Cardiol 2014; 171:e88-9. [PMID: 24360082 DOI: 10.1016/j.ijcard.2013.11.095] [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: 09/01/2013] [Accepted: 11/30/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Zia Zuberi
- Department of Cardiology, 6th Floor, East Wing, St Thomas' Hospital, Westminster Bridge Road, London, UK.
| | - Jaswinder Gill
- Department of Cardiology, 6th Floor, East Wing, St Thomas' Hospital, Westminster Bridge Road, London, UK
| | - Mark O'Neill
- Department of Cardiology, 6th Floor, East Wing, St Thomas' Hospital, Westminster Bridge Road, London, UK
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Zuberi Z, Silberbauer J, Murgatroyd F. Successful Non-fluoroscopic Radiofrequency Ablation of Incessant Atrial Tachycardia in a High Risk Twin Pregnancy. Indian Pacing Electrophysiol J 2014; 14:26-31. [PMID: 24493913 PMCID: PMC3878584 DOI: 10.1016/s0972-6292(16)30712-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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: 11/17/2022] Open
Abstract
We describe a patient presenting with incessant ectopic atrial tachycardia during a high risk twin pregnancy. Tachycardia was resistant to escalating doses of beta-blockade with digoxin. Because of increasing left ventricular dysfunction early in the third trimester, catheter ablation was performed successfully at 30 weeks gestation. Electro-anatomic mapping permitted the entire procedure to be conducted without the use of ionizing radiation. The pregnancy proceeded to successful delivery near term and after three years the patient remains recurrence free with normal left ventricular function, off all medication.
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Affiliation(s)
- Zia Zuberi
- Department of Cardiology, King College Hospital, Denmark Hill, London
| | - John Silberbauer
- Department of Cardiology, King College Hospital, Denmark Hill, London
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Affiliation(s)
- Giulia Domenichini
- Department of Cardiology, St George's Hospital, Blackshaw Road, London SW17 0QT, UK
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Zuberi Z, Kirubakaran S, Lawson C. Giant sinus of Valsalva aneurysm: the role of multimodality imaging. Heart Asia 2013; 5:188. [DOI: 10.1136/heartasia-2013-010380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Zuberi Z, Mehta P, Kirubakaran S, Rinaldi CA. Sprint Fidelis defibrillator leads--should we keep the faith? Int J Cardiol 2013; 162:e68-9. [PMID: 22743188 DOI: 10.1016/j.ijcard.2012.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 06/09/2012] [Indexed: 11/27/2022]
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Kirubakaran S, Zuberi Z, Gill J. Acute myocardial infarction due to a coronary embolus during left atrial ablation for persistent atrial fibrillation. Europace 2012; 15:211. [PMID: 22778231 DOI: 10.1093/europace/eus194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S Kirubakaran
- Cardiothoracic Department, Guy's and St Thomas' NHS Trust, Westminster Bridge London, SE1 7EH, UK.
