Publications by authors named "Mark M Gallagher"

87 Publications

Preventing esophageal complications from atrial fibrillation ablation: A review.

Heart Rhythm O2 2021 Dec 22;2(6Part A):651-664. Epub 2021 Sep 22.

Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom.

Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review. Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed. The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation.
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http://dx.doi.org/10.1016/j.hroo.2021.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8703125PMC
December 2021

Cost-effectiveness of catheter ablation versus medical therapy for the treatment of atrial fibrillation in the United Kingdom.

J Cardiovasc Electrophysiol 2021 Dec 11. Epub 2021 Dec 11.

Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK.

Introduction: Research evidence has shown that catheter ablation is a safe and superior treatment for atrial fibrillation (AF) compared to medical therapy, but real-world practice has been slow to adopt an early interventional approach. This study aims to determine the cost effectiveness of catheter ablation compared to medical therapy from the perspective of the United Kingdom.

Methods: A patient-level Markov health-state transition model was used to conduct a cost-utility analysis. The population included patients previously treated for AF with medical therapy, including those with heart failure (HF), simulated over a lifetime horizon. Data sources included published literature on utilization and cardiovascular event rates in real world patients, a systematic literature review and meta-analysis of randomized controlled trials for AF recurrence, and publicly available government data/reports on costs.

Results: Catheter ablation resulted in a favorable incremental cost-effectiveness ratio (ICER) of £8614 per additional quality adjusted life years (QALY) gained when compared to medical therapy. More patients in the medical therapy group failed rhythm control at any point compared to catheter ablation (72% vs. 24%) and at a faster rate (median time to treatment failure: 3.8 vs. 10 years). Additionally, catheter ablation was estimated to be more cost-effective in patients with AF and HF (ICER = £6438) and remained cost-effective over all tested time horizons (10, 15, and 20 years), with the ICER ranging from £9047-£15 737 per QALY gained.

Conclusion: Catheter ablation is a cost-effective treatment for atrial fibrillation, compared to medical therapy, from the perspective of the UK National Health Service.
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http://dx.doi.org/10.1111/jce.15317DOI Listing
December 2021

Hourly variability in outflow tract ectopy as a predictor of its site of origin.

J Cardiovasc Electrophysiol 2022 01 25;33(1):7-16. Epub 2021 Nov 25.

St George's University of London, Cranmer Terrace, London, UK.

Introduction: Before ablation, predicting the site of origin (SOO) of outflow tract ventricular arrhythmia (OTVA), can inform patient consent and facilitate appropriate procedural planning. We set out to determine if OTVA variability can accurately predict SOO.

Methods: Consecutive patients with a clear SOO identified at OTVA ablation had their prior 24-h ambulatory ECGs retrospectively analysed (derivation cohort). Percentage ventricular ectopic (VE) burden, hourly VE values, episodes of trigeminy/bigeminy, and the variability in these parameters were evaluated for their ability to distinguish right from left-sided SOO. Effective parameters were then prospectively tested on a validation cohort of consecutive patients undergoing their first OTVA ablation.

Results: High VE variability (coefficient of variation ≥0.7) and the presence of any hour with <50 VE, were found to accurately predict RVOT SOO in a derivation cohort of 40 patients. In a validation cohort of 29 patients, the correct SOO was prospectively identified in 23/29 patients (79.3%) using CoV, and 26/29 patients (89.7%) using VE < 50. Including current ECG algorithms, VE < 50 had the highest Youden Index (78), the highest positive predictive value (95.0%) and the highest negative predictive value (77.8%).

Conclusion: VE variability and the presence of a single hour where VE < 50 can be used to accurately predict SOO in patients with OTVA. Accuracy of these parameters compares favorably to existing ECG algorithms.
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http://dx.doi.org/10.1111/jce.15295DOI Listing
January 2022

Preventing fatal injury to the Superior Vena Cava.

Ann Thorac Surg 2021 Nov 15. Epub 2021 Nov 15.

German Heart Center Berlin, Germany.

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http://dx.doi.org/10.1016/j.athoracsur.2021.10.019DOI Listing
November 2021

Persistent left superior vena cava transvenous lead extraction: A European experience.

