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PurposeThe effect of adding contact force (CF) sensing to 56-hole tip irrigation in ventricular arrhythmia (VA) ablation has not been previously studied. We aimed to compare outcomes with and without CF sensing in VA ablation using a 56-hole radiofrequency (RF) catheter.MethodsA total of 164 patients who underwent first-time VA ablation using Thermocool SmartTouch Surround Flow (TC-STSF) catheter (Biosense-Webster, Diamond Bar, CA, USA) were propensity-matched in a 1:1 fashion to 164 patients who had first-time ablation using Thermocool Surround Flow (TC-SF) catheter. Patients were matched for age, gender, cardiac aetiology, ejection fraction and approach. Acute success, complications and long-term follow-up were compared.ResultsThere was no difference between procedures utilising either TC-SF or TC-STSF in acute success (TC-SF: 134/164 (82%), TC-STSF: 141/164 (86%), p = 0.3), complications (TC-SF: 11/164 (6.7%), TC-STSF: 11/164 (6.7%), p = 1.0) or VA-free survival (TC-SF: mean arrhythmia-free survival time = 5.9 years, 95% CI = 5.4–6.4, TC-STSF: mean = 3.2 years, 95% CI = 3–3.5, log-rank p = 0.74). Fluoroscopy time was longer in normal hearts with TC-SF (19 min, IQR: 14–30) than TC-STSF (14 min, IQR: 8–25; p = 0.04).ConclusionBoth TC-SF and TC-STSF catheters are safe and effective in treating VAs. The use of CF sensing catheters did not improve safety or acute and long-term outcomes, but reduced fluoroscopy time in normal heart VA.

The presence of supraventricular tachycardia is the leading cause of inappropriate shock in ICD recipients, and it can be a significant cause of morbidity, psychological distress and worsened clinical outcome. Modern pacing and ICD systems offer a number of discriminators that are integrated into algorithms to differentiate sustained ventricular tachycardia from supraventricular tachycardia. These algorithms can be adapted and optimised for each individual patient to ensure that only those arrhythmias that need treatment through the use of an ICD, are actually treated. This review summarises the single- and dual-chamber discriminators that can be used in the detection and classification of tachyarrhythmias.

Cardiac resynchronisation therapy (CRT) has become the cornerstone of heart failure (HF) treatment. Despite the obvious benefit from this therapy, an estimated 30% of CRT patients do not respond (“non-responders”). The cause of “non-response” is multi-factorial and includes suboptimal device settings. To optimise CRT settings, echocardiography has been considered the gold standard but has limitations: it is user dependent and consumes time and resources. CRT proprietary algorithms have been developed to perform device optimisation efficiently and with limited resources. In this review, we discuss CRT optimisation including the various adopted proprietary algorithms and conduction system pacing.

The Heart Team approach has become an integral part of modern cardiovascular medicine. To evaluate current opinions and real-world practice among lead extraction practitioners, an online survey was created and distributed among a pool of lead extraction specialists participating in the International Lead Extraction Expert Meeting (ILEEM) 2018. The online survey consisted of 10 questions and was performed using an online survey tool (www.surveymonkey.com). The collector link was sent to 48 lead extraction experts via email. A total of 43 answers were collected (89% return rate) from lead extraction experts in 16 different countries. A great majority (83.7%) of the respondents performed more than 30 lead extraction procedures per year. The most common procedural environment in this survey was the hybrid operating room (67.4%). Most procedures were performed by electrophysiologists and cardiologists (80.9%). Important additional members of the current lead extraction teams were cardiac surgeons (79.1%), anesthesiologists (95.3%) and operating room scrub nurses (76.7%). An extended Heart Team is regarded beneficial for patient care by 86.0%, with potential further members being infectious diseases specialists, intensivists and radiologists. Team training activities are performed in 48.8% of participating centers. This survey supports the importance of establishing lead extraction Heart Teams in specialized lead extraction centers to potentially improve patient outcomes. The concept of a core and an extended Heart Team approach in lead extraction procedures is introduced.

