Publications by authors named "Vaibhav R Vaidya"

48 Publications

Trends in Cardiovascular Implantable Electronic Device Insertion Between 1988 and 2018 in Olmsted County.

JACC Clin Electrophysiol 2022 Jan 25;8(1):88-100. Epub 2021 Aug 25.

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

Objectives: This study sought to describe trends in cardiovascular implantable electronic device (CIED) insertion over the past 3 decades in Olmsted County.

Background: Trends in CIED insertion in the United States have not been extensively studied.

Methods: The Rochester Epidemiology Project is a medical records linkage system comprising the records of all residents of Olmsted County from 1966 to the present. CIED insertion between 1988 and 2018 was determined using International Classification of Diseases-Ninth Revision, International Classification of Diseases-10th Revision, and Current Procedural Terminology codes. Age- and sex-adjusted incidence rates, adjusted to the 2010 US White population, were calculated. Trends in incidence over time, across age groups, and between sex are estimated using Poisson regression models.

Results: The age- and sex-adjusted incidence of device implants for the study period were as follows: overall CIED: 82.4 (95% CI: 79.2-85.6); permanent pacemaker (PPM): 62.9 (95% CI: 60.0-65.7); implantable cardioverter-defibrillator (ICD): 14.0 (95% CI: 12.6-15.3); and cardiac resynchronization therapy (CRT): 5.6 (95% CI: 4.7-6.4) per 100,000 per year. The overall incidence of CIED insertion increased between 1988 to 1993 and 2000 to 2005 and then decreased between 2000 to 2005 and 2012 to 218 (P < 0.0001). PPM and ICD insertion incidence followed these trends, whereas the incidence of CRT insertion increased between 2000 to 2005 and 2012 to 2018. CIED insertion incidence increased with age (P < 0.0001). CIED insertion incidence was greater in men (116.3 vs 57.3 per 100,000 per year in men vs women; P < 0.0001). The overall survival of CRT recipients improved (P = 0.0044).

Conclusions: The incidence values for PPM and ICD implants are decreasing, while the incidence of CRT implants is increasing. CIEDs are increasingly inserted in the elderly, men, and patients with higher comorbidities.
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http://dx.doi.org/10.1016/j.jacep.2021.06.006DOI Listing
January 2022

Catheter ablation for atrioventricular nodal reentrant tachycardia: When all is not right, ablate what is left.

Authors:
Vaibhav R Vaidya

Indian Pacing Electrophysiol J 2021 Jan-Feb;21(1):11-13

Department of Cardiovascular Diseases, Mayo Clinic Health Systems, Eau Claire, WI, United States; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States.

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http://dx.doi.org/10.1016/j.ipej.2021.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854378PMC
February 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

Injectable Flexible Subcutaneous Electrode Array Technology for Electrocardiogram Monitoring Device.

ACS Biomater Sci Eng 2020 05 15;6(5):2652-2658. Epub 2019 Nov 15.

Department of Electrical and Computer Engineering, University of Wisconsin-Madison, Madison, Wisconsin 53706, United States.

Implantable cardiac monitors have undergone considerable miniaturization. However, they continue to be associated with complications such as infection, bleeding/bruising, and device extrusion or migration. In this paper, we demonstrate the feasibility of using a small, flexible, injectable, subcutaneous microelectrode-based device to record electrocardiograms (ECGs). We describe the fabrication process and demonstrate the ease of insertion of the injectable ECG device in vivo swine model. We also demonstrate our device's high-density channel microelectrode array's ability to detect the P, R, and T waves. The amplitude of these waves showed excellent correlation with distance of the bipolar electrodes used to detect them. Given the success of our initial studies, this device has the potential to improve the safety profile of implantable cardiac monitors and simplify the implantation procedure to allow for placement in a primary care setting.
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http://dx.doi.org/10.1021/acsbiomaterials.9b01102DOI Listing
May 2020

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

Burden of arrhythmia in hospitalized HIV patients.

Clin Cardiol 2021 Jan 9;44(1):66-77. Epub 2020 Dec 9.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States.

Background: The improved life expectancy observed in patients living with human immunodeficiency virus (HIV) infection has made age-related cardiovascular complications, including arrhythmias, a growing health concern.