J Cardiovasc Electrophysiol 2022 Jan 22;33(1):102-108. Epub 2021 Nov 22.

Department of Cardiology, St George's University Hospital, London, UK.

Background: Transvenous lead extraction (TLE) is rising in parallel to cardiac implantable electronic device implantations. Persistent left side superior vena cava (PLSVC) is a relatively common anatomical variant in the healthy population; TLE in patients with a PLSVC is rare.

Method: Data were collated from 6 European TLE institutes of 10 patients who had undergone lead extraction with a PLSVC. Patient demographics, procedural challenges and outcomes were reported.

Results: Ten patients aged 73.4 ± 7.8 years (60% male) underwent TLE of 20 leads (3 left ventricle, 10 right ventricle, 7 right atrium) with dwell time of 82.95 ± 39.1 months. Of the 10 cases, 4 had an infection indication and 5 were biventricular system extractions; 25% of the extracted leads were defibrillator leads. The majority of the procedures were completed in the cardiac catheterization suite (80%) under general anaesthesia (60%) by cardiologists (80%) using a rotational powered sheath (65%). The Tandem approach was used successfully in 3 cases. Complete procedural success was obtained in 100% of cases in the absence of complications within 127.4 ± 74.7 min. There was no 30-day mortality.

Conclusion: TLE in PLSVC is feasible albeit rare. Standard extraction techniques in experienced hands are associated with favorable outcomes; the Tandem procedure may be an additional technique to improve the safety and efficacy of TLE in PLSVC.
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http://dx.doi.org/10.1111/jce.15290DOI Listing
January 2022

Subcutaneous implantable cardioverter-defibrillator: the impedance of air.

Europace 2022 Jan;24(1):30-31

Department of Cardiology, Royal Surrey County Hospital NHS Trust, Surrey, UK.

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http://dx.doi.org/10.1093/europace/euab149DOI Listing
January 2022

Innovative Cardiac Resynchronization: Deployable Lead as an Anchor to Facilitate Guidewire Advancement.

JACC Case Rep 2021 Apr 3;3(4):594-596. Epub 2021 Mar 3.

St. George's University Hospital, London, United Kingdom.

An acutely angulated coronary sinus ostium coupled with a dilated right atrium presents technical challenges for cardiac resynchronization therapy (CRT) implantation. Innovative use of a deployable left ventricle lead as an anchor to support guidewire navigation within the cardiac venous system permits optimal CRT deployment. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302769PMC
April 2021

Subacute left main stem thrombus in COVID-19: a case report.

Eur Heart J Case Rep 2021 Jun 26;5(6):ytab222. Epub 2021 Jun 26.

Department of Cardiology, Ashford and St Peter's Hospitals NHS trust, Guildford road, Surrey, KT16 0PZ, UK.

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http://dx.doi.org/10.1093/ehjcr/ytab222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274640PMC
June 2021

Prevalence of bradyarrhythmias needing pacing in COVID-19.

Pacing Clin Electrophysiol 2021 08 19;44(8):1340-1346. Epub 2021 Jul 19.

Cardiology, St George's University Hospital NHS trust, London, UK.

Background: The Sars-Cov-2 infection is a multisystem illness that can affect the cardiovascular system. Tachyarrhythmias have been reported but the prevalence of bradyarrhythmia is unclear. Cases have been described of transient high-degree atrioventricular (AV) block in COVID-19 that were managed conservatively.

Method: A database of all patients requiring temporary or permanent pacing in two linked cardiac centers was used to compare the number of procedures required during the first year of the pandemic compared to the corresponding period a year earlier. The database was cross-referenced with a database of all patients testing positive for Sars-Cov-2 infection in both institutions to identify patients who required temporary or permanent pacing during COVID-19.

Results: The number of novel pacemaker implants was lower during the COVID-19 pandemic than the same period the previous year (540 vs. 629, respectively), with a similar proportion of high-degree AV block (38.3% vs. 33.2%, respectively, p = .069). Four patients with the Sars-Cov-2 infection had a pacemaker implanted for high-degree AV block, two for sinus node dysfunction. Of this cohort of six patients, two succumbed to the COVID-19 illness and one from non-COVID sepsis. Device interrogation demonstrated a sustained pacing requirement in all cases.

