Explore the vast range of titles available.

We evaluated the effect of adenosine upon mechanisms sustaining persistent AF through analysis of contact electrograms and ECGI mapping. Persistent AF patients undergoing catheter ablation were included. ECGI maps and cycle length (CL) measurements were recorded in the left and right atrial appendages and repeated following boluses of 18 mg of intravenous adenosine. Potential drivers (PDs) were defined as focal or rotational activations completing ≥ 1.5 revolutions. Distribution of PDs was assessed using an 18 segment biatrial model. 46 patients were enrolled. Mean age was 63.4 ± 9.8 years with 33 (72%) being male. There was no significant difference in the number of PDs recorded at baseline compared to adenosine (42.1 ± 15.2 vs 40.4 ± 13.0; p = 0.417), nor in the number of segments harbouring PDs, (13 (11-14) vs 12 (10-14); p = 0.169). There was a significantly higher percentage of PDs that were focal in the adenosine maps (36.2 ± 15.2 vs 32.2 ± 14.4; p < 0.001). There was a significant shortening of CL in the adenosine maps compared to baseline which was more marked in the right atrium than left atrium (176.7 ± 34.7 vs 149.9 ± 27.7 ms; p < 0.001 and 165.6 ± 31.7 vs 148.3 ± 28.4 ms; p = 0.003). Adenosine led to a small but significant shortening of CL which was more marked in the right than left atrium and may relate to shortening of refractory periods rather than an increase in driver burden or distribution. Registered on Clinicaltrials.gov: NCT03394404.

IntroductionSupraventricular tachycardias (SVTs) are a common cause of acute hospital presentations. Adenosine is an effective treatment. To date, no studies have directly compared paramedic-with hospital-delivered treatment of acute SVT with adenosine.MethodRandomised controlled trial comparing the treatment of SVT and discharge by paramedics with conventional emergency department (ED)-based care. Patients were excluded if they had structural heart disease or contraindication to adenosine. Discharge time, follow-up management, costs and patient satisfaction were compared.ResultsEighty-six patients were enrolled: 44 were randomised to paramedic-delivered adenosine (PARA) and 42 to conventional care (ED). Of the 37 patients in the PARA group given adenosine, the tachycardia was successfully terminated in 81%. There was a 98% correlation between the paramedics' ECG diagnosis and that of two electrophysiologists. No patients had any documented adverse events in either group. The discharge time was lower in the PARA group than in the ED group (125 min (range 55–9513) vs 222 min (range 72–26 153); p=0.01), and this treatment strategy was more cost-effective (£282 vs £423; p=0.01). The majority of patients preferred this management approach. Being treated and discharged by paramedics did not result in the patients being less likely to receive ongoing management of their arrhythmia and cardiology follow-up.ConclusionsPatients with SVT can effectively and safely be treated with adenosine delivered by trained paramedics. Implementation of paramedic-delivered acute SVT care has the potential to reduce healthcare costs without compromising patient care.Trial registration numberNCT02216240.

Background: Implantable loop recorder (ILR) implants are increasingly done in an outpatient setting by different disciplines. A key component of the implant is the closure of the wound with the scar appearance often the only reminder of surgery. Several techniques for wound closure exist; sutures, staples, glue, and wound closure strips (WCS). Our service has utilised WCS for 5 years. These are porous surgical tape strips which are applied across the wound, pulling the skin on either side of the wound together avoiding the risk of tight or loose sutures, micro damage to the skin and needlestick injury to the operator. Post-COVID-19 pandemic a new process was adopted utilising a two-room model for implant to comply with local COVID-19 restrictions, with a virtual follow up and a wound image review for ILR patients. We sought to review our current practice of wound closure method to critique any complications or wound appearance. Methods: This is a single centre, retrospective audit of ILR wounds closed with WCS. The wound was assessed by pre-defined criteria: device infection, presence of haematoma, keloid/hypertrophic scarring, device erosion, skin puckering and need for medical review of wound. The wound photos were reviewed by a group of ILR implanters. The study was approved approval from the hospital Clinical Effectiveness Unit (Ref 10849). Results: 140 consecutive patients’ (51% F, age 55 ± 17) wounds were reviewed with the photo occurring 46 ± 33 days post implant. No device infections, hematomas or bruising were reported. 4 (3%) patients wounds were escalated for review, of these: 1 (0.7%) device was explanted and re-sited due to pre-erosion at the scar site; 1 device was explanted due to pain from the device site with no aesthetic compromise. One incomplete skin adhesion and 1 further patient with pain from the device site, which were both managed conservatively. Keloid/hypertrophic scarring were present in 5 patients (4%), and skin puckering was seen in 1 patient (0.7%). Of these patients there was no difference in age, gender, or operator. Discussion: There is no published literature on wound closure for ILR procedures. Guastafierro A., et. al. 2020 assessed a similar incision for carpel tunnel syndrome in a single centre study using WCS vs sub cuticular sutures. There was no difference between either group in terms of scar appearance or pain, but WCS was a more cost effective method. Our cohort of patients also reported keloid/hypertrophic scars in only 4% of patients, which is lower than expected for surgical procedures, which could be explained by the small incision site in combination with closure method. Limitations/Recommendation: Long-term wound maturation was not assessed due to only one photograph being received; this limits assessment of scar maturation and whether keloid or hypertrophic scarring was more prevalent. Standardizing wound assessment was a challenge as intervention was delivered and assessed by implanters. Recommendations could include an independent wound review and a wound assessment tool (Stony Brook Scar Evaluation Scale) to quantify appearance. Conclusion: WCS for ILR implants produces a low complication rate with good cosmetic appearance. This evidence can be a baseline standard for ILR implanting services.

