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AV conduction abnormalities are observed in 15–30% of patients with hypertrophic cardiomyopathy but are usually not severe enough to require permanent pacemaker implant. Both septal myectomy and alcohol septal ablation are effective options to relieve symptoms due to left ventricular outflow tract gradient in patients with hypertrophic cardiomyopathy but have procedure-specific effects on AV conduction and the His Purkinje system. Septal myectomy is associated with the development of LBBB in 50–100% of patients, while alcohol septal ablation is associated with RBBB in 37–70% of patients. Baseline abnormalities in the contralateral bundles and the presence of conduction disease have an important impact on the likelihood of the development of AV block for both of these therapies. AV block requiring permanent pacing occurs in approximately 2–3% of patients after septal myectomy and 10–15% of patients after alcohol septal ablation. Permanent pacemaker implant after alcohol septal ablation is more common in older patients (> 55 years old 13 vs. < 55 years old 5%; p = 0.06). Improved outcomes for septal myectomy and alcohol septal ablation are observed in experienced centers. Septal reduction therapies should be performed at medical centers with a dedicated hypertrophic cardiomyopathy program using a multidisciplinary approach.

PurposeCardiac sarcoidosis is a multisystem inflammatory disorder characterized by ventricular arrhythmias. Implantable cardioverter defibrillator (ICD) is used to prevent sudden cardiac death.MethodsWe performed literature search for studies that addressed the outcome and complications of ICD in Cardiac Sarcoidosis (CS). Multiple search sites were reviewed from January 1, 2000 until December 1, 2018. We then performed a meta-analysis using a random effects model. Two investigators independently extracted the data and assessed studies’ quality.ResultsTen studies with 585 patients qualified for the analysis. In the pooled analysis, 57% were male with mean left ventricular ejection fraction (LVEF) of 38.4%. Appropriate and inappropriate ICD treatments (AT and IAT) were reported in 39% and 15% of patients respectively over mean follow-up period of 25 months and mortality rate of 8%. A sub-analysis of four studies indicated that patients with appropriate therapy did not differ from the rest of CS population in LVEF% (mean difference (MD) = − 7.37%, 95% confidence interval (CI) − 16.89 to 2.15, p = 0.12), age (MD = − 3.87 years, 95% CI − 10.19 to 2.46, p = 0.23), primary prevention (range difference (RD) = − 0.11, 95% CI − 0.31 to 0.10, p = 0.31) or secondary prevention indication (RD = 0.09, 95% CI − 0.12 to 0.3, p = 0.37). High degree AV block was more common in patients with AT (RD = 0.07, 95% CI 0.00 to 0.14 p = 0.05).ConclusionsICD placement in CS is associated with high incidence of both appropriate and inappropriate therapy. High degree AV block appears to be predictive of appropriate ICD therapy.

Dr Kusumoto's unique new book takes a step-wise, patient-centered approach to guide readers through the thought process required during an electrophysiology study and the development of new findings. * Follows a case based step-wise approach focused on the EP lab that allows readers to follow along with the thought process behind how experienced electrophysiologists first diagnose, then prepare, treat and manage patients with common rhythmic abnormalities, including atrial fibrillation * Written by award-winning Mayo Clinic Physician-educator Dr. Fred Kusumoto * Ideal for fellows, new EPs, nursing and technical staff in the EP lab * Includes clinical questions to help readers test their understanding of the steps and concepts covered in the book and prepare for certification exams

Cardiac implantable electronic device therapy (CIED) has revolutionized treatment for advanced heart failure. Most patients considered for orthotopic heart transplantation (OHT) are treated with implantable cardioverter defibrillators, cardiac resynchronization therapy, or both. These CIEDs are surgically extracted at the time of transplant. Occasionally, CIEDs are incompletely removed. Little is known about the outcomes of post-OHT patients with retained CIED fragments. We identified 200 consecutive patients that underwent OHT at our institution between April 2006 and December 2014 and performed a retrospective analysis of available radiographic images and clinical records. Chest radiographs prior to and following OHT were reviewed for the presence of CIED or retained CIED fragments. The outcomes of patients with retained CIED fragments that had subsequent magnetic resonance imaging (MRI) studies performed were further investigated. One hundred eighty of 200 patients were identified as having CIED prior to OHT, of which 29 had retained CIED fragments after OHT. Most retained CIED fragments originated from superior vena cava defibrillator coils. There were no adverse events in the retained CIED fragment cohort, and survival was unaffected. Ten patients with retained CIED fragments safely underwent a total of 28 MRIs after OHT, all of diagnostic quality. Retained CIED fragments are not associated with adverse events or increased mortality after OHT. Diagnostic MRI has been safely performed in patients with retained CIED fragments after incomplete device extraction. Retrieval of these fragments prior to MRI does not appear warranted given the demonstrated safety and preserved image quality in this population.

Background The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S‐ICD) after left ventricular assist device (LVAD) implantation is not well established. Methods We performed a retrospective study of patients implanted with LVAD and with a pre‐existing S‐ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida). Results Of the 908 LVAD patients, a pre‐existing S‐ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third‐generation EMBLEM MRI S‐ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD‐related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S‐ICD sensing vector, adjusting S‐ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S‐ICD device therapies to be turned off permanently. Conclusions The incidence of LVAD‐related S‐ICD noise is high in patients with concomitant LVAD and S‐ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S‐ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD‐SICD device interference and the need to improve S‐ICD detection algorithms to eliminate noise. The incidence of LVAD‐related S‐ICD noise is high in patients with concomitant LVAD and S‐ICD with significant impact on device function.