Purpose Dual-site epicardial left ventricular (LV) pacing represents one strategy to improve acute cardiac resynchronization therapy (CRT) response. However, the feasibility of this approach in the longer term may be hindered by system complexity. We assessed chronic outcomes of patients receiving dual-site LV pacing. Methods Twenty patients with conventional CRT criteria were implanted with dual-site epicardial LV leads connected with bifurcating adapter. Mean energy required to capture the LV was calculated using threshold, impedance and pulse width. Values were obtained during implant and the following day. Follow-up data included lead parameters, ventricular arrhythmias and mortality. Results Nineteen patients had successful dual LV lead placement. Mean age was 66 ± 11 years, mean left ventricular ejection fraction (LVEF) 26 % ± 8 and 50 % ischemic etiology. Mean energy to capture the LV was 1.95 μJ for LV1 during implant, rising to 8.61 μJ at day 1, p  = 0.03. The energy required for LV2 was 2.37 μJ during implant, 11.55 μJ the next day, p  = 0.004. Eleven percent had LV2 turned off during the implant due to high thresholds and/or a worsened acute hemodynamic response. Eleven percent had LV2 turned off day 1 post implant due to inability to capture LV2 at maximum output. All remaining 15 patients had LV2 programmed off, with a mean time of 255 days from implant. Thirty-two percent of patients received ATP or shock, and sixteen percent died over a mean follow-up of 1271 days. Thirty-seven percent of patients required generator replacement with mean longevity of 42 months, far shorter than the suggested lifespan of the device (58 months), p  = 0.006. Conclusion Multisite epicardial LV lead placement may be acutely feasible and demonstrate beneficial hemodynamic results at implantation. Long-term delivery of this therapy is however problematic due to technical issues with pacing through the bifurcating adapter. This suggests the feasibility of this form of multisite CRT is limited.

Background and aims of study Septal flash (SF) describes early inward motion of the ventricular septum in patients with left bundle branch block (LBBB), and correction corresponds to increased response to cardiac resynchronization therapy (CRT). SF has traditionally been assessed by echocardiography. We sought to determine if cardiac magnetic resonance (CMR) imaging could identify SF and if the additional assessment of scar would improve the ability of CMR to predict CRT response. Methods Fifty-two patients with LBBB and heart failure underwent prospective CMR scanning prior to CRT implantation. The presence of SF was assessed visually and by using endocardial contour-tracking software. Presence and extent of myocardial scar was assessed by delayed enhancement imaging during CMR. The association between SF, scar and reverse remodelling (RR) at 6 months was explored. Results RR rate to CRT at 6 months was 52 %. CMR-derived SF was identified in 24 (46 %) patients. RR was seen in more patients with SF than those without (88 % vs 21 %; P  < 0.001). The absence of scar combined with the presence of SF had 96 % specificity for predicting RR. In a multivariate regression model, the presence of SF was the only independent predictor of RR. Conclusion SF can be assessed by CMR and predicts increased response to CRT. The additional value of CMR is the assessment of scar. The presence of SF with no scar is a highly specific predictor of CRT response.

Doc number: P64

Background Atrial fibrillation (AF) is the most common clinical arrhythmia and one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. Despite substantial advances in (interventional) rhythm control treatment during the last decade, anticoagulation for stroke prevention remains a major component of AF treatment. Hypothesis There are important sex‐specific differences in AF‐related stroke, resulting from sex‐specific mechanisms and therapeutic differences. Methods This review summarizes available data on sex differences in risk assessment and prevention of stroke and highlights current knowledge gaps in AF‐related stroke mechanisms, prevention and management that warrant further research. Results Increased thrombotic risk in women is multifactorial, involving hormonal changes after menopause, structural, endocrine and lifestyle/social factors and their interactions. It is clear from randomized studies that women benefit from anticoagulant treatment and that their bleeding risk is similar to men. Women should therefore receive equivalent treatment to men, based on the validated criteria for anticoagulation therapy. However, women are not represented equally in the large randomized studies and sex‐related information in many fields is lacking. Conclusions Female sex is an established risk factor for stroke in AF patients. The evidence for sex‐specific differences in stroke risk assessment and stroke prevention is accumulating. However, the underlying biological mechanisms remain incompletely understood and further studies are required in order to decrease AF‐related morbidity and mortality.

18-Fluorodeoxyglucose positron emission tomography/computerized tomography (FDG PET/CT) scanning has recently been proposed as a diagnostic tool for lead endocarditis (LE). FDG PET/CT might be also useful to localize associated septic emboli in patients with LE. We report an interesting case of a LE patient with a prosthetic aortic valve in whom a trans-esophageal echocardiogram did not show associated aortic endocarditis. FDG PET/CT revealed prosthetic aortic valve infection. A second TEE performed 2 weeks after identified aortic vegetation. A longer duration of antimicrobial therapy with serial follow-up echocardiography was initiated. There was also increased uptake in the sigmoid colon, corresponding to focal polyps resected during a colonoscopy. FDG PET/CT scanning seems to be highly sensitive for prosthetic aortic valve endocarditis diagnosis. This promising diagnostic tool may be beneficial in LE patients, by identifying septic emboli and potential sites of pathogen entry.

BackgroundThe 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.MethodsWe 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.ResultsNo 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.ConclusionsThe use of remanufactured circular mapping catheters is safe, efficient and reliable. Widespread use of remanufactured SUDs offers the possibility of significant economic benefit.