Novel use of three-dimensional mapping for cryoablation of atrial fibrillation

Background: In cryoablation of atrial fibrillation, we prefer using a 0.035-inch guidewire as a rail for the cryoballoon rather than a mini-lasso catheter. The guidewire can be passed selectively into a specific side branch of the target vein branches to allow more coaxial orientation of the cryoballoon, and thereby superior occlusion of the pulmonary vein (PV). Purpose: Endocardial Solutions Inc.’s (ESI) three-dimensional (3D) mapping system can localize a coil-tip guidewire in three dimensions and determine location in the appropriate side branch as well as the PV, which we hypothesized would facilitate cryoisolation. Methods: The study population included 26 patients (19 men) with paroxysmal atrial fibrillation who underwent cryoballoon PV isolation (mean age 65 ± 9 years, mean left atrial volume index 37.4 ± 11 ml/ m², mean left ventricular ejection fraction 56 ± 10%). Following transseptal puncture, the 0.035-inch guidewire was passed into the target branch and then into its various side branches. An alligator clip connected the guidewire to the ESI 3D system. Surface patches served as ESI reference. Results: By comparing preoperative left atrial computed tomography scan side by side with the ESI 3D map of the target branch and its side branches, it was possible to determine the location of the target PV and side branches more quickly and conveniently than occlusive venography. When complete balloon occlusion of the PV could not be achieved, introducing the guidewire into an alternate side branch allowed isolation. Conclusion: Guidewire localization with the ESI 3D system is helpful in cryoballoon ablation by allowing rapid identification of the target vein and selection of the best PV side branch for placement of the support guidewire to allow better PV occlusion

Assessment of Chronic Disease to Determine Appropriateness of Implantable Cardioverter-Defibrillator Therapy

Background: Implantable cardioverter-defibrillator (ICD) therapy is considered appropriate when a patient is felt to have a reasonable expectation of 1-year survival. Chronic diseases have been estimated to be associated with greater than 10% annual mortality and may reduce benefits of ICD therapy. Frailty has been estimated to be associated with greater than 20% annual mortality and has been suggested to contraindicate ICD therapy. Purpose: Determine a risk score that may identify patients in whom ICD implantation may not be appropriate. Methods: Patients who received an ICD for primary and secondary prevention from 2008 through 2013 at the Aurora Health Care network were studied retrospectively. Using Cox regression, a scoring system based on hazard ratios was devised to reflect risk associated with comorbidities. Survival was evaluated by Kaplan-Meier estimates. Results: The study cohort includes 1,558 patients (mean age: 61.3 years; 495 female). Comorbidities associated with mortality included in the risk score were need for hemodialysis, myocardial infarct within 3 months prior to ICD implantation, sustained monomorphic ventricular tachycardia, New York Heart Association functional class III, age greater than 70 years, intraventricular conduction delay, diabetes mellitus, and chronic lung disease. A risk score of greater than or equal to 6 was associated with 10% mortality at 1 year and more than 20% mortality by 2 years. Conclusion: Chronic comorbidities have a cumulative effect on mortality. Using our scoring system, patients with a risk score of 6 or greater have at least 10% mortality at 1 year and more than 20% mortality by 2 years

Predictors and rates of mortality in implantable cardioverter defibrillator recipients in the central midwest

Background: Implantable cardioverter defibrillator (ICD) therapy is expensive, but cost effectiveness has been demonstrated over longterm follow-up. Short-term mortality negatively impacts cost-effectiveness and ICD therapy is contraindicated in patients with expected longevityrecipients. Methods: Patients who underwent initial ICD implant from 2008-14 within the Aurora Health Care network (Wisconsin and northern Illinois) with at least 3 years of follow-up and/or suffered the primary endpoint of death were evaluated. Cox regression was used to determine hazard ratios (HR) for significant predictors identified through forward stepwise analysis. Results: In our ICD population (n=1560), total mortality was 194 (12.9%) and 42 patients died within 1 year of ICD implant (2.8%, 21.6% of total mortality). Clinical characteristics at the time of initial ICD implant that emerged as predictors of mortality included bradycardic arrest (HR 9.06, p70 (HR=2.39, p100 not meeting left bundle branch block [BBB] or right BBB criteria; HR 1.90, p Conclusions: A small but substantial percentage of central Midwestern ICD patients are at risk for 1-year mortality, and 1/5 of our total ICD mortality occurred within 1 year of implant. Several clinical characteristics at initial ICD implant predict mortality, including 1-year mortality, in our large cohort. Applying a priori knowledge of predictors of mortality, particularly 1-year mortality, may improve patient selection and cost-effectiveness of ICD therapy