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Risebro CA, Petchey LK, Smart N, Gomes J, Clark J, Vieira JM, Yanni J, Dobrzynski H, Davidson S, Zuberi Z, Tinker A, Shui B, Tallini YI, Kotlikoff MI, Miquerol L, Schwartz RJ, Riley PR. Epistatic rescue of Nkx2.5 adult cardiac conduction disease phenotypes by prospero-related homeobox protein 1 and HDAC3. Circ Res 2012; 111:e19-31. [PMID: 22647876 DOI: 10.1161/circresaha.111.260695] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Nkx2.5 is one of the most widely studied cardiac-specific transcription factors, conserved from flies to man, with multiple essential roles in both the developing and adult heart. Specific dominant mutations in NKX2.5 have been identified in adult congenital heart disease patients presenting with conduction system anomalies and recent genome-wide association studies implicate the NKX2.5 locus, as causative for lethal arrhythmias ("sudden cardiac death") that occur at a frequency in the population of 1 in 1000 per annum worldwide. Haploinsufficiency for Nkx2.5 in the mouse phenocopies human conduction disease pathology yet the phenotypes, described in both mouse and man, are highly pleiotropic, implicit of unknown modifiers and/or factors acting in epistasis with Nkx2.5/NKX2.5. OBJECTIVE To identify bone fide upstream genetic modifier(s) of Nkx2.5/NKX2.5 function and to determine epistatic effects relevant to the manifestation of NKX2.5-dependent adult congenital heart disease. METHODS AND RESULTS A study of cardiac function in prospero-related homeobox protein 1 (Prox1) heterozygous mice, using pressure-volume loop and micromannometry, revealed rescue of hemodynamic parameters in Nkx2.5(Cre/+); Prox1(loxP/+) animals versus Nkx2.5(Cre/+) controls. Anatomic studies, on a Cx40(EGFP) background, revealed Cre-mediated knock-down of Prox1 restored the anatomy of the atrioventricular node and His-Purkinje network both of which were severely hypoplastic in Nkx2.5(Cre/+) littermates. Steady state surface electrocardiography recordings and high-speed multiphoton imaging, to assess Ca(2+) handling, revealed atrioventricular conduction and excitation-contraction were also normalized by Prox1 haploinsufficiency, as was expression of conduction genes thought to act downstream of Nkx2.5. Chromatin immunoprecipitation on adult hearts, in combination with both gain and loss-of-function reporter assays in vitro, revealed that Prox1 recruits the corepressor HDAC3 to directly repress Nkx2.5 via a proximal upstream enhancer as a mechanism for regulating Nkx2.5 function in adult cardiac conduction. CONCLUSIONS Here we identify Prox1 as a direct upstream modifier of Nkx2.5 in the maintenance of the adult conduction system and rescue of Nkx2.5 conduction disease phenotypes. This study is the first example of rescue of Nkx2.5 function and establishes a model for ensuring electrophysiological function within the adult heart alongside insight into a novel Prox1-HDAC3-Nkx2.5 signaling pathway for therapeutic targeting in conduction disease.
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Zuberi Z, Nobles M, Sebastian S, Dyson A, Lim SY, Breckenridge R, Birnbaumer L, Tinker A. Absence of the inhibitory G-protein Galphai2 predisposes to ventricular cardiac arrhythmia. Circ Arrhythm Electrophysiol 2010; 3:391-400. [PMID: 20495013 DOI: 10.1161/circep.109.894329] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We explored the role that inhibitory heterotrimeric G-proteins play in ventricular arrhythmia. METHODS AND RESULTS Mice with global genetic deletion of Galpha(i2) [Galpha(i2) (-/-)] were studied and found, based on telemetry, to have a prolonged QT interval on surface ECG when awake. In vivo electrophysiology studies revealed that the Galpha(i2) (-/-) mice have a reduced ventricular effective refractory period and a predisposition to ventricular tachycardia when challenged with programmed electrical stimulation. Neither control nor combined global deletion of Galpha(i1) and Galpha(i3) mice showed these abnormalities. There was no evidence for structural heart disease at this time point in the Galpha(i2) (-/-) mice as assessed by cardiac histology and echocardiography. The absence of Galpha(i2) thus leads to a primary electrical abnormality, and we explored the basis for this finding. With patch clamping, single isolated ventricular cells showed that Galpha(i2) (-/-) mice had a prolonged ventricular action potential duration (APD) but steeper action potential shortening as the diastolic interval was reduced in restitution studies. Gene expression studies showed increased expression of L-type Ca(2+) channel subunits, and patch clamping revealed an increase in these currents in Galpha(i2) (-/-) mice. There were no changes in K(+) currents. CONCLUSIONS The absence of inhibitory G-protein signaling mediated through Galpha(i2) is a substrate for ventricular arrhythmias.
