Publications by authors named "Samuel J Asirvatham"

552 Publications

Sub-mitral valve aneurysm ventricular tachycardia masquerading as arrhythmogenic right ventricular cardiomyopathy.

HeartRhythm Case Rep 2021 Sep 29;7(9):588-592. Epub 2021 May 29.

Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1016/j.hrcr.2021.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8441204PMC
September 2021

Doppler mean gradient is discordant to aortic valve calcium scores in patients with atrial fibrillation undergoing transcatheter aortic valve replacement.

J Am Soc Echocardiogr 2021 Sep 7. Epub 2021 Sep 7.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Background: Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared to sinus rhythm (SR). Whether AS is more advanced at the time of referral to aortic valve intervention in AF compared to SR is unknown. The aim of this study was to examine flow-independent computed tomography aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods: Patients who underwent TAVR from 2016-2020 for native valve severe AS with left ventricular ejection fraction ≥50% were identified from our institution TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared to AVCS (AVCS:MG ratio). AVCS were obtained within 90 days of the pre-TAVR echocardiogram.

Results: 633 patients were included; age 82 years [76-86] and 46% were female. AF was present in 109/633 (17%) and SR 524/633 (83%) during the echocardiogram. Aortic valve area index was slightly smaller in AF versus SR (0.43; interquartile range [IQR] 0.39-0.47 vs 0.46 cm/m; IQR 0.41-0.51, p=0.0003). Stroke volume index, trans-aortic flow rate, and MG were lower in AF (p<0.0001 for all). The AVCS were higher in men with AF compared to SR (3510; IQR 2803-4030 vs 2722 AU; IQR 2180-3467, p <0.0001) in HGAS, but not in LGAS. The AVCS were not different in women with AF versus SR. Overall AVCS:MG ratios were higher in AF versus SR in HGAS and LGAS (p<0.03 for all), except in women with LGAS.

Conclusion: AVCS were higher than expected by MG in AF compared to SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.
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http://dx.doi.org/10.1016/j.echo.2021.08.024DOI Listing
September 2021

Outcomes and periprocedural management of cardiac implantable electronic devices in patients with carcinoid heart disease.

Heart Rhythm 2021 Aug 21. Epub 2021 Aug 21.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocrine tumors that often requires surgical intervention. Data on cardiac implantable electronic device (CIED) implantation in patients with CHD are limited.

Objective: The purpose of this study was to evaluate the experience of CIED implantation in patients with CHD.

Methods: Patients with a diagnosis of CHD and a CIED procedure from January 1, 1995, through June 1, 2020, were identified using a Mayo Clinic proprietary data retrieval tool. Retrospective review was performed to extract relevant data, which included indications for implant, procedural details, complications, and mortality.

Results: A total of 27 patients (55.6% male; mean age at device implant 65.6 ± 8.8 years) with cumulative follow-up of 75 patient-years (median 1.1 years; interquartile range 0.4-4.6 years) were included for analysis. The majority of implanted devices were dual-chamber permanent pacemakers (63%). Among all CHD patients who underwent any cardiac surgery, the incidence of CIED implantation was 12%. The most common indication for implantation was high-grade heart block (66.7%). Device implant complication rates were modest (14.8%). No patient suffered carcinoid crisis during implantation, and there was no periimplant mortality. Median time from implant to death was 2.5 years, with 1-year mortality of 15%.

Conclusion: CHD is a morbid condition, and surgical valve intervention carries associated risks, particularly a high requirement for postoperative pacing needs. Our data suggest that CIED implantation can be performed relatively safely. Clinicians must be aware of the relevant carcinoid physiology and take appropriate precautions to mitigate risks.
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http://dx.doi.org/10.1016/j.hrthm.2021.08.021DOI Listing
August 2021

Electrogram-guided endomyocardial biopsy yield in patients with suspected cardiac sarcoidosis and relation to outcomes.

J Cardiovasc Electrophysiol 2021 Sep 9;32(9):2486-2495. Epub 2021 Aug 9.

Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

Objective: Endomyocardial biopsy (EMB) is a useful diagnostic tool though the yield may be limited in many myocardial diseases. Data on the diagnostic yield and prognostic significance of EMB guided by abnormal electrograms (EGM-Bx) in suspected cardiac sarcoidosis (CS) are scarce.

Methods: Seventy-nine patients (mean age: 56 ± 12 years; 61% men) with suspected CS based on clinical and imaging features underwent right or left ventricular EGM-Bx guided by electroanatomic mapping. Tissue samples were obtained from sites with abnormal EGMs and/or abnormal cardiac imaging. The diagnostic yield of EGM-Bx was evaluated in reference to histopathologic analysis. Left ventricular assist device (LVAD) and transplantation-free survival were compared between patients with positive and negative EGM-Bx for CS.

Results: A total of 254 samples were obtained from abnormal EGM sites, and 126 samples from normal EGM sites guided by pre-procedure imaging findings. Abnormal histopathology was noted in 65 (26%) and 10 (8%) samples from abnormal and normal EGM sites, respectively. Histopathology confirmed CS in 16 (20%) patients, while an alternative tissue diagnosis emerged in 10 (13%) patients. Abnormal EGMs at the biopsy site had sensitivity 89% and specificity 33% for a histopathologic diagnosis of CS. LVAD and transplantation-free survival were not significantly associated with the EGM-Bx result (log-rank p = .91).