Conclusion: High-degree AV block remained unaltered in prevalence during the COVID-19 pandemic. There was no evidence of transient high-degree AV block in patients with the Sars-Cov-2 infection. Our experience suggests that all clinically significant bradyarrhythmia should be treated by pacing according to usual protocols regardless of the COVID status.
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http://dx.doi.org/10.1111/pace.14313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8447422PMC
August 2021

Transvenous lead extraction: The influence of age on patient outcomes in the PROMET study cohort.

Pacing Clin Electrophysiol 2021 Sep 5;44(9):1540-1548. Epub 2021 Aug 5.

Cardiology, St. George's University Hospitals, London, UK.

Background: Cardiac implantable electronic device (CIED) therapy contributes to an improvement in morbidity and mortality across all patient demographics. Patient age is a recognized risk factor for unfavorable outcomes in invasive procedures. This is the largest series of non-laser transvenous lead extraction (TLE) evaluating the association between patient age and procedure outcomes.

Methods: Data of 2205 (3849 leads) patients was collected retrospectively from six European TLE centers between January 2005-December 2018 in the PROMET study. Of these, 153 patients with 319 leads were excluded for incomplete data. A comparison of outcomes was performed between the age groups young [< 50 years], young intermediate [50-69 years], older intermediate [70-79 years], and octogenarian [≥80 years].

Results: Infection was most common indication for TLE in the octogenarian cohort, less common in the younger population (60.1% vs. 33.2%, respectively, p < .01). High-voltage leads were extracted most frequently from young patients, less frequently from octogenarians (31.6% vs. 10%, p < .001), while the opposite was evident for pacemaker leads (p < .001). Rotational sheath use was equally prevalent across all patient groups (p = .79). Minor and major complications across all the age groups were statistically similar, as was procedural success; the 30-day mortality was most significant in the octogenarian and least in the young patients (4.9% vs. 0.4%, p = .005). Propensity matching multivariate analysis found systemic infection, lead dwell time, and patient age (p = .013, OR 1.064 [1.013-1.116]) increased risk of 30-day mortality.

Conclusion: TLE is safe and effective across all age groups. 30-day mortality risk is significantly higher in the older patients.
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http://dx.doi.org/10.1111/pace.14310DOI Listing
September 2021

Performance and outcomes of transvenous rotational lead extraction: Results from a prospective, monitored, international clinical study.

Heart Rhythm O2 2021 Apr 2;2(2):113-121. Epub 2021 Mar 2.

Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.

Background: Transvenous lead extraction (TLE) plays a critical role in managing patients with cardiovascular implantable electronic devices. Mechanical TLE tools, including rotational sheaths, are used to overcome fibrosis and calcification surrounding leads. Prospective clinical data are limited regarding the safety and effectiveness of use of mechanical TLE devices, especially rotational tools.

Objective: To prospectively investigate the safety and effectiveness of mechanical TLE in real-world usage.

Methods: Patients were enrolled at 10 sites in the United States and Europe to evaluate the use of mechanical TLE devices. Clinical success, complete procedural success, and complications were evaluated through follow-up (median, 29 days). Patient data were source verified and complications were adjudicated by an independent clinical events committee (CEC).

Results: Between October 2018 and January 2020, mechanical TLE tools, including rotational sheaths, were used to extract 460 leads with a median indwell time of 7.4 years from 230 patients (mean age 64.3 ± 14.4 years). Noninfectious indications for TLE were more common than infectious indications (61.5% vs 38.5%, respectively). The extracted leads included 305 pacemaker leads (66.3%) and 155 implantable cardioverter-defibrillator leads (33.7%), including 85 leads with passive fixation (18.5%). A bidirectional rotational sheath was needed for 368 leads (88.0%). Clinical success was obtained in 98.7% of procedures; complete procedural success was achieved for 96.3% of leads. CEC-adjudicated device-related major complications occurred in 6 of 230 (2.6%) procedures. No isolated superior vena cava injury or procedural death occurred.

