Emile G. Daoud

Background: Prior reports of internal jugular vein (IJV) access for implantation of leadless pacemakers (LLPM) are primarily small series and for ventricular LLPM. Objectives: To describe outcomes of consecutive patients undergoing IJV access for both atrial and ventricular LLPM implantation. Methods: This observational multicenter study included 32 consecutive patients (17 female; 69 ± 14 years; range 17–91) undergoing LLPM implantation via IJV access. Dual chamber LLPM was implanted in 16 patients, right ventricular (RV) only in 13, and right atrial (RA) only in 3. Electrical parameters were measured at implantation, 7–10 days post implantation, and at last follow‐up (mean 215 ± 98 days). Results: IJV access was successful in all patients. Mean procedure and fluoroscopy times were 82 ± 40 and 16 ± 9 min, respectively. RV implant required 1.3 ± 0.6 deployments with mean of 21 min and RA implant required 1.6 ± 0.9 deployments with mean of 31 min. Electrical parameters were excellent. Current of injury for the RA LLPM is the primary indicator of engagement of the atrial myocardium. Two device‐related complications occurred without clinical sequelae; no late complications were observed. Fifteen patients were discharged the same day. Conclusions: IJV access for atrial and ventricular LLPM implantation is safe and effective across a broad age range and is an alternative to FV access, enabling same‐day discharge and early ambulation. Elevated acute atrial capture thresholds with robust current of injury should not prompt repositioning, as thresholds significantly improve at early follow‐up.

Introduction: The feasibility and outcomes of simultaneous atrioventricular node ablation (AVNA) and leadless pacemaker (LLPM) implantation from the internal jugular (IJ) vein are not well studied. We report our single‐center case series experience with concomitant implantation of the AVEIR LLPM and AVNA from the IJ venous approach. Methods: Patients with persistent atrial fibrillation (AF) with frequent rapid ventricular rate (RVR) episodes refractory to pharmacological therapy and not ideal for AF ablation were selected for LLPM and AVNA. These procedures were performed simultaneously via the IJ vein due to patient preference and anatomical challenges (presence of severe scar tissue from prior procedures, presence of an inferior vena cava [IVC] filter, etc.). All patients were followed for at least 4 weeks post procedure. Results: Ten patients (mean age of 76.1 ± 11.5 years, 60% female) underwent successful simultaneous AVEIR implantation and AVNA via IJ venous access. Median device implantation time was 15.5 min, procedure time was 45 min, fluoroscopy time was 6.4 min, and radiation dose was 82 mGy. No device repositioning occurred. Mean pacing capture threshold at implant was 0.65 ± 0.316 V and impedance of 848 ± 209 Ω. At follow‐up, pacing capture threshold was 0.5 V at 0.4 ms in all patients. Mean radiofrequency (RF) time to successful AVN ablation was 191.6 ± 86 s. Hemostasis was obtained within 5 min in all cases. There were no procedure‐related complications and no adverse interaction from performing these procedures simultaneously. Specifically, there was no interaction with radiofrequency current and LLPM function. Mean time to ambulation post procedure was 82 ± 12 min and six out of seven patients scheduled for an elective procedure were able to be discharged home the same day. Conclusion: This early series suggests that simultaneous AVNA and LLPM implantation from the IJ is feasible and safe. This IJ approach provides an alternative access option for the ablate and pace strategy and allows for early ambulation and discharge.

Introduction: The prospective, nonrandomized, multicenter Q‐FFICIENCY study demonstrated the safety and 12‐month efficacy of paroxysmal atrial fibrillation (AF) ablation with the novel QDOT MICRO temperature‐controlled, contact force‐sensing, radiofrequency (RF) catheter. Participants underwent pulmonary vein isolation with very high‐power short‐duration (vHPSD) mode (90 W, ≤4 s) alone or combined with conventional‐power temperature‐controlled (CPTC) mode (25–50 W). This study aimed to assess quality‐of‐life (QOL) and healthcare utilization (HCU) benefits experienced by Q‐FFICIENCY study participants.Methods: Besides evaluating procedural efficiency, QOL and HCU were assessed through 12 months postablation via Atrial Fibrillation Effect on Quality‐of‐Life Tool (AFEQT) score, antiarrhythmic drug (AAD) use, and incidence of cardioversion and cardiovascular hospitalization.Results: Of 191 participants enrolled, 166 were ablated with the new catheter. Compared to baseline, statistically significant, clinically meaningful improvements in composite and subcategories of AFEQT scores were observed at 3 months and sustained through 12 months (12‐month increase, 29.3–44.2 points). Class I/III AAD use decreased from 97.6% (162/166) at baseline to 19.6% (31/158) during Months 6–12, representing a significant 79.9% reduction. The cardioversion rate significantly declined by 93.9% from 31.3% (12 months preablation) to 1.9% (evaluation period). One‐year Kaplan–Meier estimates of freedom from all‐cause and cardiovascular hospitalization were 80.9% (95% confidence interval [CI], 74.8%–86.9%) and 88.8% (95% CI, 84.0%–93.7%), respectively.Conclusions: Paroxysmal AF ablation with the novel temperature‐controlled RF catheter in vHPSD mode, alone or with CPTC mode, led to clinically meaningful improvement in QOL and significant reduction in AAD use, cardioversion, and cardiovascular hospitalization.