Hypothesis: We describe the temporal trends in frequency of various arrhythmias and assess impact of arrhythmias on hospitalized HIV patients using the Nationwide Inpatient Sample (NIS).

Methods: Data on HIV-related hospitalizations from 2005 to 2014 were obtained from the NIS database using International Classification of Diseases, 9th Revision (ICD-9) codes. Data was further subclassified into hospitalizations with associated arrhythmias and those without. Baseline demographics and comorbidities were determined. Outcomes including in-hospital mortality, cost of care, and length of stay were extracted. SAS 9.4 (SAS Institute Inc., Cary, NC) was utilized for analysis. A multivariable analysis was performed to identify predictors of arrhythmias among hospitalized HIV patients.

Results: Among 2 370 751 HIV-related hospitalizations identified, the overall frequency of any arrhythmia was 3.01%. Atrial fibrillation (AF) was the most frequent arrhythmia (2110 per 100 000). The overall frequency of arrhythmias increased over time by 108%, primarily due to a 132% increase in AF. Arrhythmias are more frequent among older males, lowest income quartile, and nonelective admissions. Patients with arrhythmias had a higher in-hospital mortality rate (9.6%). In-hospital mortality among patients with arrhythmias decreased over time by 43.8%. The cost of care and length of stay associated with arrhythmia-related hospitalizations were mostly unchanged.

Conclusions: Arrhythmias are associated with significant morbidity and mortality in hospitalized HIV patients. AF is the most frequent arrhythmia in hospitalized HIV patients.
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http://dx.doi.org/10.1002/clc.23506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803370PMC
January 2021

Feasibility of selective cardiac ventricular electroporation.

PLoS One 2020 21;15(2):e0229214. Epub 2020 Feb 21.

Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America.

Introduction: The application of brief high voltage electrical pulses to tissue can lead to an irreversible or reversible electroporation effect in a cell-specific manner. In the management of ventricular arrhythmias, the ability to target different tissue types, specifically cardiac conduction tissue (His-Purkinje System) vs. cardiac myocardium would be advantageous. We hypothesize that pulsed electric fields (PEFs) can be applied safely to the beating heart through a catheter-based approach, and we tested whether the superficial Purkinje cells can be targeted with PEFs without injury to underlying myocardial tissue.

Methods: In an acute (n = 5) and chronic canine model (n = 6), detailed electroanatomical mapping of the left ventricle identified electrical signals from myocardial and overlying Purkinje tissue. Electroporation was effected via percutaneous catheter-based Intracardiac bipolar current delivery in the anesthetized animal. Repeat Intracardiac electrical mapping of the heart was performed at acute and chronic time points; followed by histological analysis to assess effects.

Results: PEF demonstrated an acute dose-dependent functional effect on Purkinje, with titration of pulse duration and/or voltage associated with successful acute Purkinje damage. Electrical conduction in the insulated bundle of His (n = 2) and anterior fascicle bundle (n = 2), was not affected. At 30 days repeat cardiac mapping demonstrated resilient, normal electrical conduction throughout the targeted area with no significant change in myocardial amplitude (pre 5.9 ± 1.8 mV, 30 days 5.4 ± 1.2 mV, p = 0.92). Histopathological analysis confirmed acute Purkinje fiber targeting, with chronic studies showing normal Purkinje fibers, with minimal subendocardial myocardial fibrosis.

Conclusion: PEF provides a novel, safe method for non-thermal acute modulation of the Purkinje fibers without significant injury to the underlying myocardium. Future optimization of this energy delivery is required to optimize conditions so that selective electroporation can be utilized in humans the treatment of cardiac disease.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229214PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034868PMC
May 2020

Venoarterial Extracorporeal Membrane Oxygenation Support for Ventricular Tachycardia Ablation: A Systematic Review.