Conclusion: This prospective clinical study demonstrates that use of mechanical TLE tools, especially bidirectional rotational sheaths, are effective and safe.
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http://dx.doi.org/10.1016/j.hroo.2021.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183877PMC
April 2021

'Close' cardiac monitoring: life-threatening complication of a loop recorder implant.

Europace 2021 09;23(9):1492

Cardiology department, Ashford and St Peter's Hospital NHS trust, Surrey, KT16 0PZ, UK.

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http://dx.doi.org/10.1093/europace/euab086DOI Listing
September 2021

To the Editor-A double-blind case study?

HeartRhythm Case Rep 2021 Apr 6;7(4):259. Epub 2021 Feb 6.

Department of Cardiological Sciences, St. George's Hospital Medical School, London, UK.

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http://dx.doi.org/10.1016/j.hrcr.2021.01.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129052PMC
April 2021

Prolonged QT predicts prognosis in COVID-19.

Pacing Clin Electrophysiol 2021 05 13;44(5):875-882. Epub 2021 Apr 13.

Department of Cardiology, Ashford and St Peter's NHS trust, Chertsey, Surrey, UK.

Background: Coronavirus disease-2019 (COVID-19) causes severe illness and multi-organ dysfunction. An abnormal electrocardiogram is associated with poor outcome, and QT prolongation during the illness has been linked to pharmacological effects. This study sought to investigate the effects of the COVID-19 illness on the corrected QT interval (QTc).

Method: For 293 consecutive patients admitted to our hospital via the emergency department for COVID-19 between 01/03/20 -18/05/20, demographic data, laboratory findings, admission electrocardiograph and clinical observations were compared in those who survived and those who died within 6 weeks. Hospital records were reviewed for prior electrocardiograms for comparison with those recorded on presentation with COVID-19.

Results: Patients who died were older than survivors (82 vs 69.8 years, p < 0.001), more likely to have cancer (22.3% vs 13.1%, p = 0.034), dementia (25.6% vs 10.7%, p = 0.034) and ischemic heart disease (27.8% vs 10.7%, p < 0.001). Deceased patients exhibited higher levels of C-reactive protein (244.6 mg/L vs 146.5 mg/L, p < 0.01), troponin (1982.4 ng/L vs 413.4 ng/L, p = 0.017), with a significantly longer QTc interval (461.1 ms vs 449.3 ms, p = 0.007). Pre-COVID electrocardiograms were located for 172 patients; the QTc recorded on presentation with COVID-19 was longer than the prior measurement in both groups, but was more prolonged in the deceased group (448.4 ms vs 472.9 ms, pre-COVID vs COVID, p < 0.01). Multivariate Cox-regression analysis revealed age, C-reactive protein and prolonged QTc of >455 ms (males) and >465 ms (females) (p = 0.028, HR 1.49 [1.04-2.13]), as predictors of mortality. QTc prolongation beyond these dichotomy limits was associated with increased mortality risk (p = 0.0027, HR 1.78 [1.2-2.6]).

Conclusion: QTc prolongation occurs in COVID-19 illness and is associated with poor outcome.
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http://dx.doi.org/10.1111/pace.14232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251438PMC
May 2021

Leadless cardiac resynchronization therapy: a distant Utopia.

Europace 2021 05;23(5):817

Department of Cardiology, St George's University Hospital, Blackshaw Road, London SW17 0RE, UK.

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http://dx.doi.org/10.1093/europace/euab057DOI Listing
May 2021

Mechanical deviation of the esophagus: Not an easy concept to swallow.

J Cardiovasc Electrophysiol 2021 04 2;32(4):1209-1210. Epub 2021 Mar 2.

Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1111/jce.14960DOI Listing
April 2021

Percutaneous management of lead-related cardiac perforation with limited use of computed tomography and cardiac surgery.

Pacing Clin Electrophysiol 2021 04 8;44(4):614-624. Epub 2021 Mar 8.

Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.

Background: Cardiac implantable electronic device (CIED)-related perforation is uncommon but potentially lethal. Management typically includes the use of computed tomography (CT) scanning and often involves cardiac surgery.