Introduction: Among patients with non‐valvular atrial fibrillation (AF) and percutaneous left atrial appendage closure (LAAC) undergoing direct current cardioversion (DCCV), the need for and use of LAA imaging and oral anticoagulation (OAC) is unclear.Objective: The purpose of this study is to evaluate the real‐world use of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) before DCCV and use of OAC pre‐ and post‐DCCV in patients with AF status post percutaneous LAAC.Methods: This retrospective single center study included all patients who underwent DCCV after percutaneous LAAC from 2016 to 2022. Key measures were completion of TEE or CCTA pre‐DCCV, OAC use pre‐ and post‐DCCV, incidence of left atrial thrombus (LAT) or device‐related thrombus (DRT), incidence of peri‐device leak (PDL), and DCCV‐related complications (stroke, systemic embolism, device embolization, major bleeding, or death) within 30 days.Results: A total of 76 patients with AF and LAAC underwent 122 cases of DCCV. LAAC consisted of 47 (62%), 28 (37%), and 1 (1%) case of Watchman 2.5, Watchman FLX, and Lariat, respectively. Among the 122 DCCV cases, 31 (25%) cases were identified as “non‐guideline based” due to: (1) no OAC for 3 weeks and no LAA imaging within 48 h before DCCV in 12 (10%) cases, (2) no OAC for 4 weeks following DCCV in 16 (13%) cases, or (3) both in 3 (2%) cases. Among the 70 (57%) cases that underwent TEE or CCTA before DCCV, 16 (23%) cases had a PDL with a mean size of 3.0 ± 1.1 mm, and 4 (6%) cases had a LAT/DRT on TEE resulting in cancellation. There were no DCCV‐related complications within 30 days.Discussion: There is a widely varied practice pattern of TEE, CCTA, and OAC use with DCCV after LAAC, with a 6% rate of LAT/DRT. LAA imaging before DCCV appears prudent in all cases, especially within 1 year of LAAC, to assess for device position, PDL, and LAT/DRT.

Introduction: Defibrillation testing (DT) is recommended during the subcutaneous defibrillator (S‐ICD) placement. We sought to compare 10 J shock impedance in sinus rhythm (SR) with 65 J defibrillation impedance and evaluate device position on a postimplant chest X‐ray (CXR) using an intermuscular (IM) technique.Methods: Consecutive S‐ICD implantations between 12/2019 and 12/2020 at The Ohio State University were reviewed. All implantations were performed using a two‐incision IM technique. Standard DT with 65 J shock and 10 J shock in SR were performed unless contraindicated. The PRAETORIAN score was calculated based on CXR.Results: A total of 37 patients (age: 47.2 ± 15.8 years old, male: n = 26 [70.3%], body mass index: 30.1 ± 6.7 kg/m²) underwent IM S‐ICD implantation, and of those, 27 (73%) underwent both 65 J shock and 10 J shock in SR. The coefficient of determination (R²) between 10 J shock impedance and 65 J shock impedance was 0.84. The mean of an impedance difference was 1.6 ± 4.8 Ω (minimum – 11 and maximum 8). Postimplant CXR was available for 33 out of 37 patients (89.2%). The PRAETORIAN score was less than 90 in all patients and the mean score was 32.7 ± 8.8.Conclusion: We demonstrated that 10 J shock impedance in SR correlated well with 65 J defibrillation impedance during IM S‐ICD implantation. An IM implantation technique provides excellent generator location on postimplant CXR. The IM technique combined with 10 J shock in SR may be sufficient to predict and ensure the defibrillation efficacy of the S‐ICD.