Malcolm Finlay

Graphical Abstract A standardized step-by-step approach to vascular access during electrophysiological procedures: Begin by identifying patients at higher risk for vascular complications and consider alternative access routes in cases of inferior vena cava interruption. Allow the patient to drink clear fluids and adopt an uninterrupted anticoagulation strategy when feasible. Choose the access site based on procedural needs and patient anatomy, giving preference to ultrasound-guided puncture to improve accuracy and reduce complications. At the end of the procedure, select the most appropriate closure technique – manual compression, figure-of-eight suture, or a vascular closure device – based on access site, sheath size, and patient-specific factors.

Introduction: Leadless pacing is increasingly used in patients with contraindications to transvenous systems. However, a common presentation of life-threatening bradyarrhythmia is in the out-of-hours emergency setting. The perceived complexities of leadless implantation anecdotally inhibit their use as destination devices implanted in the acute setting. Our centre offers a 24-7 emergency pacing service, we examined our use of leadless pacemaker implantation for patients requiring out of hours emergency pacing at our centre from December 2021 to December 2023. Purpose: The purpose of this study looking to examine the feasibility and safety of leadless pacing in out of hours emergency situations. Methods: This is a single centre retrospective cohort study examining all patients (pts) undergoing leadless pacemaker implantation at 1 hospital. Out of hours (OOH) implantation was defined as being after 18:00 during the week and any time during the weekend. Clinical and procedural parameters were compared between in-hours and out of hours (OOH) implantation. Haemodynamic instability was defined as any patient requiring inotrope support. Results: 118 leadless pacing systems were implanted between 0/1/12/2021 and 01/12/2023; 95 being performed in-hours and 23 OOH. Pacing indication was high-degree AV block in 20 pts (87%) in the OOH group, with frailty (8pts), dialysis (4pts) and infection (3pts) being listed as the most common reasons for selection of a leadless system in the OOH group. OOH pts had greater haemodynamic instability [in-hours: 3pts (3.2%) vs OOH: 4pts (17.4%)]. Procedural time (mean ± Standard deviation, mins) was similar between groups [52.4 (±3.6) in-hours vs 59.7(+/- 6.4) OOH; p= 0.33] as was fluoroscopy time (mins) [in-hours: 4.9 (+/- 1.0) vs OOH: 5.1(+/- 2.3) p=0.97] and radiation dose (cGy*cm²) [in-hours: 56.73 (+/- 9.87) vs OOH: 53.8(+/- 14.1), p=0.89]. 3 (3.1%) major complications occurred in the in-hours group [tamponade (2pts), infection (1pt)]. One pt in the OOH group had a significant post procedure access site bleed (4.3%), but no tamponade occurred in this group. Four pts (4.2%) died before discharge in the in-hours group, four patients (17.4%) died in the OOH group, reflecting their poor premorbid condition. Conclusions: Leadless pacemakers can be safely implanted in the emergency, out of hours setting. In selected patients, this technology can offer an immediate destination therapy as an important alternative to placing a temporary system.

BACKGROUND: Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device infections, but their cost restricts routine use in the United Kingdom. Risk scoring could help to identify which patients would most benefit from this technology. METHODS: A novel risk score (BLISTER [Blood results, Long procedure time, Immunosuppressed, Sixty years old (or younger), Type of procedure, Early re-intervention, Repeat procedure]) was derived from multivariate analysis of factors associated with cardiac implantable electronic device infection. Diagnostic utility was assessed against the existing PADIT score (Prior procedure, Age, Depressed renal function, Immunocompromised, Type of procedure) in both standard and high-risk external validation cohorts, and cost-utility models examined different BLISTER and PADIT score thresholds for TYRX (Medtronic; Minneapolis, MN) antimicrobial envelope allocation. RESULTS: In a derivation cohort (n=7383), cardiac implantable electronic device infection occurred in 59 individuals within 12 months of a procedure (event rate, 0.8%). In addition to the PADIT score constituents, lead extraction (hazard ratio, 3.3 [95% CI, 1.9–6.1]; P 50 mg/L (hazard ratio, 3.0 [95% CI, 1.4–6.4]; P =0.005), reintervention within 2 years (hazard ratio, 10.1 [95% CI, 5.6–17.9]; P P =0.001) were independent predictors of infection. The BLISTER score demonstrated superior discriminative performance versus PADIT in the standard risk (n=2854, event rate: 0.8%, area under the curve, 0.82 versus 0.71; P =0.001) and high-risk validation cohorts (n=1961, event rate: 2.0%, area under the curve, 0.77 versus 0.69; P =0.001), and in all patients (n=12 198, event rate: 1%, area under the curve, 0.8 versus 0.75, P =0.002). In decision-analytic modeling, the optimum scenario assigned antimicrobial envelopes to patients with BLISTER scores ≥6 (10.8%), delivering a significant reduction in infections (relative risk reduction, 30%; P =0.036) within the National Institute for Health and Care Excellence cost-utility thresholds (incremental cost-effectiveness ratio, £18 446). CONCLUSIONS: The BLISTER score ( https://qxmd.com/calculate/calculator_876/the-blister-score-for-cied-infection ) was a valid predictor of cardiac implantable electronic device infection, and could facilitate cost-effective antimicrobial envelope allocation to high-risk patients.

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF). There are limited data on the PolarX Cryoballoon. The study aimed to establish the safety, efficacy, and feasibility of same day discharge for Cryoballoon PVI. Multi-centre study across 12 centres. Procedural metrics, safety profile, and procedural efficacy of the PolarX Cryoballoon with the Arctic Front Advance (AFA) Cryoballoon were compared in a cohort large enough to provide definitive comparative data. A total of 1688 patients underwent PVI with cryoablation (50% PolarX and 50% AFA). Successful PVI was achieved with 1677 (99.3%) patients with 97.2% (n = 1641) performed as day case procedures with a complication rate of P < 0.001] and nadir temperature (OR 1.24; P < 0.001) with an optimal cut-off of ≤34 s [area under the curve (AUC) 0.73; P < 0.001] and nadir temperature of ≤−54.0°C (AUC 0.71; P < 0.001), respectively. This large-scale UK multi-centre study has shown that Cryoballoon PVI is a safe, effective day case procedure. PVI using the PolarX Cryoballoon was similarly safe and effective as the AFA Cryoballoon. The cryoablation metrics achieved with the PolarX Cryoballoon were different to that reported with the AFA Cryoballoon. Modified cryoablation targets are required when utilizing the PolarX Cryoballoon. Demonstrates the spread of temperature profiles on a per vein basis with the PolarX Cryoballoon for cryoablations with a TTI that demonstrated successful PVI.