Conclusion: In patients with suspected CS, abnormal EGM-Bx has high sensitivity and low specificity for establishing a definite CS diagnosis. Consideration of substrate abnormalities apparent on preprocedural imaging as an adjunct for selection of biopsy sites may further improve EGM-Bx yield.
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http://dx.doi.org/10.1111/jce.15191DOI Listing
September 2021

Comparing High-Frequency With Monophasic Electroporation Protocols in an In Vivo Beating Heart Model.

JACC Clin Electrophysiol 2021 Aug 30;7(8):959-964. Epub 2021 Jun 30.

Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Israel; Heart Center, Sheba Medical Center, Tel Hashomer, Israel. Electronic address:

This study compared monophasic 100-μs pulses with high-frequency electroporation (HF-EP) bursts using an in vivo animal model. Myocardial damage was evaluated by histologic analysis. Compared with 10 monophasic pulses, 20 bursts of HF-EP at 100 and 150 kHz were associated with less damage. However, when the number of HF-EP bursts was increased to 60, myocardial damage was comparable to that of the monophasic group. HF-EP protocols were associated with attenuated collateral muscle contractions. This study shows that HF-EP is feasible and effective and that pulse frequency has a significant effect on extent of ablation.
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http://dx.doi.org/10.1016/j.jacep.2021.05.003DOI Listing
August 2021

Infection Rate and Outcomes of Watchman Devices: Results from a Single-Center 14-Year Experience.

Biomed Hub 2021 May-Aug;6(2):59-62. Epub 2021 Jun 3.

Department of Cardiovascular Disease, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.

The Watchman device (WD) is a commonly used alternative strategy to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation who have an increased bleeding risk. There are rare case reports of WD-related infection. Currently, there is no formal study that has systematically evaluated the incidence and outcomes WD-related infections. The objective of this study was to evaluate the incidence, risk factors, and outcomes for WD-associated infections in a single-center cohort over a 14-year period. All patients who underwent WD implantation over a 14-year study period (July 2004 through December 2018) comprised our cohort. Baseline characteristics, procedural data, and postimplantation events were identified through a retrospective chart review. Primary study outcomes included WD-related infection, other cardiovascular device-related infection, bacteremia, and mortality. A total of 181 patients (119 males; 65.7%) with a mean age of 75 years at implantation were included in the analysis. A total of 534.7 patient years of follow-up was accrued, with an average of 2.9 years per patient. The most common indications for implantation included gastrointestinal bleeding (56 patients; 30.9%) and intracerebral bleeding (51 patients; 28.2%). During the follow-up period, 37 (20.4%) patients died. Six developed evidence of bacteremia. Only 1 developed an implantable cardioverter defibrillator infection that required a complete system extraction. None of the cohort developed a WD-related device infection during the study period. We concluded that there is a low risk of WD-related infection even in the setting of a blood stream infection.
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http://dx.doi.org/10.1159/000516400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215937PMC
June 2021

An under-recognized phenomenon: Myocardial volume change during the cardiac cycle.

Echocardiography 2021 08 4;38(8):1235-1244. Epub 2021 Jun 4.

Department of Cardiology, Mayo Clinic, Rochester, MN, USA.

Background: Myocardial volume is assumed to be constant over the cardiac cycle in the echocardiographic models used by professional guidelines, despite evidence that suggests otherwise. The aim of this paper is to use literature-derived myocardial strain values from healthy patients to determine if myocardial volume changes during the cardiac cycle.

Methods: A systematic review for studies with longitudinal, radial, and circumferential strain from echocardiography in healthy volunteers ultimately yielded 16 studies, corresponding to 2917 patients. Myocardial volume in systole (MVs) and diastole (MVd) was used to calculate MVs/MVd for each study by applying this published strain data to three models: the standard ellipsoid geometric model, a thin-apex geometric model, and a strain-volume ratio.

Results: MVs/MVd<1 in 14 of the 16 studies, when computed using these three models. A sensitivity analysis of the two geometric models was performed by varying the dimensions of the ellipsoid and calculating MVs/MVd. This demonstrated little variability in MVs/MVd, suggesting that strain values were the primary determinant of MVs/MVd rather than the geometric model used. Another sensitivity analysis using the 97.5th percentile of each orthogonal strain demonstrated that even with extreme values, in the largest two studies of healthy populations, the calculated MVs/MVd was <1.

Conclusions: Healthy human myocardium appears to decrease in volume during systole. This is seen in MRI studies and is clinically relevant, but this study demonstrates that this characteristic was also present but unrecognized in the existing echocardiography literature.
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http://dx.doi.org/10.1111/echo.15093DOI Listing
August 2021

Arrhythmia Recurrence After Atrial Fibrillation Ablation: Impact of Warfarin vs. Non-Vitamin K Antagonist Oral Anticoagulants.

Cardiovasc Drugs Ther 2021 May 18. Epub 2021 May 18.

Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Purpose: Both warfarin and non-vitamin K antagonist oral anticoagulants (NOACs) have pleiotropic effects including anti-inflammatory and anti-fibrotic properties. This study aims to explore whether arrhythmia recurrence after AF ablation is influenced by the choice of oral anticoagulant.

Methods: We retrospectively studied all patients who underwent primary AF ablation between 2011 and 2017 and divided them into two groups according to the anticoagulant used: Warfarin vs. NOACs. The primary endpoint was atrial tachyarrhythmia recurrence after ablation.

