Madhu Reddy

Scar homogenization improves long-term ventricular arrhythmia-free survival compared with standard limited-substrate ablation in patients with post-infarction ventricular tachycardia (VT). Whether such benefit extends to patients with nonischemic cardiomyopathy and scar-related VT is unclear. The aim of this study was to assess the long-term efficacy of an endoepicardial scar homogenization approach compared with standard ablation in this population. Consecutive patients with dilated nonischemic cardiomyopathy (n = 93), scar-related VTs, and evidence of low-voltage regions on the basis of pre-defined criteria on electroanatomic mapping (i.e., bipolar voltage <1.5 mV) underwent either standard VT ablation (group 1 [n = 57]) or endoepicardial ablation of all abnormal potentials within the electroanatomic scar (group 2 [n = 36]). Acute procedural success was defined as noninducibility of any VT at the end of the procedure; long-term success was defined as freedom from any ventricula...

Significant differences have been described between women and men regarding presentation, mechanism, and treatment outcome of certain arrhythmias. Previous studies of ventricular tachycardia (VT) ablation have not included sufficient women for meaningful comparison. To compare outcomes between women and men with structural heart disease undergoing VT ablation. Investigator-initiated, multicenter, observational study performed between 2002 and 2013, conducted by the International VT Ablation Center Collaborative Group, consisting of 12 high-volume ablation centers. Consecutive patients with structural heart disease undergoing VT ablation were studied. Structural heart disease was defined as left ventricular ejection fraction less than 55%, hypertrophic cardiomyopathy, or right ventricular cardiomyopathy, with scar confirmed during electroanatomic mapping. Catheter ablation. Ventricular tachycardia-free survival and transplant-free survival were compared between women and men. Cox pro...

Novel oral anticoagulants (NOACs) have been approved for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). A large number of patients are on NOACs when they present for AF ablation. We intended to evaluate the safety and efficacy of NOACs for AF ablation during the periprocedural period by performing a meta-analysis of trials comparing NOACs with warfarin. Studies comparing NOACs (dabigatran and rivaroxaban) with warfarin as periprocedural anticoagulants for AF ablation were identified using an electronic search. Primary outcomes were: (1) a composite endpoint of stroke, transient ischemic attack (TIA), peripheral arterial embolism, or silent cerebral lesions on magnetic resonance imaging (MRI) and (2) major bleeding complications. A random effects model was used to pool the safety and efficacy data across all included trials. When compared to warfarin, there was an increased risk of the composite endpoint of stroke, TIA, peripheral...

-Whether catheter ablation (CA) is superior to Amiodarone (AMIO) for the treatment of persistent AF in patients with HF is unknown. -This was an open-label, randomized, parallel-group, multicenter study. Patients with persistent AF, dual chamber ICD or CRTD, NYHA II-III and LV EF <40% within the last 6 months were randomly assigned (1:1 ratio) to undergo CA for AF (group 1, n=102) or receive AMIO, (group 2, n=101). Recurrence of AF was the primary end point. All-cause mortality and unplanned hospitalization were the secondary endpoints. Patients were followed-up for a minimal of 24 months. At the end of follow-up, 71(70% [95% CI 60% - 78%]) patients in group 1 were recurrence-free after average 1.4±0.6 procedures as compared to 34 (34% [95% CI 25% - 44%]) in group 2 (log-rank p <0.001). Success rate of CA in the different centers after a single procedure ranged from 29% to 61%. After adjusting for covariates in multivariable model, patients on AMIO therapy were found to be significantly more likely to fail (HR 2.5 [95% CI 1.5 to 4.3], p <0.001) compared to CA. Over the 2 year follow-up, unplanned hospitalization rate was (32 [31%] in group 1 and 58 [57%] in group 2, p <0.001), showing 45% relative risk (RR) reduction (RR 0.55, 95% CI 0.39-0.76). A significant lower mortality was observed in CA (8 [8%] vs AMIO (18 [18%], p=0.037). -This multicenter randomized study shows that CA of AF is superior to AMIO in achieving freedom from AF at long term follow up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF.Clinical Trial Registration Information-clinicaltrials.gov. Identifier:NCT00729911.

Published data regarding epicardial ligation of left atrial appendage (LAA) has discordant results. To delineate the safety and efficacy of LAA closure with LARIAT. This is a multicenter registry of 712 consecutive patients undergoing LAA ligation with LARIAT at 18 US hospitals. The primary endpoint was successful suture deployment, no leak by intra-procedure transesophageal echocardiography (TEE), and no major complication (death, stroke, cardiac perforation, bleeding requiring transfusion) at discharge. A leak of 2-5 mm on follow-up TEE was the secondary endpoint. LARIAT was successfully deployed in 682 (95.5 %) patients. A complete closure was achieved in 669 (98%) patients while 13 patients (1.8%) had a trace leak (<2mm). There was one death related to the procedure. Ten patients (1.44%) had cardiac perforation necessitating open-heart surgery while another 14 (2.01%) did not need surgery. The risk of cardiac perforation decreased significantly after introduction of micropuncture (MP) needle for pericardial access. Delayed complications (pericarditis requiring >2 weeks of treatment with NSAIDs/Colchicine, pericardial and pleural effusion after discharge) occurred in 34 patients and the risk decreased significantly with the peri-procedural use of colchicine. The follow-up TEE (n=480) showed a leak of 2-5 mm in 6.5 % and a thrombus in 2.5 %. One patient had a leak of > 5 mm. LARIAT effectively closes the LAA, and has acceptable procedural risks with the evolution of the use of the MP needle for pericardial access and colchicine to mitigate the post-inflammatory response associated with LAA ligation and pericardial access.