ASAIO J 2020 Sep/Oct;66(9):980-985

From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Refractory ventricular tachycardia (VT) and electrical storm are frequently associated with hemodynamic compromise requiring mechanical support. This study sought to review the current literature on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for hemodynamic support during VT ablation. This was a systematic review of all published literature from 2000 to 2019 evaluating patients with VT undergoing ablation with VA-ECMO support. Studies that reported mortality, safety, and efficacy outcomes in adult (>18 years) patients were included. The primary outcome was short-term mortality (intensive care unit stay, hospital stay, or ≤30 days). The literature search identified 4,802 citations during the study period, of which seven studies comprising 867 patients met the inclusion criteria. Periprocedural VA-ECMO was used in 129 (15%) patients and all were placed peripherally. Average inducible VTs were 2-3 per procedure and ablation time varied between 34 mins and 4.7 hours. Median ages were between 61 and 68 years with 93% males. Median duration of VA-ECMO varied between 140 minutes and 6 days. Short-term mortality was 15% (19 patients), with the most frequent causes being refractory VT, cardiac arrest, and acute heart failure. All-cause mortality at the longest follow-up was 25%. Major bleeding, vascular/access complications, limb ischemia, stroke, and acute kidney injury were reported with varying frequency of 1-6%. In conclusion, VA-ECMO is used infrequently for hemodynamic support for VT ablation. Further data on patient selection, procedural optimization, and clinical outcomes are needed to evaluate the efficacy of this strategy.
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http://dx.doi.org/10.1097/MAT.0000000000001125DOI Listing
March 2021

Nanostim leadless pacemaker retrieval and simultaneous micra leadless pacemaker replacement: a single-center experience.

J Interv Card Electrophysiol 2020 Jan 14;57(1):125-131. Epub 2019 Nov 14.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, 55902, USA.

Purpose: The leadless pacemaker (LP) is a promising new technology in pacing therapy that avoids a generator pocket and transvenous lead-related complications. However, extraction experience with simultaneous re-implant of a leadless device remains limited. We sought to study the outcomes of Nanostim LP retrieval and simultaneous reimplantation of Micra LP.

Methods: Patients undergoing retrieval of the Nanostim LP and receiving a Micra LP implant between 2016 and 2018 at Mayo Clinic (Rochester, MN) were studied. The procedural and outcome data were collected from the electronic medical record.

Results: Nine patients underwent attempted Nanostim LP retrieval and 6 of these simultaneously received a Micra LP reimplant. All retrievals were considered chronic due to implant durations of > 1 year. Extraction procedures were completed with a success rate of 89% and simultaneous reimplantations were performed successfully in all cases with no major complications. Newly implanted Micra LP device function was normal at follow-up. Factors such as duration of device implant and device positioning appeared to impact ease of extraction.

Conclusions: Retrieval of the Nanostim LP system and simultaneous replacement with an alternate Micra leadless device appears to be a feasible approach.
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http://dx.doi.org/10.1007/s10840-019-00647-3DOI Listing
January 2020

Incidence and Natural History of Left Bundle Branch Block Induced Cardiomyopathy.

Circ Arrhythm Electrophysiol 2019 09 12;12(9):e007393. Epub 2019 Sep 12.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1161/CIRCEP.119.007393DOI Listing
September 2019

Fundamentals of Cardiac Mapping.

Card Electrophysiol Clin 2019 09;11(3):433-448

Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA; Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA. Electronic address:

To characterize cardiac activity and arrhythmias, electrophysiologists can record the electrical activity of the heart in relation to its anatomy through a process called cardiac mapping (electroanatomic mapping, EAM). A solid understanding of the basic cardiac biopotentials, called electrograms, is imperative to construct and interpret the cardiac EAM correctly. There are several mapping approaches available to the electrophysiologist, each optimized for specific arrhythmia mechanisms. This article provides an overview of the fundamentals of EAM.
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http://dx.doi.org/10.1016/j.ccep.2019.05.005DOI Listing
September 2019

Epicardial access: Adjusting the approach as we discover complications.

J Cardiovasc Electrophysiol 2019 08 12;30(8):1341-1344. Epub 2019 Jul 12.

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

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http://dx.doi.org/10.1111/jce.14036DOI Listing
August 2019

A novel percutaneous stabilizing sheath for minimal invasive epicardial echocardiography and ablation.

J Interv Card Electrophysiol 2020 Apr 6;57(3):453-464. Epub 2019 Jun 6.

Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

Purpose: Epicardial ablation and mapping are critical adjuncts to the electrophysiologist's approach to arrhythmias; however, ablation within the epicardial space requires the avoidance of coronary arteries (CA). We aimed to evaluate the feasibility and performance of a novel-stabilizing ablation sheath housing an intracardiac echocardiography (ICE) catheter to (1) obtain Epicardial Echocardiography (EE) images, (2) visualize CAs, and (3) enable targeted delivery of radiofrequency energy away from visualized CAs.