Results: Of the 1106 patients who underwent AF ablation in the study period (median age 62.5 years; 71.5% males, 48.2% persistent AF), 697 (63%) received warfarin and 409 (37%) received NOACs. After a median of 26.4 months follow-up, arrhythmia recurrence was noted in 368 patients in warfarin group and 173 patients in NOACs group, with a 1-year recurrence probability of 35% vs. 36% (log rank P = 0.81) and 5-year recurrence probability of 62% vs. 63% (Log rank P = 0.32). However, NOACs use was associated with a higher probability of recurrence (46% for 1 year, 68% for 5 years) in patients with persistent AF compared with those taking warfarin (34% for 1 year, 63% for 5 years; log rank P = 0.01 and P = 0.02 respectively). Multivariate analysis indicated that in patients with persistent AF, use of NOACs was an independent risk factor of atrial tachyarrhythmia recurrence after ablation (HR 1.39, 95% CI 1.07-1.81, P = 0.013).

Conclusion: In this large contemporary cohort, overall AF recurrence after ablation was similar with NOACs or warfarin use. However, in patients with persistent AF, NOACs use was associated with a higher probability of arrhythmia recurrence and was an independent risk factor of recurrence at long-term follow-up.
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http://dx.doi.org/10.1007/s10557-021-07200-3DOI Listing
May 2021

Hemodynamic Benefits From Left Atrial Pacing to Treat Interatrial Conduction Delay Following Atrial Fibrillation Ablation.

Circ Heart Fail 2021 May 30;14(5):e008191. Epub 2021 Apr 30.

Department of Cardiovascular Medicine (M.K.M., Y.N.V.R., S.J.A., R.A.N.), Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.008191DOI Listing
May 2021

Differentiating wide complex tachycardias: A historical perspective.

Indian Heart J 2021 Jan-Feb;73(1):7-13. Epub 2020 Sep 23.

Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA.

One of the most critical and challenging skills is the distinction of wide complex tachycardias into ventricular tachycardia or supraventricular wide complex tachycardia. Prompt and accurate differentiation of wide complex tachycardias naturally influences short- and long-term management decisions and may directly affect patient outcomes. Currently, there are many useful electrocardiographic criteria and algorithms designed to distinguish ventricular tachycardia and supraventricular wide complex tachycardia accurately; however, no single approach guarantees diagnostic certainty. In this review, we offer an in-depth analysis of available methods to differentiate wide complex tachycardias by retrospectively examining its rich literature base - one that spans several decades.
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http://dx.doi.org/10.1016/j.ihj.2020.09.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961210PMC
July 2021

Catheter Ablation in Patients With Neuroendocrine (Carcinoid) Tumors and Carcinoid Heart Disease: Outcomes, Peri-Procedural Complications, and Management Strategies.

JACC Clin Electrophysiol 2021 02 29;7(2):151-160. Epub 2020 Oct 29.

Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Objectives: This report describes a series of patients with neuroendocrine tumors with or without carcinoid heart disease undergoing catheter ablation at the authors' institution.

Background: Neuroendocrine (carcinoid) tumors are a rare form of neoplasm with the potential for systemic vasoactive effects and cardiac valvular involvement. These tumors can create peri-operative management challenges for the electrophysiologist. However, there are few data regarding ablation outcomes, periprocedural complications, and management of these patients.

Methods: All patients with neuroendocrine tumors undergoing catheter ablation at the Mayo Clinic, Rochester, Minnesota over a 25-year period were retrospectively reviewed. From this cohort, the type of arrhythmias ablated, the recurrence of arrhythmia, perioperative complications, and mortality were reviewed and analyzed.

Results: A total of 17 patients (52.9% male; mean age 62.4 ± 9.3 years) with neuroendocrine tumors underwent catheter ablation during the study period. Primary tumor sites included the gastrointestinal tract (n = 11), lung (n = 4), ovary (n = 1), and lymph node (n = 1). Nine patients had metastatic disease, 5 of whom were on somatostatin analog therapy at the time of ablation. Three patients had active symptoms of carcinoid syndrome at the time of ablation, and 2 of those patients had carcinoid heart disease. Ablations were performed mainly for atrial arrhythmias (76.5%): atrioventricular nodal re-entry tachycardia (n = 7), atrial fibrillation (n = 4), and atrial flutter (n = 2). Four patients underwent ablation of ventricular arrhythmias. During a mean follow-up of 19.2 ± 26.2 months, arrhythmia recurred in 35.3% of patients. Three patients (17.6%) had periprocedural complications: pericardial effusion (n = 1), groin site hematoma (n = 1), and carcinoid crisis (n = 1). No deaths were noted in the peri-operative period.

Conclusions: In a unique cohort of patients with neuroendocrine tumors, catheter ablation was feasible in patients with or without carcinoid syndrome. Carcinoid crisis may occur during the periprocedural period, which can be life-threatening, and a specified protocol for management is important to mitigate this risk.
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http://dx.doi.org/10.1016/j.jacep.2020.08.009DOI Listing
February 2021

Sinus rhythm heart rate increase after atrial fibrillation ablation is associated with lower risk of arrhythmia recurrence.

Pacing Clin Electrophysiol 2021 04 25;44(4):651-656. Epub 2021 Feb 25.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Background: Pulmonary vein isolation (PVI) with autonomic modulation may be more successful than PVI alone for atrial fibrillation (AF) ablation and may be signaled by changes in sinus rhythm heart rate (HR) post ablation. We sought to determine if a change in sinus rhythm HR predicted AF recurrence post PVI.