Aims: Cardiac perforations caused by pacemaker and implantable-cardioverter defibrillator (ICD) leads are serious events. Due in part to their infrequency, management options and outcomes are unclear. Methods: A single-centre retrospective study was conducted at a high-volume tertiary centre to identify patients in whom cardiac perforation occurred due to lead implantation or intervention. The search included all lead procedures spanning 3 years from 2016-2019. 6 months follow-up was assessed in all patients with perforation. Results: Of 4619 procedures 32 patients were diagnosed with lead related cardiac perforation (involving 33 leads), mean age 74±15 years, 20 (63%) female, mean left ventricular ejection fraction 51% (±11). 9 devices were implanted at other centres; therefore, the institutional rate of perforation was 0.5% (n=23 patients, 24 leads). 9 (39%) were identified acutely (<24 hours), median time to diagnosis was 32 (±49) days in sub-acute/chronic perforation. All but one leads were active fixation models; 25/32 (78%) had abnormal electrical parameters at device interrogation. 6/33 (18%) were ICD leads. 27/33 (82%) leads perforated the right ventricle (RV) in the apex or anterior apical region, 3 (9%) mid anterior RV and 2 (6%) lateral right atrium. Management was trans-venous in 31/32 (97%) patients with lead extraction or repositioning; pericardial drainage was required in 10/32 (31%), sternotomy with surgical repair was required in 1 (3%). 1 (3%) patient was deceased within 30 days, all other patients made a full recovery and were well at 6 months follow-up. Conclusion: Although infrequent (0.5%), perforation occurred predominantly in the RV apex. No clear patient factors were identified as risk factors. Trans-venous lead extraction was safe and effective with surgical intervention rarely required.

Introduction: Implantable cardiac monitor (ICM) is a small device implanted to detect and record arrhythmias and symptomatic events. The procedure has a low complication rate, with procedures being performed in an outpatient setting. Due to greater accessibility to ICMs there has been an increasing amount of ICM devices on the market with new innovations in hardware and software. We sought to conduct a quality assessment of each device to evaluate each ICM with regard to procedural complications and remote monitor (RM) connectivity to provide a guide for NHS services. Methods: Patients referred for ICMs for any indication were prospectively enrolled in a tertiary, adult cardiac centre. We aimed to implant 30 of each ICM: Medtronic (Reveal Linq, L1 & Linq II, L2), Abbott (Confirm Rx, CRx) and Biotronik (Biomonitor III, BMIII). Implants for each device were performed in series; 1st BMIII, 2nd L1, 3rd CRx, 4th L2, in an outpatient clinic area by experienced (50-250 procedures each) Specialist Nurses or Cardiac Scientists. Closure technique using wound closure strips, which were removed 7–10 days post procedure. Outcomes were assessed using electronic records, remote monitoring data and patient wound images. Remote monitoring was assessed at the 1-month check with patients being seen face to face (pre COVID-19) and virtually (post March 2020). The study was registered with the hospital clinical effectiveness unit. Results: 94 patients were enrolled between January 2020 and April 2021: 32 CRx, 25 L1, 25 L2 and 12 BMIII. Outcomes can be seen in Table 1. Biomonitors implants were reduced due to a high protrusion rate (33%), resulting in them being withdrawn from QA assessment. Procedural complications showed 0 infections, with the only complication being device protrusion. [Image Omitted] Discussion: Our data shows that there is a disparity in the type of device with the model of care we provide. The BMII has significantly more wound complications that other devices when the wound is closed with wound closure strips (WCS) (e.g. steri-strips). This is likely to be because the incision blade is wider than that of its counterparts, relying more on the WCS to support the wound. Compounding this, the device antenna design acts as a spring if any counter pressure is applied to it, such as a female patient wearing a bra, effectively pushing the device back towards the scar. There was also 1 complication in the CRx arm due to protrusion, which could be attributed due to its wider blade compared to L1/L2. However, 1 complication does not prove any systemic issues and should be assessed in a comparison with larger implant numbers. Remote monitoring connectivity has shown to be excellent across all manufacturers. There are external factors at play to produce these high results. Specifically, the L1 patients were enrolled on FocusOn with troubleshooting for connectivity utilising the BeConnected (Medtronic telephone support) service. Therefore, this does not attribute just the technology but also the service. Unfortunately, the L1 device does not download full disclosure of recordings in contrast to the L2, CRx and BMIII, which send all recordings and were connected prior to departure. RM should be assessed on a wider cohort from multiple centres over longer periods. Conclusion: Our findings show there is a good compliance with RM connectivity at 1 month with all devices. The BMII having significant wound complications if used with WCS. We would recommend BMIII is utilised with stitches to secure the deep layers of the wound.