Methods: Patients presenting to a single referral centre with CIED-related cardiac perforation between 2013 and 2019 were identified. Demographics, diagnostic modalities, the method of lead revision, and 30-day complications were examined.

Results: A total of 46 cases were identified; median time from implantation to diagnosis was 14 days (interquartile range = 4-50). Most were females (29/46, 63%), 9/46 (20%) had cancer, 18 patients (39%) used oral anticoagulants, and no patients had prior cardiac surgery. Active fixation was involved in 98% of cases; 9% involved an implantable cardioverter defibrillator lead. Thirty-seven leads perforated the right ventricle (apex: 24) and 9 punctured the right atrium (lateral wall: 5). Abnormal electrical parameters were noted in 95% of interrogated cases. Perforation was visualized in 41% and 6% of cases with chest X-ray (CXR) and transthoracic echocardiography, respectively. CXR revealed a perforation, gross lead displacement, or left-sided pleural effusion in 74% of cases. Pericardial effusion occurred in 26 patients (57%) of whom 11 (24%) developed tamponade, successfully drained percutaneously. Pre-extraction CT scan was performed in 19 patients but was essential in four cases. Transvenous lead revision (TLR) was successfully performed in all cases with original leads repositioned in six patients, without recourse to surgery. Thirty-day mortality and complications were low (0% and 26%, respectively).

Conclusion: CT scanning provides incremental diagnostic value in a minority of CIED-related perforations. TLR is a safe and effective strategy.
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http://dx.doi.org/10.1111/pace.14204DOI Listing
April 2021

Subcutaneous or Transvenous Defibrillator Therapy.

N Engl J Med 2021 02;384(7):677

St. George's University Hospitals NHS Foundation Trust, London, United Kingdom

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http://dx.doi.org/10.1056/NEJMc2034917DOI Listing
February 2021

Finding the heart of the problem: A letter to the editor on 'Detection of oesophageal course during left atrial ablation' by Santoro et al.

Indian Pacing Electrophysiol J 2021 Mar-Apr;21(2):137. Epub 2021 Feb 9.

Department of Cardiological Sciences, St. George's Hospital Medical School, London, UK.

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http://dx.doi.org/10.1016/j.ipej.2021.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952889PMC
February 2021

Multi-lead cephalic venous access and long-term performance of high-voltage leads.

J Cardiovasc Electrophysiol 2021 04 18;32(4):1131-1139. Epub 2021 Feb 18.

Department of Cardiology, St George's University Hospital, London, UK.

Background: Cardiac resynchronization therapy-defibrillator (CRT-D) implantation via the cephalic vein is feasible and safe. Recent evidence has suggested a higher implantable cardioverter-defibrillator (ICD) lead failure in multi-lead defibrillator therapy via the cephalic route. We evaluated the relationship between CRT-D implantation via the cephalic and ICD lead failure.

Methods: Data was collected from three CRT-D implanting centers between October 2008 and September 2017. In total 633 patients were included. Patient and lead characteristics with ICD lead failure were recorded. Comparison of "cephalic" (ICD lead via cephalic) versus "non-cephalic" (ICD lead via non-cephalic route) cohorts was performed. Kaplan-Meier survival and a Cox-regression analysis were applied to assess variables associated with lead failure.

Results: The cephalic and non-cephalic cohorts were equally male (81.9% vs. 78%; p = .26), similar in age (69.7 ± 11.5 vs. 68.7 ± 11.9; p = .33) and body mass index (BMI) (27.7 ± 5.1 vs. 27.1 ± 5.7; p = .33). Most ICD leads were implanted via the cephalic vein (73.5%) and patients had a mean of 2.9 ± 0.28 leads implanted via this route. The rate of ICD lead failure was low and statistically similar between both groups (0.36%/year vs. 0.13%/year; p = .12). Female gender was more common in the lead failure cohort than non-failure (55.6% vs. 17.9%, respectively; p = .004) as was hypertension (88.9% vs. 54.2%, respectively, p = .038). On multivariate Cox-regression, female sex (p = .008; HR, 7.12 [1.7-30.2]), and BMI (p = .047; HR, 1.12 [1.001-1.24]) were significantly associated with ICD lead failure.