Methods: Patients who underwent AF ablation from 2000 to 2011 were included if sinus rhythm was noted on ECG within 90 days pre and 7 days post ablation. Basic ECG interval and HR changes were analyzed and outcomes determined.

Results: A total of 1152 patients were identified (74.3% male, mean age 57 ± 11 years). Mean AF duration was 5.2 ± 5.3 years. Paroxysmal AF was noted in 712 (61.8%) of the patients. Mean EF was 61% ± 6%. Sinus rhythm HR was 61 ± 11 pre-ablation and 76 ± 13 bpm post-ablation (27% ± 24% increase, p < .001). The ability of relative HR change post-ablation to predict AF recurrence was borderline (hazard ratio 0.65 [0.41-1.01], p = .067). With patients separated into quartiles based on the relative HR change, the upper quartile with the largest relative increase in HR had a significantly lower rate of AF recurrence compared to the lowest quartile following multi variable modeling (p = .038). There were significant changes in PR (171 ± 28 to 167 ± 30 ms) and QTc (424 ± 25 to 434 ± 29 ms) intervals (both p < .001) but these were not predictive of outcome.

Conclusion: Relative changes in HR post AF ablation correlates with AF recurrence. Further prospective studies are needed to confirm this relationship.
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http://dx.doi.org/10.1111/pace.14197DOI Listing
April 2021

Outcomes of cardiac resynchronization therapy in patients with chemotherapy-induced cardiomyopathy.

Pacing Clin Electrophysiol 2021 04 15;44(4):625-632. Epub 2021 Mar 15.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: Several chemotherapy agents are associated with the development of non-ischemic cardiomyopathy (NIC). When chemotherapy-induced cardiomyopathy (CHIC) is associated with left bundle branch block (LBBB) and a left ventricular ejection fraction (LVEF) 35% or lower, cardiac resynchronization therapy (CRT) is often utilized to improve cardiac function and relieve symptoms.

Objective: To determine the echocardiographic and clinical outcomes of CRT in patients with CHIC.

Methods: The study included 29 patients with CHIC (CHIC group) and 58 patients with other types of NIC (control group) who underwent CRT implantation between 2004 and 2017. The primary endpoints were changes in LVEF, left ventricular end-systolic diameter (LVESD), and left ventricular end-diastolic diameter (LVEDD) at 6-18 months after CRT. The secondary outcomes included changes in left ventricular global longitudinal strain (GLS), systolic strain rate (SRS), early diastolic strain rate (SRE), and overall survival.

Results: Out of 29 patients with CHIC, 62.1% received chemotherapy for lymphoma, 13.7% for breast cancer, and 24.1% for sarcoma. The agent implicated in 93.1% of the patients was an anthracycline. Half of the patients had LBBB. The mean baseline LVEF was 28% ± 8%. The mean baseline QRS duration was 146 ± 26 ms. Twenty-eight patients had post-CRT follow-up data. CRT was associated with improvement in echocardiographic outcomes in the CHIC group and the control group. There was no difference in overall survival between the two groups (log-rank p = .148).

Conclusion: CRT improves left ventricular function and reverses remodeling in patients with CHIC.
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http://dx.doi.org/10.1111/pace.14196DOI Listing
April 2021

Sound wave balloon-assisted device implantation: a novel approach that merits consideration.

Europace 2021 05;23(5):747

Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, USA.

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http://dx.doi.org/10.1093/europace/euaa281DOI Listing
May 2021

Efficacy of medical and ablation therapy for inappropriate sinus tachycardia: A single-center experience.

J Cardiovasc Electrophysiol 2021 04 24;32(4):1053-1061. Epub 2021 Feb 24.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: Effective therapy for inappropriate sinus tachycardia (IST) remains challenging with high rates of treatment failure and symptom recurrence. It is uncertain how effective pharmacotherapy and procedural therapy are long-term, with poor response to medical therapy in general.

Methods: We retrospectively reviewed all patients with the diagnosis of IST at a tertiary academic medical center from 1998 to 2018. We extracted data related to prescribing patterns and symptom response to medical therapy and sinus node modification (SNM), assessing efficacy and periprocedural complication rates.

Results: A total of 305 patients with a formal diagnosis of IST were identified, with 259 (84.9%) receiving at least one prescription medication related to the condition. Beta-blockers were the most commonly used medication (n = 245), with a majority of patients reporting no change or worsening of symptoms, and poor response was seen to other medication classes. Improvement was seen significantly more often with ivabradine than beta blockers, though the sample size was limited (p = .003). Fifty-five patients (18.0% of all IST patients), mean age 32.0 ± 9.1 years, underwent a SNM procedure, with an average of 1.8 ± 0.9 procedures per patient. Acute symptomatic improvement (<6 months) was seen in 58.2% of patients. Long-term complete resolution of symptoms was seen in 5.5% of patients, modest improvement in 29.1%, and no long-term benefit was seen in 65.5% of patients.

