Bruce A. Koplan

Catheter Ablation of Atrial Arrhythmias: Background: Management of atrial arrhythmias (AA) in orthotopic heart transplant (OHT) patients is challenging.Objective: The purpose of this study was to define the mechanisms of these arrhythmias and to evaluate the role of ablation.Methods: Patients with OHT referred for ablation of AA from 1999 to 2011 were included (n = 15). Entrainment and anatomic 3‐D mapping were utilized to identify AA mechanism and guide ablation.Results: The median time from OHT to ablation was 8 years (range: 1 month–16 years). AA types included 1 (7%) AVNRT, 5 (33%) cavotricuspid isthmus (CTI) dependent donor atrial flutter (AFl), 3 (20%) non‐CTI‐dependent donor AFL (n = 3), focal atrial tachycardia (AT) (n = 2) and in 4 (27%) recipient to donor atria conduction (RDC) that involved the right atrial anastomosis in 3 and left atrial anastamosis in 1 patient. In RDC tachycardia, ablation was performed at the site of earliest donor atrial activation on the suture line. AA in the recipient atria were not targeted. This resulted in acute success in all cases. In most patients 12/15 (80%) only right atrial ablation was necessary. Regardless of surgical technique (bicaval vs biatrial) right‐sided AA was most common. Acute success occurred in 14/15 (93%) patients and 3/15 (20%) required repeat Abl for recurrence. There were no major complications.Conclusion: AA after OHT are most commonly due to atrial macroreentry, but focal arrhythmias and RDC atrial conduction also occur. Ablation of organized AA is usually successful with low risk, warranting early consideration in preference to medical treatment.

Background: Atrial fibrillation (AF) can have a significant effect on quality of life (QoL). Other chronic diseases are known to not only affect the patient but to also impact the QoL of persons living with them. Scant data exist on the QoL effect of AF in spouses/significant others (SOs). Methods: An anonymous survey regarding the perceived effect of AF on QoL was designed and distributed to both patients and spouses/SOs during an educational symposium about living with AF. Both were asked to fill out the survey independently according to how their life was affected by either their AF or their partner's AF. Questions included demographics, perceived impairment of overall QoL on a 5‐point scale, as well as effect on subcategories of QoL, namely daily activity, work life, sex life, physical activity, psychological well‐being, and social activity. Results: Five hundred and sixty‐eight subjects completed the survey of which 411 were AF patients and 129 were spouses/SOs. The perceived effect of AF on overall QoL (N = 527) was similar in patients and spouses (AF patients: mild 42.0%, moderate 26.0%, severe 32.0% vs. spouses: 44.1%, 25.2%, 31.7%; P = 0.917). This result did not change when adjusted for age and gender. There was also no significant difference between patients and spouses in the subcategories of QoL with the exception of the perceived effect on work life, which was greater in patients than spouses (P = 0.041). Conclusions: AF has a similar perceived impact on the QoL of spouses and patients. QoL improvement strategies for patients with AF should take spouses into account. (PACE 2011; 34:804–809)

An automatic capture (AC) algorithm adjusts ventricular pacing output to capture the ventricle while optimizing output to 0.5 V above threshold. AC maintains this output and confirms capture on a beat-to-beat basis in bipolar and unipolar pacing and sensing. To assess the AC algorithm and its impact on device longevity. Patients implanted with a pacemaker were randomized 1:1 to have the AC feature on or off for 12 months. Two threshold tests were conducted at each visit- automatic threshold and manual threshold. Average ventricular voltage output and projected device longevity were compared between AC on and off using nonparametric tests. Nine hundred ten patients were enrolled and underwent device implantation. Average ventricular voltage output was 1.6 V for the AC on arm (n = 444) and 3.1 V for the AC off arm (n = 446) (P < 0.001). Projected device longevity was 10.3 years for AC on and 8.9 years for AC off (P < 0.0001), or a 16% increase in longevity for AC on. The proportion of patients in whom there was a difference between automatic threshold and manual threshold of <or=0.5 V through follow-up was 99.0% (95% CI: 98.6, 99.3). The average difference between automatic threshold and manual threshold was 0.07 V (P = 0.002). This study showed that automatic threshold testing at follow-up provided comparable information to manually measured threshold testing. AC provided a significant increase in projected device longevity compared to standard programing.

Background: In the event of infection, erosion, or failure, fibrosis of a defibrillation lead can make extraction difficult. In the ENDOTAK RELIANCE G defibrillation lead, coils are covered with expanded polytetrafluoroethylene (ePTFE) to prevent tissue ingrowth. Objective: The objective of the REFLEx Study was to evaluate if RELIANCE G defibrillation leads with ePTFE‐covered coils are as good as comparative defibrillation leads with respect to electrical performance and termination of spontaneous tachyarrhythmias. Methods: Patients were randomized to type of defibrillation lead—Guidant RELIANCE G lead or a non‐ePTFE‐covered lead of choice. Electrical performance success was defined as meeting all minimum standards in the respective manufacturer's manual for amplitude, threshold, and impedance. A noninferiority margin of 5% was prespecified. Results: Electrical performance success at 12 months was 93.0% (280/301) for RELIANCE G and 94.5% (291/308) for comparative leads. The performance success rate for RELIANCE G did not differ significantly from study comparative (P = 0.04, noninferiority). For spontaneous episodes, first shock conversion success rate was 90% for RELIANCE G and 95% for study comparative (P = 0.89, noninferiority). Implant conversion testing was successful in 96.7% (524/542) of RELIANCE G patients and 94.3% (512/543) of comparative patients (chi‐square P‐value = 0.0784). About 55% (609/1115) of patients completed follow‐up through month 12. Conclusion: Data from the REFLEx study indicate that ePTFE‐covered leads are not inferior to comparative leads with respect to electrical performance and implant conversion testing. We cannot conclude that the first shock conversion efficacy of ePTFE covered leads was statistically noninferior to comparative leads.