Introduction: It is now quite common for patients to be able go home on the same day after their AF ablation. A contributing factor of this is the Proglide Suture-Mediated Closure System which allows quick recovery after large bore venous access (>12F). This study is one of the first to see whether the Proglide device enables early mobilisation after AF ablation. Objective: We compared outcomes in patients whose vascular access site was closed with the Proglide device with those whose site was closed with the standard Z suture. We looked for any significant differences in ambulation time as well as bleeding outcomes. Methods: Patients undergoing cryoablation at a tertiary centre for paroxysmal or persistent AF were included in this study. There were 104 participants in total. Pulmonary vein isolation (PVI) was performed using US guidance for access with 14F cryosheath and second 7F sheath. 5 minutes pressure was used at the 7F site. Transeptal puncture was performed and a 28 mm cryoballoon was used. Patients were subsequently transferred to the ward for recovery post sedation and nurse led discharge. Operator preference determined whether a Proglide Closure device was used (PD; Abbott Ltd) or a Z suture (ZS). All patients received protamine for heparin reversal and their usual anticoagulant agent remained uninterrupted. Time to ambulation (TTA) and time to discharge (TTD) was measured. Complications such as bleeding, haematoma and minor ooze were recorded. Results: The group demographics were largely similar and the mean age was 64 ± 11. 52 (50%) patients had paroxysmal AF. 65 patients were male (64%). 73 (70%) patients received the Z suture whilst 31 (30%) patients were in the PD group. There were 2 haematomas (2.8%) in the ZS group compared with none in the PD group. There was no significant difference between the incidence of minor bleeding between the two groups (PD 3 [9.7%]; ZS 2 [2.7 %]; p=0.155). No major bleeding occurred in either group. The PD group had a significantly shorter mean TTA (3.3 ± 1.1 vs 4.1 ± 1.7 hrs; p=0.025). But there was no significant difference in same-day discharge (PD: 25 [81%] vs ZS: 53 [73%]; p=0.386) and TTD (5.0 ± 3.6 vs 6.1 ± 4.2 hrs; p=0.275) between the two groups. There was 1 patient in the ZS group which complained of groin pain that delayed discharge. This did not occur in the PD group. There were no differences in any incidence of complications after a mean follow up of 2.2 ± 1.4 months. Conclusion: Relative to the conventional Z suture technique for haemostasis, this study has shown an association between the use of the Proglide closure device and quicker mobilisation times after cryoablation for AF. Groin access complications were infrequent in both groups. This study shows that the Proglide device may contribute to improving patient flow in AF cryoablation.

Introduction: Implantable Loop Recorder (ILR) procedures are now done by allied health professionals in outpatients; however, it is expensive with a single device costing £3,878. This is in spite of limited evidence regarding the diagnostic utility of ILR so we performed a detailed examination of its performance in the real-world. Methods: The detailed clinical records of all consecutive individuals who underwent ILR insertion at Barts Heart Centre, London between May 2017 and October 2018 were examined to determine indication for insertion and their clinical outcomes. Results: There were 325 patients, (54% female; mean age of 59 ± 18). The median follow-up was 575 days (IQR = 323-791). A diagnosis that altered management was made in 86 (26%) patients, at a median time of 90 days (range = 1-775). Indications for ILR implantation were pre-syncope/syncope (64%), palpitations (18%) and AF detection (13%). Only a single patient under the age of 55 who presented with syncope or presyncope underwent a pacemaker implant, this patient had suffered severe injury following syncope, and was diagnosed with sinus pauses on day 14 post-implant. Data concerning PPM/ICD implantation in those undergoing ILR insertion for pre-syncope/syncope by age group are presented in Figure 1. No patient undergoing implant for the indication of “palpitations” was implanted with a pacemaker or ICD. The highest diagnostic yield (≈40%) for ILR was in AF detection for patients with cryptogenic stroke. Conclusion: Management-altering diagnoses provided by ILR are rare in younger patients, particularly in syncope, presyncope or palpitations. A focus on the medical history, in addition to consumer non-invasive monitoring devices for symptom-arrhythmia correlation, is preferable in younger patients. [Image Omitted]

