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Heart Rhythm 2012. Nick Jackson. Boston. The 23 versus the 28mm cryoballoon. We followed 200 consecutive patients with paroxysmal (139 patients) and persistent AF (61 patients) for a median of 482 (20-1095) days following cryoballoon ablation.
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Heart Rhythm 2012 • Nick Jackson
The 23 versus the 28mm cryoballoon • We followed 200 consecutive patients with paroxysmal (139 patients) and persistent AF (61 patients) for a median of 482 (20-1095) days following cryoballoon ablation. • The 23mm balloon was used in 50 cases, the 28mm balloon in 146 cases and both were used in four cases. • Balloon use was by operator preference based primarily on the angiographic appearance of the veins at the time of the procedure.
Freezes per vein, vein diameter and mean temperature achieved
Isolation rates at initial and repeat procedure Mean procedure (128 vs 156 minutes, P <0.01) and fluroscopy (24 vs 35 minutes, P <0.01) times were also shorter with the 23 mm balloon.
The 23 versus the 28mm cryoballoon • The 23mm diameter cryoballoon achieved lower mean temperatures during ablation and greater rates of persistent pulmonary vein isolation at repeat procedure than the 28mm cryoballoon. • This translated into a significantly greater proportion of patients being free from symptomatic AF recurrence at two years in the 23mm balloon group. • There were no significant differences in the safety profiles of the two balloon sizes in this study and we feel therefore that the use of a 23mm cryoballoon is justified and may be beneficial when ablating patients with smaller pulmonary vein diameters.
Social networks • How do social networks affect health? • If you friends are obese there is a 45% higher likelihood of you being obese. • Friends that are up to 3 degrees of separation away from you influence your health and behaviour. • 4 or more degrees of separation away from you do not.
Social networks • Reasons for this association: • Induction: One person does it because another does. • Monophily: Birds of a feather flock together. • Confounding: People who are friends have the same exposures. • Can you then map obesity in a population and determine how this changes over time?
Social networks • Unable to show obesity spreading in waves over time in their population. Instead multi-centric spread of obesity. • Happiness also clusters in a similar way to obesity. • There is an emotional contaigen whereby if someone is nice to you -you are more likely to then be nice to the next person you see. And vica versa. • Networks have the effect of magnifying whatever they are seeded with eg. fascism, germs.
Social networks • Connections between people are important. • Some people keep friends from different areas apart and other bring them together.
Social networks • This creates the density of a group (how many connections). • In various situations different densities are more advantageous. Eg. broadway musicals perform best with an intermediate density of connections (people that new each other before). • Doctor connections -Januvia prescribing occurs with a 3 degrees of separation model. • Depending on where you are in the network (central or on the outside). The habits will reach you sooner or later.
Social networks • We have on average 6.1 friends and 110 facebook friends. • Facebook friends don’t have the same influence on you as your ‘real friends’. • Alyssa Milano tweeted about Dr. Christakis’ book... • There is a lot of information on line but less influence.
Social networks • Most people feel the benefits of a connected life outweigh the costs. • Your choices may have a ripple effect on those around you. • Social networks are needed for ‘goodness’ to flourish. • Manipulating networks -target a node or target links.
SCD-HeFT 10 year follow up • Sudden cardiac death in heart failure trial. • The largest, prospective, randomised multicentre ICD trial. Pts had EF <35% and NYHA class 2 or 3 symptoms. • 3 arms of study: ICD therapy, placebo, amiodarone. • Mortality data was available on 2291 pts (91%) with a median follow up of 11 years.
SCD-HeFT 10 year follow up • Absolute mortality benefit of a conservatively programmed shock only ICD was 5% over placebo (despite a significant number of patients crossing over to and ICD after the original trial was completed). • As in the original trial mortality benefit was greatest for pts with NYHA class II heart failure (NYHA class 3 pts did not have CRT in the original trial). • Ischaemic aetiology was also associated with a greater mortality benefit.
Competitive sports for ICD Patients • In the 2005 Bethesda conference moderate and high intensity sports were considered to be contraindicated for ICD pts. • Low intensity sports like golf, bowling, snooker were allowed. • In a registry of pts who chose to play competitive sports in spite of their ICD, there were no tachyarrhythmic deaths or externally resuscitated tachyarrhythmias during or after sport. • There were no injuries from arrhythmia or shock.