Methods: We designed a sheath that could enclose a regular ICE catheter. This sheath has flanges and a balloon, with three interspersed windows surrounded by an electrode. In an acute canine model (N = 6), the sheath was manipulated within the pericardial space to visualize cardiac structures and CAs. Visualization of CAs was confirmed with angiography. Ablation was then performed through the window either proximal or distal to the CA.

Results: The novel sheath was successfully deployed in six canines, with no acute procedural complications. Images with an excellent spatial resolution of cardiac structures were obtained including the right ventricular outflow tract; aortic, pulmonary, and mitral valves; and left atrial appendage. CAs were successfully visualized, and ablation from a sheath window either proximal or distal to the CA did not produce angiographic or histopathological evidence of CA damage despite evidence of acute injury to the adjacent ablated myocardium.

Conclusions: This novel percutaneous stabilizing sheath was able to successfully obtain high-quality EE images as well as provide a non-fluoroscopic intra-procedural means to visualize CAs. Use of this sheath enabled successful delivery of energy to avoided CA damage.
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http://dx.doi.org/10.1007/s10840-019-00553-8DOI Listing
April 2020

Comparing the incidence of ventricular arrhythmias during epicardial ablation in swine versus canine models.

Pacing Clin Electrophysiol 2019 07 29;42(7):862-867. Epub 2019 Apr 29.

International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.

Background: Choosing the appropriate animal model for development of novel technologies requires an understanding of anatomy and physiology of these different models. There are little data about the characteristics of different animal models for the study of technologies used for epicardial ablation. We aimed to compare the incidence of ventricular arrhythmias during epicardial radiofrequency ablation between swine and canine models using novel epicardial ablation catheters.

Methods: We conducted a retrospective study using data obtained from epicardial ablation experiments performed on swine (Sus Scrofa) and canine (Canis familiaris) models. We compared the incidence of ventricular arrhythmias during ablation between swine and canine using multivariate regression analysis. Six swine and six canine animals underwent successful epicardial radiofrequency ablation. A total of 103 ablation applications were recorded.

Results: Ventricular arrhythmias requiring cardioversion occurred in 13.11% of radiofrequency ablation applications in swine and 9.75% in canine (relative risk: 117.6%, 95% confidence interval [CI]: 83.97-164.69, animal-based odds ratio [OR]: .55, 95% CI: .23-61.33; P = .184). When adjusting for application position, duration of ablation and power, the odds of developing potentially lethal ventricular arrhythmia in swine increased significantly compared to canine (OR: 3.60, 95% CI: 1.35-9.55; P = .010).

Conclusions: The swine myocardium is more susceptible to developing ventricular arrhythmias compared to canine model during epicardial ablation. This issue should be carefully considered in future studies.
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http://dx.doi.org/10.1111/pace.13698DOI Listing
July 2019

Three-Dimensional Printed Biopatches With Conductive Ink Facilitate Cardiac Conduction When Applied to Disrupted Myocardium.

Circ Arrhythm Electrophysiol 2019 03;12(3):e006920

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.M.P., A.M.S., C.L., V.R.V., C.J.M., S.J.A., S.K.).

Background: Reentrant ventricular arrhythmias are a major cause of sudden death in patients with structural heart disease. Current treatments focus on electrically homogenizing regions of scar contributing to ventricular arrhythmia with ablation or altering conductive properties using antiarrhythmic drugs. The high conductivity of carbon nanotubes may allow restoration of conduction in regions where impaired electrical conduction results in functional abnormalities. We propose a new concept for arrhythmia treatment using a stretchable, flexible biopatch with conductive properties to attempt to restore conduction across regions in which activation is disrupted.

Methods: Carbon nanotube patches composed of nanofibrillated cellulose/single-walled carbon nanotube ink 3-dimensionally printed in conductive patterns onto bacterial nanocellulose were developed and evaluated for conductivity, flexibility, and mechanical properties. The patches were applied on 6 canines to epicardium before and after surgical disruption. Electroanatomic mapping was performed on normal epicardium, then repeated over surgically disrupted epicardium, and then finally with the patch applied passively.