Conclusions: Among all medical therapies, there were high rates of treatment failure or symptom worsening in over three-quarters of patients in our study. Ivabradine was most beneficial, though the sample size was small. While most patients receiving SNM ablation for IST perceive an acute symptomatic improvement, almost two-thirds of patients have no long-term improvement, and resolution of symptoms is quite rare. AV node ablation with pacemaker implantation following lack of response to SNM offered increased success, though the sample size was limited.
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http://dx.doi.org/10.1111/jce.14942DOI Listing
April 2021

Liposomal bupivacaine during subcutaneous implantable cardioverter defibrillator implantation for pain management.

Pacing Clin Electrophysiol 2021 03 3;44(3):513-518. Epub 2021 Feb 3.

Department of cardiovascular diseases, Mayo Clinic Rochester, Rochester, Minnesota, USA.

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has a larger generator and its implantation involves more dissection and tunneling compared to traditional transvenous defibrillator system. Liposomal bupivacaine, an extended-release bupivacaine with 72 h of duration has been used for postoperative pain management in patients undergoing S-ICD implantation. Our aim was to compare postoperative pain and opioid prescription patterns among patients undergoing S-ICD implantation who received intraprocedural liposomal bupivacaine and those who did not.

Methods: We performed a retrospective analysis of all patients who underwent subcutaneous ICD implantation from January 1, 2013 to March 30, 2018 at the Mayo Clinic in Rochester, Minnesota. Patients were categorized into those who received liposomal bupivacaine and those who did not. Data on inpatient pain score, outpatient opioid prescription rates at discharge, and doses based on oral morphine equivalents (OME) were collected.

Results: A total of 104 patients underwent S-ICD implantation. Intraprocedural liposomal bupivacaine was used in 69% of patients. Patients who received intraprocedural liposomal bupivacaine had similar mean inpatient pain scores (2.9 vs. 2.9, p = .786). There was also no difference in the rate of inpatient opioid administration (79.2% vs. 87.5%, p = .4139), outpatient opioid prescription (23.6% vs. 12.5%, p = .29), or mean OME (41.7-mg vs. 16.6-mg, p = .188) when comparing patients those who received intraprocedural liposomal bupivacaine and those who did not.

Conclusion: Intraprocedural liposomal bupivacaine administration was not associated with any significant impact on postoperative pain scores, inpatient opioid administration, and outpatient opioid prescription rates or OME amounts at discharge.
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http://dx.doi.org/10.1111/pace.14175DOI Listing
March 2021

Sustained Improvement in Diastolic Reserve Following Percutaneous Pericardiotomy in a Porcine Model of Heart Failure With Preserved Ejection Fraction.

Circ Heart Fail 2021 02 22;14(2):e007530. Epub 2021 Jan 22.

Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN.

Background: Heart failure with preserved ejection fraction is increasing in prevalence, but few effective treatments are available. Elevated left ventricular (LV) diastolic filling pressures represent a key therapeutic target. Pericardial restraint contributes to elevated LV end-diastolic pressure, and acute studies have shown that pericardiotomy attenuates the rise in LV end-diastolic pressure with volume loading. However, whether these acute effects are sustained chronically remains unknown.

Methods: Minimally invasive pericardiotomy was performed percutaneously using a novel device in a porcine model of heart failure with preserved ejection fraction. Hemodynamics were assessed at baseline and following volume loading with pericardium intact, acutely following pericardiotomy, and then again chronically after 4 weeks. Cardiac structure was assessed by magnetic resonance imaging.

Results: The increase in LV end-diastolic pressure with volume loading was mitigated by 41% (95% CI, 27%-45%, <0.0001; ΔLV end-diastolic pressure reduced from +9±3 mm Hg to +5±3 mm Hg, =0.0003, 95% CI, -2.2 to -5.5). The effect was sustained at 4 weeks (+5±2 mm Hg, =0.28 versus acute). There was no statistically significant effect of pericardiotomy on ventricular remodeling compared with age-matched controls. None of the animals developed hemodynamic or pathological indicators of pericardial constriction or frank systolic dysfunction.

Conclusions: The acute hemodynamic benefits of pericardiotomy are sustained for at least 4 weeks in a swine model of heart failure with preserved ejection fraction, without excessive chamber remodeling, pericarditis, or clinically significant systolic dysfunction. These data support trials evaluating minimally invasive pericardiotomy as a novel treatment for heart failure with preserved ejection fraction in humans.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887064PMC
February 2021

Gastric ablation as a novel technique for modulating electrical conduction in the in vivo stomach.

Am J Physiol Gastrointest Liver Physiol 2021 04 20;320(4):G573-G585. Epub 2021 Jan 20.

Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.

Gastric motility is coordinated by underlying bioelectrical "slow wave" activity. Slow wave dysrhythmias are associated with motility disorders, including gastroparesis, offering an underexplored potential therapeutic target. Although ablation is widely used to treat cardiac arrhythmias, this approach has not yet been trialed for gastric electrical abnormalities. We hypothesized that ablation can create localized conduction blocks and modulate slow wave activation. Radiofrequency ablation was performed on the porcine serosa in vivo, encompassing a range of parameters (55-85°C, adjacent points forming a line, 5-10 s/point). High-resolution electrical mapping (16 × 16 electrodes; 6 × 6 cm) was applied to define baseline and acute postablation activation patterns. Tissue damage was evaluated by hematoxylin and eosin and c-Kit stains. Results demonstrated that RF ablation successfully induced complete conduction block and a full thickness lesion in the muscle layer at energy doses of 65-75°C for 5-10 s/point. Gastric ablation may hold therapeutic potential for gastric electrical abnormalities in the future. This study presents gastric ablation as a new method for modulating slow wave activation and propagation in vivo, by creating localized electrical conduction blocks in the stomach, validated by high-resolution electrical mapping and histological tissue analysis. The results define the effective energy dose range for creating conduction blocks, while maintaining the mucosal and submucosal integrity, and demonstrate the electrophysiological effects of ablation. In future, gastric ablation can now be translated toward disrupting dysrhythmic slow wave activation.
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http://dx.doi.org/10.1152/ajpgi.00448.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238161PMC
April 2021

Long-Term Survival of Patients With Left Ventricular Noncompaction.