Catheter ablation reduces ventricular tachycardia (VT) recurrence and implantable cardioverter defibrillator shocks in patients with VT and ischemic cardiomyopathy. The most effective catheter ablation technique is unknown. This study determined rates of VT recurrence in patients undergoing ablation limited to clinical VT along with mappable VTs ("clinical ablation") versus substrate-based ablation. Subjects with ischemic cardiomyopathy and hemodynamically tolerated VT were randomized to clinical ablation (n = 60) versus substrate-based ablation that targeted all "abnormal" electrograms in the scar (n = 58). Primary endpoint was recurrence of VT. Secondary endpoints included periprocedural complications, 12-month mortality, and rehospitalizations. At 12-month follow-up, 9 (15.5%) and 29 (48.3%) patients had VT recurrence in substrate-based and clinical VT ablation groups, respectively (log-rank…

ABSTRACT Introduction: In patients who undergo cardiac device (ICD) implantation for primary prevention of sudden cardiac death (SCD), data is unclear if their generator needs to be replaced at end of life if their ejection fraction improves. Despite improvement in EF however, the underlying scar may remain the same.Methods: A retrospective study was performed at two high volume centers. Data on 280 patients who underwent ICD implantation for primary prevention of SCD was obtained after excluding patients with incomplete follow-up data. These patients were followed until November 2013 for any improvement in EF and if they underwent a generator change at device ERI. All arrhythmic events and appropriate and inappropriate shocks/ATP were all recorded. Mortality records were obtained from social security death index and chart review.Results: Thirty percent (n=86/280) of patients improved their EF to > 35% of which 41% (n=36) underwent a generator change by the study ending period for ERI/lead malfunction/infection issues with the rest not yet at ERI. Mean baseline EF in patients with and without EF improvement was 26±7% and 23±7%, p=0.2. Data for arrhythmic events was unavailable in n=25 patients in those with EF improvement and n =39 patients in those without EF improvement. Among the remaining 61 patients, appropriate events (shock+ATP) were noted in 22% of patients (n=14/61) and inappropriate shocks and ATP in 6% of (n=4/61) patients after their EF improved to > 35%. Two patients received a prior shock when their EF was low. In contrast, in patients who had no improvement in EF, 31% (n=48/155) received an appropriate event (p=<0.01) while 14% (n=22/155) (p<0.02) received inappropriate shocks and ATP. All-cause mortality in patients without subsequent improvement in EF versus those with EF improvement (38% vs. 17% (p=.006). Mean time to EF improvement was 44±35 months and mean duration of follow-up since EF improvement was 38±27 months.Conclusions: Although patients with improvement in EF had fewer total events (ATP+shock) than those without improvement, the percentage of patients with ICD therapy post EF improvement with no prior ICD discharges is high enough (20%, n=12/59) to warrant an ICD despite EF improvement.

Left atrial appendage (LAA) can be effectively and safely excluded using a novel percutaneous LARIAT ligation system. However, due to pericardial catheter manipulation and LAA ligation and subsequent necrosis, post-procedural course is complicated by pericarditis. We intended to evaluate the pre-procedural use of colchicine on the incidence of post-procedural pericardial complications. In this multicenter observational study, we included all consecutive patients who underwent LARIAT procedure at the participating centers. Many patients received peri-procedural colchicine at the discretion of the physician. We compared the post-procedural outcomes of patients who received prophylactic peri-procedural colchicine (colchicine group) with those who did not receive colchicine (standard group). A total of 344 consecutive patients, 243 in "colchicine group" and 101 in "standard group" were included. The mean age, median CHADS2VASc score and HASBLED scores were 70±11 year...

Background: Staphylococcus aureus bacteremia (SAB) is commonly associated with cardiac implantable electronic device infection (CIED-I). This usually requires explantation of the device. In cases of SAB in the presence of CIED that is not obviously infected (after examination of the pocket and transesophageal echocardiogram), decision about device removal is less clear. Predicting CIED-I in those cases would be helpful. Methods: This case-control study included all adults admitted to the University of Kansas Medical Center with SAB in the presence of a CIED between 1/1/2007 and 12/31/2012, using ICD 9 codes, CIED registry, and microbiology database. Cases had device infection evidenced by pocket infection or CIED related endocarditis; controls did not, over a 12 weeks follow up period. Clinical predictors of CIED-I were evaluated using logistic regression. Mortality was evaluated at 30 and 365 days. Results: We identified 64 patients with CIED who had 70 separate episodes of SAB dur...

Whether in patients with paroxysmal atrial fibrillation (PAF) ablation of non-pulmonary vein triggers after antral pulmonary vein isolation (PVAI) improves the long-term outcome in patients with LV systolic dysfunction (LVSD) is unknown. We sought to evaluate whether a more extensive ablation improve outcomes at follow up. Consecutive patients with PAF refractory to AADs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: Group I patients with LVEF ≤ 35% (N = 175) and Group II patients with LVEF ≥ 50% (N = 545). Patients in Group I were further divided according to whether additional ablation of non-PV triggers was performed (Group IA, N = 88) or not (Group IB, N = 87). Long-term ablation success off AAD after a single procedure was analyzed. Patients in Group I had more non-PV triggers than patients in Group II (69.1% vs. 26.6%; p < 0.001). During a follow-up of 15.8 ± 4.7 months, less patients in Group I remained free from recurrences compared to Group II (53.7% vs. 81.7% p < 0.001). Group IA long-term ablation success was higher compared to Group IB (75.0% vs. 32.2%, p < 0.001), and similar to Group II (75.0% vs. 81.7%, p = 0.44). In the multivariate analysis, LVEF ≤ 35% (hazard ratio [HR], 1.68; p = 0.003), and non-PV triggers (HR, 3.12; p…