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Affiliation(s)
- Zia Zuberi
- Department of Medicine and Hatter Cardiovascular Institute, University College London, 5 University Street, London, England, UK
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Breckenridge RA, Zuberi Z, Gomes J, Orford R, Dupays L, Felkin LE, Clark JE, Magee AI, Ehler E, Birks EJ, Barton PJR, Tinker A, Mohun TJ. Overexpression of the transcription factor Hand1 causes predisposition towards arrhythmia in mice. J Mol Cell Cardiol 2009; 47:133-41. [PMID: 19376125 DOI: 10.1016/j.yjmcc.2009.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 03/30/2009] [Accepted: 04/01/2009] [Indexed: 11/28/2022]
Abstract
Elevated levels of the cardiac transcription factor Hand1 have been reported in several adult cardiac diseases but it is unclear whether this change is itself maladaptive with respect to heart function. To test this possibility, we have developed a novel, inducible transgenic system, and used it to overexpress Hand1 in adult mouse hearts. Overexpression of Hand1 in the adult mouse heart leads to mild cardiac hypertrophy and a reduction in life expectancy. Treated mice show no significant fibrosis, myocyte disarray or congestive heart failure, but have a greatly reduced threshold for induced ventricular tachycardia, indicating a predisposition to cardiac arrhythmia. Within 48 h, they show a significant loss of connexin43 protein from cardiac intercalated discs, with increased intercalated disc beta-catenin expression at protein and RNA levels. These changes are sustained during prolonged Hand1 overexpression. We propose that cardiac overexpression of Hand1 offers a useful mouse model of arrhythmogenesis and elevated HAND1 may provide one of the molecular links between the failing heart and arrhythmia.
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Zuberi Z, Birnbaumer L, Tinker A. The role of inhibitory heterotrimeric G proteins in the control of in vivo heart rate dynamics. Am J Physiol Regul Integr Comp Physiol 2008; 295:R1822-30. [PMID: 18832081 DOI: 10.1152/ajpregu.90625.2008] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Multiple isoforms of inhibitory Galpha-subunits (Galphai1,2,3, as well as Galphao) are present within the heart, and their role in modulating pacemaker function remains unresolved. Do inhibitory Galpha-subunits selectively modulate parasympathetic heart rate responses? Published findings using a variety of experimental approaches have implicated roles for Galphai2, Galphai3, and Galphao in parasympathetic signal transduction. We have compared in vivo different groups of mice with global genetic deletion of Gialpha1/Galphai3, Galphai2, and Galphao against littermate controls using implanted ECG telemetry. Significant resting tachycardia was observed in Galphai2(-/-) and Galphao(-/-) mice compared with control and Galphai1(-/-)/Galphai3(-/-) mice (P < 0.05). Loss of diurnal heart rate variation was seen exclusively in Galphao(-/-) mice. Using heart rate variability (HRV) analysis, compared with littermate controls (4.02 ms2 +/- 1.17; n = 6, Galphai2(-/-)) mice have a selective attenuation of high-frequency (HF) power (0.73 ms2 +/- 0.31; n = 5, P < 0.05). Galphai1(-/-)/Galphai3(-/-) and Galphao(-/-) cohorts have nonsignificant changes in HF power. Galphao(-/-) mice have a different basal HRV signature. The observed HRV phenotype in Galphai2(-/-) mice was qualitatively similar to atropine (1 mg/kg)-treated controls [and mice treated with the GIRK channel blocker tertiapinQ (0.05 mg/kg)]. Maximal cardioinhibitory response to the M(2)-receptor agonist carbachol (0.5 mg/kg) compared with basal heart rate was attenuated in Galphai2(-/-) mice (0.08 +/- 0.04; n = 6) compared to control (0.27 +/- 0.04; n = 7 P < 0.05). Our data suggest a selective defect of parasympathetic heart rate modulation in mice with Galphai2 deletion. Mice with Galphao deletion also have a defect in short-term heart rate dynamics, but this is qualitatively different to the effects of atropine, tertiapinQ, and Galphai2 deletion. In contrast, Galphai1 and Galphai3 do not appear to be essential for parasympathetic responses in vivo.
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Affiliation(s)
- Zia Zuberi
- British Heart Foundation, Laboratories and Department of Medicine, University College London, 5 University St., London, WC1E 6JJ, UK
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