J Am Heart Assoc 2021 01 14;10(2):e015563. Epub 2021 Jan 14.

Department of Cardiovascular Diseases Mayo Clinic Rochester MN.

Background The prognosis of left ventricular noncompaction (LVNC) remains elusive despite its recognition as a clinical entity for >30 years. We sought to identify clinical and imaging characteristics and risk factors for mortality in patients with LVNC. Methods and Results 339 adults with LVNC seen between 2000 and 2016 were identified. LVNC was defined as end-systolic noncompacted to compacted myocardial ratio >2 (Jenni criteria) and end-diastolic trough of trabeculation-to-epicardium (X):peak of trabeculation-to-epicardium (Y) ratio <0.5 (Chin criteria) by echocardiography; and end-diastolic noncompacted:compacted ratio >2.3 (Petersen criteria) by magnetic resonance imaging. Median age was 47.4 years, and 46% of patients were female. Left ventricular ejection fraction <50% was present in 57% of patients and isolated apical noncompaction in 48%. During a median follow-up of 6.3 years, 59 patients died. On multivariable Cox regression analysis, age (hazard ratio [HR] 1.04; 95% CI, 1.02-1.06), left ventricular ejection fraction <50% (HR, 2.37; 95% CI, 1.17-4.80), and noncompaction extending from the apex to the mid or basal segments (HR, 2.11; 95% CI, 1.21-3.68) were associated with all-cause mortality. Compared with the expected survival for age- and sex-matched US population, patients with LVNC had reduced overall survival (<0.001). However, patients with LVNC with preserved left ventricular ejection fraction and patients with isolated apical noncompaction had similar survival to the general population. Conclusions Overall survival is reduced in patients with LVNC compared with the expected survival of age- and sex-matched US population. However, survival rate in those with preserved left ventricular ejection fraction and isolated apical noncompaction was comparable with that of the general population.
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http://dx.doi.org/10.1161/JAHA.119.015563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955291PMC
January 2021

Inappropriate Dosing of Direct Oral Anticoagulants in Patients with Atrial Fibrillation.

Am J Cardiol 2021 04 29;144:52-59. Epub 2020 Dec 29.

Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota. Electronic address:

Direct Oral Anticoagulants (DOACs) require dose adjustment based on specific patient characteristics, making them prone to incorrect dosing. The current study aimed to evaluate the prevalence of inappropriate DOAC dosing, its predictors, and corresponding outcomes in a single-center cohort of atrial fibrillation (AF) patients. We reviewed all patients with AF treated at Mayo Clinic with a DOAC (Apixaban, Rivaroxaban, or Dabigatran) between 2010 and 2017. Outcomes examined were ischemic stroke /transient ischemic attack (TIA)/embolism and bleeding. 8,576 patients (mean age 69.5 ± 11.9 years, 35.1 % female, CHADS-VASc 3.0±1.8) received a DOAC (38.6% apixaban, 35.8% rivaroxaban, 25.6% dabigatran). DOAC dosing was inappropriate in 1,273 (14.8%) with 1071 (12.4%) receiving an inappropriately low dose, and 202(2.4%) an inappropriately high dose. Patients prescribed inappropriate doses were older (72.4 ± 11.7 vs 69.0 ± 11.8, p <0.0001), more likely to be female (43.1% vs 33.7%, p <0.0001), had a higher CHADS-VASc score (3.4 ± 1.8 vs 2.9 ± 1.8, p <0.0001) and a greater Charlson co-morbidity index (3.5 ± 3.3 vs 2.9 ± 3.2, p<0.0001). Over 1.2 ±1.6 years (median 0.5 years) follow up; there was no significant difference in the incidence of stroke and/or TIA and/or embolism and bleeding between patients who were inappropriately dosed versus appropriately dosed. In conclusion, DOAC dosing was not in compliance with current recommendations in 15% of AF patients. Patients at higher risk of stroke and/or TIA based on older age, female gender, and higher CHADS-VASc score were more likely to be underdosed, but there was no significant difference in outcomes including stroke/TIA/embolism and bleeding.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088343PMC
April 2021

Catheter ablation of premature ventricular contractions originating from periprosthetic aortic valve regions.

J Cardiovasc Electrophysiol 2021 02 23;32(2):400-408. Epub 2020 Dec 23.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: Little is known about the ablation outcomes of premature ventricular contractions (PVCs) that originate from the periprosthetic aortic valve (PPAV) regions of patients with aortic valve replacement (AVR).