Introduction Although warfarin has traditionally been used for reducing risk of stroke in patients with atrial fibrillation, over the past year, the direct thrombin inhibitor dabigatran has become an accepted alternative. No study has conclusively investigated bleeding risks of patients treated with dabigatran immediately following radiofrequency catheter ablation (RFCA) procedures. Methods We evaluated 156 consecutive patients referred for RFCA of atrial arrhythmias: 31 patients were on dabigatran and 125 patients were on warfarin. The incidence of bleeding complications during the first 48 h and the first week following ablation were recorded and comparisons made using Fisher's exact test. Major complications were defined as hemorrhage requiring blood products or the need for vascular intervention. Minor complications were defined as prolonged bleeding from the catheter insertion site, hematoma formation, or development of ecchymosis. Our study also took into account the intraprocedure activated clotting time (ACT) levels in an effort to describe any differences between both patient groups. Results There were no differences in age, gender, procedure type, or level of intraprocedural anticoagulation between the warfarin and dabigatran groups. No major bleeding complications were observed in either patient group at either 48 h or 1 week postprocedure. Six of the 31 dabigatran patients and 21 of the 125 warfarin patients had minor bleeding complications. There was no statistically significant difference between the incidence of minor bleeding complications between the two groups ( p  = 0.7384), although rebleeding was more commonly observed in patients on dabigatran. In regard to the intraprocedure ACT levels, there was more variability in the dabigatran patient group, and it was more difficult to achieve the goal ACT level, yet these results did not affect overall bleeding complications. Conclusion In our cohort, bleeding-related complications 48 h and 1 week post-ablation were similar for warfarin and dabigatran. Dabigatran is associated with more intraprocedural variability in ACT than warfarin.

On May 27, 2022, the Asia Pacific Heart Rhythm Society and the Heart Rhythm Society convened a meeting of leaders from different professional societies of healthcare providers committed to arrhythmia care from the Asia Pacific region. The overriding goals of the meeting were to discuss clinical and health policy issues that face each country for providing care for patients with electrophysiologic issues, share experiences and best practices, and discuss potential future solutions. Participants were asked to address a series of questions in preparation for the meeting. The format of the meeting was a series of individual country reports presented by the leaders from each of the professional societies followed by open discussion. The recorded presentations from the Asia Summit can be accessed at https://www.heartrhythm365.org/URL/asiasummit‐22. Three major themes arose from the discussion. First, the major clinical problems faced by different countries vary. Although atrial fibrillation is common throughout the region, the most important issues also include more general issues such as hypertension, rheumatic heart disease, tobacco abuse, and management of potentially life‐threatening problems such as sudden cardiac arrest or profound bradycardia. Second, there is significant variability in the access to advanced arrhythmia care throughout the region because of differences in workforce availability, resources, drug availability, and national health policies. Third, collaboration in the area already occurs between individual countries, but no systematic regional method for working together is present.

This is a book for any care provider - from advanced students and nurses to residents and even specialists - who needs to master the interpretation of ECGs, especially while \"on the spot\" at the point of care. This easy-to-use, visual guide takes a novel approach, foregrounding the visual clues or \"keys\" that readers can learn to recognize in ECGs and thus make rapid decisions about next steps at the point of care. The comparatively minimal text focuses on \"must-know\" information about the underlying cause of ECG abnormalities. This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from Google Play or the MedHand Store.

Since the mid 1980s, the world has experienced an unprecedented explosion in the capacity to produce, store, and communicate data, primarily in digital formats. Simultaneously, access to computing technologies in the form of the personal PC, smartphone, and other handheld devices has mirrored this growth. With these enhanced capabilities of data storage and rapid computation as well as real-time delivery of information via the internet, the average daily consumption of data by an individual has grown exponentially. Unbeknownst to many, Big Data has silently crept into our daily routines and, with continued development of cheap data storage and availability of smart devices both regionally and in developing countries, the influence of Big Data will continue to grow. This influence has also carried over to healthcare. This paper will provide an overview of Big Data, its benefits, potential pitfalls, and the projected impact on the future of medicine in general and cardiology in particular.

Introduction Catheter ablation (CA) of atrial fibrillation (AF) has become a treatment option for younger patients with drug refractory AF. It is not known whether pulmonary veins (PV) have an important mechanistic role in elderly patients with AF or whether CA is an effective treatment for the elderly. Methods We evaluated 240 consecutive patients that were referred to the electrophysiology laboratory for CA for AF using a PV antral isolation approach. Linear ablations were not routinely performed. Clinical outcomes and healthcare resource utilization was evaluated during the 12 months after CA in patients <65 years old (Group 1; 91 patients), 65–75 years old (Group II; 88 patients), and >75 years old (Group III; 61 patients). Results Older patients were more likely to have persistent atrial fibrillation (I: 24%, II: 34%, III: 66%). Major complication rates (I: 1%; II: 1%; III: 0%; p=ns) and minor complication rates (I: 4%; II: 5%; III: 5%; p=ns) were similar for all three groups. At 12 month follow-up younger patients were more likely to be in sinus rhythm without prolonged episodes of atrial fibrillation without antiarrhythmic drug therapy (AARx) (I: 94%, II: 84%, III: 61%). However in Group III, effective treatment (AF <1 h/mo ± AARx) was achieved in 82% of patients. After radiofrequency catheter ablation, hospitalizations, emergency room and nonroutine clinic visits decreased significantly for all three groups during the 12 months after RFA (I: pre 22; post: 3; Group II: pre 26; post 4; III: pre 20; post 2). Conclusions CA can be effective for treating AF in selected older patients as stand-alone therapy or as hybrid therapy with AARx. PVs appear to be an important arrhythmogenic structure regardless of age. CA is associated with decreased healthcare resource utilization in all age groups.