Conclusion: CRT-D implantation via the cephalic route is not significantly associated with premature ICD lead failure. Female gender and BMI are predictors of lead failure.
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http://dx.doi.org/10.1111/jce.14939DOI Listing
April 2021

Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study.

Europace 2021 02;23(2):205-215

Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK.

Aims: Thermal injury to the oesophagus is an important cause of life-threatening complication after ablation for atrial fibrillation (AF). Thermal protection of the oesophageal lumen by infusing cold liquid reduces thermal injury to a limited extent. We tested the ability of a more powerful method of oesophageal temperature control to reduce the incidence of thermal injury.

Methods And Results: A single-centre, prospective, double-blinded randomized trial was used to investigate the ability of the ensoETM device to protect the oesophagus from thermal injury. This device was compared in a 1:1 randomization with a control group of standard practice utilizing a single-point temperature probe. In the protected group, the device maintained the luminal temperature at 4°C during radiofrequency (RF) ablation for AF under general anaesthesia. Endoscopic examination was performed at 7 days post-ablation and oesophageal injury was scored. The patient and the endoscopist were blinded to the randomization. We recruited 188 patients, of whom 120 underwent endoscopy. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 vs. 2/60; P = 0.008), with a trend toward reduction in gastroparesis (6/60 vs. 2/60, P = 0.27). There was no difference between groups in the duration of RF or in the force applied (P value range= 0.2-0.9). Procedure duration and fluoroscopy duration were similar (P = 0.97, P = 0.91, respectively).

Conclusion: Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared with standard care. This method of oesophageal protection is safe and does not compromise the efficacy or efficiency of the ablation procedure.
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http://dx.doi.org/10.1093/europace/euaa276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868886PMC
February 2021

Multi-catheter cryotherapy compared with radiofrequency ablation in long-standing persistent atrial fibrillation: a randomized clinical trial.

Europace 2021 03;23(3):370-379

Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK.

Aims: Restoring sinus rhythm (SR) by ablation alone is an endpoint used in radiofrequency (RF) ablation for long-standing persistent atrial fibrillation (AF) but not with cryotherapy. The simultaneous use of two cryotherapy catheters can improve ablation efficiency; we compared this with RF ablation in chronic persistent AF aiming for termination to SR by ablation alone.

Methods And Results: Consecutive patients undergoing their first ablation for persistent AF of >6 months duration were screened. A total of 100 participants were randomized 1:1 to multi-catheter cryotherapy or RF. For cryotherapy, a 28-mm Arctic Front Advance was used in tandem with focal cryoablation catheters. Open-irrigated, non-force sensing catheters were used in the RF group with a 3D mapping system. Pulmonary vein (PV) isolation and non-PV triggers were targeted. Participants were followed up at 6 and 12 months, then yearly. Acute PVI was achieved in all cases. More patients in the multi-catheter cryotherapy group were restored to SR by ablation alone, with a shorter procedure duration. Sinus rhythm continued to the last available follow-up in 16/49 patients (33%) in the multi-catheter at 3.0 ± 1.6 years post-ablation and in 12/50 patients (24%) in the RF group at 4.0 ± 1.2 years post-ablation. The yearly rate of arrhythmia recurrence was similar.

Conclusion: Multi-catheter cryotherapy can restore SR by ablation alone in more cases and more quickly than RF ablation. Long-term success is difficult to achieve by either methods and is similar with both.
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http://dx.doi.org/10.1093/europace/euaa289DOI Listing
March 2021

Why just detect? We can protect: A letter to the authors of "Prevention of left atrium esophagus fistula".

Pacing Clin Electrophysiol 2021 02 28;44(2):406-407. Epub 2021 Jan 28.

Cardiology Clinical Academic Group, St George's University Hospitals NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1111/pace.14087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898476PMC
February 2021

Electrophysiology in the time of coronavirus: coping with the great wave.

Europace 2020 12;22(12):1841-1847

Cardiology Clinical Academic Group, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK.

Aims: To chart the effect of the COVID-19 pandemic on the activity of interventional electrophysiology services in affected regions.