Introduction: The frequency of catheter ablation for atrial fibrillation (AF) has increased dramatically, stretching resources. Discharge on the same day as treatment may increase the efficiency and throughput. There are limited data regarding the safety of this strategy. Methods: We performed a retrospective analysis of consecutive patients undergoing AF ablation in a tertiary centre and in a district general hospital, and identified those discharged on the same day of treatment. The safety endpoint was any major complication and/or presentation to hospital in the 48-hours post discharge. We performed an economic analysis to calculate potential cost saving. Results: Among a total population of 2628 patients, we identified 727 subjects (61.1±12.5 years, 69.6% male) undergoing day-case AF ablation. Most of them suffered from paroxysmal AF (58%) and underwent a de novo procedure (86.1%). Cryoballoon technique was used in 79.2% of the day-cases, and 91.6% of the procedures were performed under conscious sedation. 1.8% (13) of the participants met the safety composite endpoint, however only 0.7% (5) required at least one day of hospitalisation. Bleeding/haematoma at the femoral access site (0.5%) and pericarditic chest pain (0.5%) were the main reasons for readmission. None experienced cardiac tamponade or other life-threatening complications in the 48-hours post-discharge. Our day-case policy resulted in a cost-saving of approximately £287,422 for our hospital (average of £83,927 annually). Conclusion: In this large multicentre cohort, same-day discharge in selected patients following AF ablation appears to be safe and cost-effective, with a very low rate of early readmission or post-discharge complication.

Background: We evaluated the effect of adenosine upon mechanisms sustaining persistent AF through analysis of contact electrograms and ECGI mapping. Methods: Persistent AF patients undergoing catheter ablation were included. ECGI maps and cycle length (CL) measurements were recorded in the left and right atrial appendages and repeated following adenosine administration. Potential drivers (PDs) were defined as focal or rotational activations completing ≥1.5 revolutions. Distribution of PDs was assessed using an 18 segment biatrial model. Results: 46 patients were enrolled. Mean age was 63.4 ± 9.8 years with 33 (72%) being male. There was no significant difference in the number of PDs recorded at baseline compared to adenosine (42.1 ± 15.2 vs 40.4 ± 13.0; p=0.417), nor in the number of segments harbouring PDs, (13 (11–14) vs 12 (10–14); p=0.169). There was a significantly higher percentage of PDs that were focal in the adenosine maps (36.2 ± 15.2 vs 32.2 ± 14.4; p<0.001). There was a significant shortening of CL in the adenosine maps compared to baseline which was more marked in the right atrium than left atrium (176.7 ± 34.7 vs 149.9 ± 27.7 ms; p<0.001 and 165.6 ± 31.7 vs 148.3 ± 28.4 ms; p=0.003). Conclusion: Adenosine led to a small but significant shortening of CL which was more marked in the right than left atrium and may relate to shortening of refractory periods rather than an increase in driver burden or distribution.

Introduction: Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device (CIED) infections; however, patient selection strategies are poorly defined and cost–utility data are limited. Methods: In a preliminary internal analysis, we examined the factors associated with infection for all transvenous CIED implants, generator changes and non-infected lead interventions at a single tertiary centre from 2016 to 2019. The primary outcome was hospitalisation for device infection within 12 months. We subsequently developed a novel risk score (BLISTER) and, in a multicentre validation cohort, compared prognostic utility versus the PADIT score. Finally, both scores were tested as gatekeepers in cost–utility modelling of the TYRX antimicrobial envelope; quality-adjusted life-year (QALY) increments were extrapolated from analysis of EQ-5D-3L data for all UK patients enrolled in the WRAP-IT trial. Results: A total of 6,035 patients underwent 7,383 procedures; CIED infection occurred in 59 individuals (0.8%). In addition to the PADIT score constituents, lead extraction (HR 3.3 [1.9–6.1]; p<0.0001), C-reactive protein >50 mg/L (HR 3.0 [1.4–6.4]; p=0.005), re-intervention within 2 years (HR 10.1 [5.6–17.9]; p<0.0001), and procedure duration over 2 hours (HR 2.6 [1.6–4.1]; p=0.001) were independent predictors of infection, and were incorporated into the novel BLISTER score. In a validation cohort comprising 2,701 additional patients from three tertiary centres, BLISTER demonstrated superior prognostic utility versus PADIT (AUC 0.83 vs 0.73; p=0.01). The optimum cost–utility model assigned TYRX envelopes to all patients with a BLISTER score ≥6, and predicted a reduction in infections (0.55% versus 0.8%; p=0.033; number needed to treat 63) with a cost per QALY gained of £24,581. Conclusions: The BLISTER score was a powerful predictor of infection in a heterogeneous CIED population and may facilitate cost-effective TYRX envelope allocation. [Image Omitted]