Competitive sports for ICD Patients • Concerns include that the device may not work properly during exercise, pts may be injured due to syncopal arrhythmia or shock or that the ICD or lead may be damaged. • There were 372 patients in this registry (10-60 years of age) followed for a median of 31 months. • 59% of patients had secondary prevention devices (HCM, LQT, ARVC and CAD were the most common diagnoses).
Competitive sports for ICD Patients • Most common sports pts were involved in were running, soccer, basketball and skiing/snowboarding. • 20.1% of pts received shocks during the study, including 37 who were shocked during sports. • Of those shocked 4 stopped playing sport altogether and 7 gave up at least one sport. • Pts in this study were obviously self selected and authors stress the need for individualised discussions with patients about the risks and benefits of sports participation.
RAAFT-2, catheter ablation first line in paroxysmal AF • 127 pts with AF not previously treated with AADs (87.5% paroxysmal) were randomised to RF ablation within 4-6 weeks or AADs within 90 days. • Patients had normal systolic function, none had hypertension of CCF. • Pts had an average of 47 episodes of AF in the previous 6 months. • Mean CHADS2 scores were 0.5 for RF and 0.7 for AADs.
RAAFT-2, catheter ablation first line in paroxysmal AF • In the ablation group 15.2% required an additional ablation. Seven pts went of AAD therapy. • In the AAD group 59% had to discontinue at least one AAD and 47.5% underwent catheter ablation during follow up. (AADs consisted mainly of flecainide or propafenone). • TTM was performed routinely twice a week and with symptoms and both groups were very compliant with this practice.
RAAFT-2, catheter ablation first line in paroxysmal AF • When the TTM was excluded 24% and 31% of pts met the primary endpoint in the ablation and AAD groups respectively (P=NS).
RAAFT-2, catheter ablation first line in paroxysmal AF • In the ablation group 7.7% of pts had a safety event (death, tamponade, PVS, thromboembolism, vascular complications, phrenic nerve injury or complete AV block within 30 days). (Tamponade was the dominant safety outcome). • In the AAD group 19.7% experienced a safety event (death, Torsade, bradycardia requiring PPM, syncope, QRS prolongation >50% from baseline, atrial flutter, or any other event leading to drug withdrawal). Drug withdrawal being the dominant safety outcome). • RAAFT investigators commented that most pts with paroxysmal AF will require more than one procedure and that this is by far more likely to occur within one year.
Safety and efficacy of a subcutaneous implantable defibrillator • Prospective, non-randomised, open label study for pts who met conventional criteria for ICD implantation or replacement who did not require pacing. • 321 pts, mean age 52. Primary prevention in 79%. • 61% of pts had CCF, 58% had hypertension, 41% had had an AMI. • Subcutaneous leadless defibrillator was approved for use in europe in 2009. • Acute VF testing was successful in 98.5% of patients.
Safety and efficacy of a subcutaneous implantable defibrillator • All 109 spontaneous VT/VF episodes were successfully treated. • The 180 day serious complication rate was 1%. • There were 18 suspected or confirmed infections (14 were managed without removing the device). • During follow up 38 pts received 39 inappropriate shocks (comparable to trans-venous ICD systems). • 8 pts died (seven unrelated to the device/procedure and one was undetermined).
Safety and efficacy of a subcutaneous implantable defibrillator • One shock occurred due to over-sensing and one device had premature battery depletion. • These results are in keeping with the EFFORTLESS S-ICD registry for pts who have received the device following approval in europe. • Advantages include ease of implant, fewer complications at implant without the need for trans-venous leads and probably fewer lead complications in the longer term. • Disadvantages include: Device does not provide a pacing function for bradycardia or ATP.
Echo guided CRT lead placement • 187 pts eligible for CRT based on LVEF, QRS duration and NYHA 2-4 HF were randomised to lead placement guided or not guided by speckle tracking echocardiography. (Follow up was 1.8 yrs). • The site of latest mechanical activation was determined by assessing the time to peak radial strain associated with myocardial wall thickening. • Procedure and fluroscopy times were similar in the two groups. • Echo guided placement at the exact myocardial target or adjacent to it was possible 85% of the time.
Echo guided CRT lead placement • Lead placement at the optimal site happened fortuitously without TTE, in 66% of pts.
Echo guided CRT lead placement • Both TTE guided lead placement and lead position at or near the target site considered separately lead to improved reverse re-modelling by several measures. • The presence of scar on the success of speckle tracking was not included in the current analysis. Scar position varied widely in patients with ischaemic CM (62% of the cohort). • Analysis on how taking myocardial scar position into account could further improve echo guided lead placement will be performed later.
