Beyond pulmonary vein isolation for persistent atrial fibrillation: sequential high-resolution mapping to guide ablation

Purpose We aimed to evaluate whether outcomes with ablation in persistent (PsAF) and long-standing persistent (LsPsAF) AF can be improved beyond what can be achieved with pulmonary vein isolation (PVI) alone, using individualized mapping to guide ablation. Methods We studied 20 pts (15 M, 68 ± 11y) with PsAF (14) or LsPsAF (6) referred for first-time AF ablation. Following antral PVI, individualized mapping (IM) was performed using a high-density mapping catheter stably and fully deployed for 30 s at each of 23 ± 9 sites per patient. Activation data were reviewed, and an ablation strategy designed to intersect areas of focal and rotational activity. Mean follow-up was 429 ± 131 days. The study population was compared to a matched contemporary control cohort (CC) of 20 consecutive patients undergoing conventional ablation. Results Despite the IM group having a higher median comorbidities score, 3.5 vs. 2.5 in the CC group, indicating potentially more complex patients and more advanced substrate, cumulative freedom from AF after a single procedure was achieved in 94% of patients in the IM group vs. 75% in the CC group at 1 year and remained the same in both groups at the conclusion of the study (p = 0.02). There was a similar trend in atrial arrhythmia-free survival between both groups (84% vs. 67% at 1 year) that did not reach statistical significance. The procedure duration was longer in the IM group by a median of 31.5 min (p = 0.004). Conclusions Individualized mapping to guide AF ablation appears to achieve significantly greater AF-free survival compared to conventional PVI when applied as a primary ablation treatment. The results of this pilot study need to be confirmed in a larger, randomized trial.

Percutaneous Extraction of a Large Device Related Thrombus on a Watchman™ Device: A Case Report

Background Left atrial appendage occlusion devices are commonly used to prevent stroke in patients with persistent atrial fibrillation who are unable to tolerate anticoagulation. However certain patient and device related characteristics increase the risk for the development of a device related thrombus. The presence of a device related thrombus increases the risk of stroke and should be treated. Management of device related thrombus lacks consensus but is mostly focused on anticoagulation. In patients with large thrombi that need to be managed urgently, percutaneous extraction may be a viable option. Case Summary In this report we describe the successful management of a device related thrombus via percutaneous thrombus extraction technology in an 81-year-old woman with a large thrombus attached to a WATCHMAN™ device. The patient initially presented with shortness of breath, and on imaging a pedunculated thrombus was detected. The thrombus was extracted using a Penumbra Lightning 12™ (Penumbra Inc., Alameda, CA) catheter with a Sentinel™ (Boston Scientific, Marlborough, Massachusetts) cerebral embolic protection device. The patient had no neurologic sequelae and was started on anticoagulation. Discussion Percutaneous thrombectomy can be safely performed to extract large left atrial occlusion device related thrombus that require urgent management, without any neurologic sequelae. We believe this can be used in patients with a large device related thrombus who would not be adequately managed with anticoagulation and in whom surgery is not feasible.

Myocarditis in the Presence of Respiratory Syncytial Virus (RSV) Infection: A Case Study

Background/Objective: Respiratory syncytial virus (RSV) causes acute respiratory infections in children and adults. RSV has many non-specific symptoms such as cough and dyspnea. RSV is associated with high mortality in children, the elderly, and immunocompromised individuals. Although rare, RSV has been reported to cause extrapulmonary complications such as arrhythmias and myocarditis. This case focuses on a patient infected with RSV who presents with acute sustained monomorphic ventricular tachycardia (SMVT). Case Overview: An 83 year-old patient with a history of type 2 diabetes mellitus, hypertension, persistent atrial fibrillation, and asthma presented to the emergency department with concerns of cough, malaise, and a syncopal episode. Upon admission, the patient tested positive for RSV and was diagnosed with acute bronchitis exacerbated by history of asthma. The patient soon developed SMVT with heart rates as high as 235 beats per minute. After consultation with an electrophysiologist, the VT was attributed to myocarditis as a result of the RSV infection. Oral amiodarone was prescribed, and the patient was discharged two weeks later. In a follow-up visit, no SMVT was reported, and the dosage of amiodarone was decreased. Discussion: With the onset of the SARS-CoV2 pandemic in early 2020, myocarditis associated with viral infection has been of interest in recent literature. Many cases of cardiovascular complications have been reported in patients infected with SARS-CoV2. Consequently, it is important to discuss cases of other respiratory viruses also presenting with arrhythmia and myocarditis. In the current case, a patient with RSV developed new onset VT. VT can be life-threatening and can cause further cardiovascular complications. Conclusion: RSV can cause new onset cardiovascular complications, albeit rare. It is important for clinicians to be aware of such complications especially in cases in which patients have preexisting cardiovascular conditions. Patients infected with RSV should be closely monitored for new onset complications.