Methods And Results: Our study had 11 patients who underwent catheter ablation for PVCs arising from the PPAV regions (bioprosthetic aortic valve, n = 5; mechanical aortic valve, n = 6). The PVC characteristics, procedure characteristics, and efficacy of ablation were compared with the control group (n = 33). At baseline, the PPAV group had a lower left ventricular ejection fraction (mean [SD], 41% [12%] vs. 51% [8%]; p = .002). The rate of acute ablation success was 90.9% in the PPAV group. Ablation sites were identified above the left coronary cusp (LCC) and right coronary cusp commissure (LRCC) in one PVC, below the prosthetic valve in eight PVCs (four below LCC and four below LRCC), and within the distal coronary sinus in two PVCs. The mean procedure time, fluoroscopy time, and radiation in the PPAV group were all significantly greater than those in the control group (all p < .05). However, the number of radiofrequency ablation energy deliveries was not different. The PPAV group had a long-term success rate compared with the control group (72.7% vs. 87.9%, p = .48) and an increase of left ventricular ejection fraction from 43% to 49% after successful PVC ablation at follow-up (p < .001). Echocardiography showed no significant change in valve regurgitation after ablation. No new atrioventricular block occurred.

Conclusion: PVCs arising from PPAV regions can be successfully ablated in patients with prior AVR, without damaging the prosthetic aortic valve and atrioventricular conduction.
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http://dx.doi.org/10.1111/jce.14836DOI Listing
February 2021

Echocardiography-Guided Risk Stratification for Long QT Syndrome.

J Am Coll Cardiol 2020 12;76(24):2834-2843

Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Background: The ability to identify those patients at the highest phenotypic risk for long QT syndrome (LQTS)-associated life-threatening cardiac events remains suboptimal.

Objectives: This study sought to validate the association between electromechanical window (EMW) negativity, as derived from echocardiography, and symptomatic versus asymptomatic status in patients with LQTS.

Methods: We analyzed a cohort of 651 patients with LQTS (age 26 ± 17 years; 60% females; 158 symptomatic; 51% LQTS type 1; 33% LQTS type 2; 11% LQTS type 3; 5% multiple mutations) and 50 healthy controls. EMW was calculated as the difference between the interval from QRS onset to aortic valve closure midline, as derived for continuous-wave Doppler, and the electrocardiogram-derived QT interval for the same beat.

Results: A negative EMW was found among nearly all patients with LQTS compared to controls, with more profound EMW negativity in patients with symptomatic LQTS compared to those with asymptomatic LQTS (-52 ± 38 ms vs. -18 ± 29 ms; p < 0.0001). Logistic regression identified EMW, heart rate-corrected QT interval (QTc), female sex, and LQTS genotype as univariate predictors of symptomatic status. After multivariate analysis, EMW remained an independent predictor of symptomatic status (odds ratio for each 10-ms decrease in EMW: 1.37; 95% confidence interval: 1.27 to 1.48; p < 0.0001). EMW outperformed QTc in predicting symptomatic patients (area under the curve: 0.78 vs. 0.70; p = 0.01). After training and implementation, EMW correlation from echocardiographic sonographers showed excellent reliability (intraclass correlation coefficient: 0.93; 95% confidence interval: 0.89 to 0.96).

Conclusions: In this validation study, patients with a history of LQTS-associated life-threatening cardiac events had a more profoundly negative EMW. EMW outperformed heart rate-corrected QT interval as a predictor of symptomatic status. EMW is now a clinically validated risk factor. In December 2019, our institution's echocardiography clinical practice committee approved use of EMW for patients with LQTS, making it a routinely reported echocardiographic finding.
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http://dx.doi.org/10.1016/j.jacc.2020.10.024DOI Listing
December 2020

The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope.

Circ Arrhythm Electrophysiol 2020 12 16;13(12):e008659. Epub 2020 Nov 16.

Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.).

Background: Increased parasympathetic activity is thought to play important roles in syncope events of patients with vasovagal syncope (VVS). However, direct measurements of the vagal control are difficult. The novel deceleration capacity (DC) of heart rate measure has been used to characterize the vagal modulation. This study aimed to assess vagal control in patients with VVS and evaluate the diagnostic value of the DC in VVS.

Methods: Altogether, 161 consecutive patients with VVS (43±15 years; 62 males) were enrolled. Tilt table test was positive in 101 and negative in 60 patients. Sixty-five healthy subjects were enrolled as controls. DC and heart rate variability in 24-hour ECG, echocardiogram, and biochemical examinations were compared between the syncope and control groups.

Results: DC was significantly higher in the syncope group than in the control group (9.6±3.3 versus 6.5±2.0 ms, <0.001). DC was similarly increased in patients with VVS with a positive and negative tilt table test (9.7±3.5 and 9.4±2.9 ms, =0.614). In multivariable logistic regression analyses, DC was independently associated with syncope (odds ratio=1.518 [95% CI, 1.301-1.770]; =0.0001). For the prediction of syncope, the area under curve analysis showed similar values when comparing single DC and combined DC with other risk factors (=0.1147). From the receiver operator characteristic curves for syncope discrimination, the optimal cutoff value for the DC was 7.12 ms.

Conclusions: DC>7.5 ms may serve as a good tool to monitor cardiac vagal activity and discriminate VVS, particularly in those with negative tilt table test.
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http://dx.doi.org/10.1161/CIRCEP.120.008659DOI Listing
December 2020

Incremental benefit of a novel signal recording system during mapping and ablation.

Europace 2021 01;23(1):130-138

Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

Aims: Current electrophysiology signal recording and mapping systems have limited dynamic range (DR) and bandwidth, which causes loss of valuable information during acquisition of cardiac signals. We evaluated a novel advanced signal processing platform with the objective to obtain and assess additional information of clinical importance.