Methods And Results: We reviewed the electrophysiology laboratory records in three affected cities: Wenzhou in China, Milan in Italy, and London in the UK. We inspected catheter lab records and interviewed electrophysiologists in each centre to gather information on the impact of the pandemic on working patterns and on the health of staff members and patients. There was a striking decline in interventional electrophysiology activity in each of the centres. The decline occurred within a week of the recognition of widespread community transmission of the virus in each region and shows a striking correlation with the national figures for new diagnoses of COVID-19 in each case. During the period of restriction, workflow dropped to <5% of normal, consisting of emergency cases only. In two of three centres, electrophysiologists were redeployed to perform emergency work outside electrophysiology. Among the centres studied, only Wenzhou has seen a recovery from the restrictions in activity. Following an intense nationwide programme of public health interventions, local transmission of COVID-19 ceased to be detectable after 18 February allowing the electrophysiology service to resume with a strict testing regime for all patients.

Conclusion: Interventional electrophysiology is vulnerable to closure in times of great social difficulty including the COVID-19 pandemic. Intense public health intervention can permit suppression of local disease transmission allowing resumption of some normal activity with stringent precautions.
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http://dx.doi.org/10.1093/europace/euaa185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543596PMC
December 2020

Esophageal cooling for protection: an innovative tool that improves the safety of atrial fibrillation ablation.

Expert Rev Med Devices 2020 Oct 21;17(10):981-982. Epub 2020 Sep 21.

Cardiology Clinical Academic Group, St George's NHS Foundation Trust , London, UK.

This letter to the editor concerns the article: 'Innovative tools for atrial fibrillation ablation' by Rottner et al., published in the journal on 13th of May 2020. We read the article with great interest and congratulate the authors on an impressively detailed summary of the current tools and technological advances in atrial fibrillation ablation. Improving the safety of this procedure is very important due to widespread clinical practice and the increasing demand for this procedure. We would like to share further discussion with the authors and the journal's readership on current advances in improving the safety of this procedure - esophageal cooling. The results of a large randomized trial was recently presented, the IMPACT study (NCT03819946), which showed that a simple, standardized method of esophageal cooling with the ensoETM® device can significantly reduce esophageal thermal injury by 83.4%. Esophageal protection is important as esophageal injury has a high mortality rate to those that sustain this injury although the overall incidence is low. Rottner et al. discuss a much smaller study on esophageal cooling and the limitations of this study are also discussed.
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http://dx.doi.org/10.1080/17434440.2020.1824674DOI Listing
October 2020

Exclusively cephalic venous access for cardiac resynchronisation: A prospective multi-centre evaluation.

Pacing Clin Electrophysiol 2020 12 17;43(12):1515-1520. Epub 2020 Sep 17.

Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK.

Background: Small series has shown that cardiac resynchronisation therapy (CRT) can be achieved in a majority of patients using exclusively cephalic venous access. We sought to determine whether this method is suitable for widespread use.

Methods: A group of 19 operators including 11 trainees in three pacing centres attempted to use cephalic access alone for all CRT device implants over a period of 8 years. The access route for each lead, the procedure outcome, duration, and complications were collected prospectively. Data were also collected for 105 consecutive CRT device implants performed by experienced operators not using the exclusively cephalic method.

Results: A new implantation of a CRT device using exclusively cephalic venous access was attempted in 1091 patients (73.6% male, aged 73 ± 12 years). Implantation was achieved using cephalic venous access alone in 801 cases (73.4%) and using a combination of cephalic and other access in a further 180 (16.5%). Cephalic access was used for 2468 of 3132 leads implanted (78.8%). Compared to a non-cephalic reference group, complications occurred less frequently (69/1091 vs 12/105; P = .0468), and there were no pneumothoraces with cephalic implants. Procedure and fluoroscopy duration were shorter (procedure duration 118 ± 45 vs 144 ± 39 minutes, P < .0001; fluoroscopy duration 15.7 ± 12.9 vs 22.8 ± 12.2 minutes, P < .0001).

Conclusions: CRT devices can be implanted using cephalic access alone in a substantial majority of cases. This approach is safe and efficient.
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December 2020
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