Methods And Results: Over 10 canines, we compared intracardiac recordings within all cardiac chambers, in various rhythms, in pacing and during radiofrequency (RF) ablation across two platforms; a conventional system and the PURE EP™ [(PEP); Bio Sig Technologies, Inc., Los Angeles, CA, USA]. Recording cardiac signals with varying amplitudes were consistently and reproducibly observed, without loss of detail or introduction of artefact. Further the amplitude of current of injury (COI) on the unipolar signals correlated with the instantaneous contact force (CF) recorded on the sensing catheter in all the animals (r2 = 0.94 in ventricle). The maximum change in the unipolar COI correlated with the change in local electrogram amplitude during non-irrigated RF ablation (r2 = 0.61 in atrium). Reduction in artefact attributable to pacing (20 sites) and noise during ablation (48 sites) was present on the PEP system. Within the PEP system, simultaneous display of identical signals, filtered differently, aided the visualization of discrete conduction tissue signals.

Conclusion: Compared to current system, the PEP system provided incremental information including identifying conduction tissue signals, estimates of CF and a surrogate for lesion formation. This novel signal processing platform with increased DR and minimal front-end filtering may be useful in clinical practice.
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http://dx.doi.org/10.1093/europace/euaa194DOI Listing
January 2021

Ventricular automaticity: A path to premature ventricular contraction ablation success.

Indian Pacing Electrophysiol J 2020 Nov - Dec;20(6):227-230. Epub 2020 Sep 25.

Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, USA; Department of Pediatrics and Adolescent Medicine, USA; Department of Biomedical Engineering, USA; Department of Clinical Anatomy, Mayo Clinic, Rochester, MN, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ipej.2020.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691781PMC
September 2020

Injectable conductive hydrogel restores conduction through ablated myocardium.

J Cardiovasc Electrophysiol 2020 12 5;31(12):3293-3301. Epub 2020 Oct 5.

Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.

Introduction: Therapies for substrate-related arrhythmias include ablation or drugs targeted at altering conductive properties or disruption of slow zones in heterogeneous myocardium. Conductive compounds such as carbon nanotubes may provide a novel personalizable therapy for arrhythmia treatment by allowing tissue homogenization.

Methods: A nanocellulose carbon nanotube-conductive hydrogel was developed to have conduction properties similar to normal myocardium. Ex vivo perfused canine hearts were studied. Electroanatomic activation mapping of the epicardial surface was performed at baseline, after radiofrequency ablation, and after uniform needle injections of the conductive hydrogel through the injured tissue. Gross histology was used to assess distribution of conductive hydrogel in the tissue.

Results: The conductive hydrogel viscosity was optimized to decrease with increasing shear rate to allow expression through a syringe. The direct current conductivity under aqueous conduction was 4.3 × 10  S/cm. In four canine hearts, when compared with the homogeneous baseline conduction, isochronal maps demonstrated sequential myocardial activation with a shift in direction of activation to surround the edges of the ablated region. After injection of the conductive hydrogel, isochrones demonstrated conduction through the ablated tissue with activation restored through the ablated tissue. Gross specimen examination demonstrated retention of the hydrogel within the tissue.

Conclusions: This proof-of-concept study demonstrates that conductive hydrogel can be injected into acutely disrupted myocardium to restore conduction. Future experiments should focus on evaluating long-term retention and biocompatibility of the hydrogel through in vivo experimentation.
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http://dx.doi.org/10.1111/jce.14762DOI Listing
December 2020

Trends in reported industry payments to physicians practicing cardiac electrophysiology from 2013 to 2018 in the United States.

J Cardiovasc Electrophysiol 2020 12 7;31(12):3106-3114. Epub 2020 Oct 7.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: The need for transparency in financial relationships in the healthcare system, has culminated in Open Payments database, managed by the Center for Medicare and Medicaid Services (CMS). Since its inception in 2013, the trend in such payments to physicians practicing cardiac electrophysiology was not examined.

Methods And Results: Payment information reported to CMS from January 2013 to December 2018 was obtained from the publicly available Open Payments data set using the online query tool. The data were analyzed by an individual provider and by state. An in-depth analysis of payments in the year 2018 payments was performed. From 2014 to 2018, there was an 18% increase in the total number of payments reported from 88 877 payments in 2014 to 105 000 in 2018. Despite the increase in the total number of payments reported, the average payment steadily decreased over time, resulting in an overall reduction in the total amount of payments from 2014 to 2018 ($34.9 million to $28.2 million). Payments to the top 5% of individual recipients have also decreased over this time. In 2018, 2888 unique providers received reportable payments, a total of 105 000 payments, with a median payment amount of $1378 (interquartile range: $165-$5781). The majority of these payments were for food and beverage (82%) and travel/lodging (10%). The top five payers include Boston Scientific, Medtronic Vascular, Abbott Laboratories, Janssen Pharmaceuticals, and Biotronik.

Conclusion: Among cardiac electrophysiologists, there is increased reporting of payments in the Open Payments program over time, with a notable decrease in the payment amount.
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http://dx.doi.org/10.1111/jce.14754DOI Listing
December 2020

Digital health innovation in cardiology.

Cardiovasc Digit Health J 2020 Jul-Aug;1(1):6-8. Epub 2020 Aug 28.

Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

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http://dx.doi.org/10.1016/j.cvdhj.2020.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452824PMC
August 2020
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