Results: We developed a 3-dimensional printable carbon nanotube ink complexed on bacterial nanocellulose that was (1) expressable through 3-dimensional printer nozzles, (2) electrically conductive, (3) flexible, and (4) stretchable. Six canines underwent thoracotomy, and, during epicardial ventricular pacing, mapping was performed. We demonstrated disruption of conduction after surgical incision in all 6 canines based on activation mapping. The patch resulted in restored conduction based on mapping and assessment of conduction direction and velocities in all canines.

Conclusions: We have demonstrated 3-dimensional custom-printed electrically conductive carbon nanotube patches can be surgically manipulated to improve cardiac conduction when passively applied to surgically disrupted epicardial myocardium in canines.
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http://dx.doi.org/10.1161/CIRCEP.118.006920DOI Listing
March 2019

Pulsed electric fields for cardiac ablation and beyond: A state-of-the-art review.

Heart Rhythm 2019 07 11;16(7):1112-1120. Epub 2019 Jan 11.

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

Irreversible electroporation (IRE) occurs when a strong, pulsed electric field (PEF) causes permeabilization of the cell membrane, leading to cellular homeostasis disruption and cell death. IRE is a Food and Drug Administration-approved treatment of tumor ablation and has been gaining attention in cardiology as an ablation modality. Applications of PEF in cardiology are vast and include atrial fibrillation, ventricular fibrillation, septal ablation, and targeting vascular structures. PEF has appealing characteristics, including the ability to be tissue specific and its nonthermal nature. This review provides information on the biophysics and mechanisms of IRE, summarizes key studies and applications to date, and provides insight into future applications.
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http://dx.doi.org/10.1016/j.hrthm.2019.01.012DOI Listing
July 2019

Real-world experience with leadless cardiac pacing.

Pacing Clin Electrophysiol 2019 Mar 30;42(3):366-373. Epub 2019 Jan 30.

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

Background: Leadless cardiac pacing (LCP) has emerged as a new modality for permanent pacing. We sought to describe comparative outcomes between LCP and transvenous pacemakers.

Methods: Patients receiving LCP (Micra [Medtronic, Minneapolis, MN, USA] and Nanostim [St. Jude Medical/Abbott Laboratories, Chicago, IL, USA]) between 2014 and 2017 at the Mayo Clinic Heart Rhythm Enterprise practice (Rochester, MN, USA; Jacksonville, FL, USA; and Scottsdale, AZ, USA) were identified. We identified 1:1 age- and sex-matched controls receiving single-chamber transvenous ventricular pacemakers (TVP). Statistical analyses were performed with JMP 13.0.0 (SAS, Institute Cary, NC, USA).

Results: Ninety patients underwent LCP implantation (73 Micra and 17 Nanostim) with a median follow-up duration of 62 (interquartile range 28-169) days. Both groups had 100% successful device implant rates. There were no differences in procedure-related major (0% vs 1%) or minor complications (8% vs 3%) in the LCP versus TVP groups (P > 0.05). Excluding Nanostim patients, there was a lower rate of device-related revision or extraction in the Micra versus TVP groups (0% vs 5%, P = 0.028). Device endocarditis was more common in the TVP group (0% vs 3%, P = 0.04). Estimated longevity was greater for the LCP group (median 12.0 vs 10.0 years, P < 0.0001). An increase in severity of tricuspid valve regurgitation (TR) by ≥2 grades occurred in none of the LCP patients, and in 19% of the TVP patients (P = 0.017).

Conclusion: There are no significant differences in procedural complications among patients receiving LCP versus TVP. The Micra group had lower rates of device-related revision/extraction compared to the TVP group. Patients with leadless pacemaker were less likely to develop endocarditis or worsening TR.
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http://dx.doi.org/10.1111/pace.13601DOI Listing
March 2019

Electrocardiogram algorithms used to differentiate wide complex tachycardias demonstrate diagnostic limitations when applied by non-cardiologists.

J Electrocardiol 2018 Nov - Dec;51(6):1103-1109. Epub 2018 Oct 2.

Department of Cardiovascular Diseases, Mayo Clinic, United States of America.

Aims: Non-cardiologists (NCs) are often responsible for the preliminary diagnosis and early management of patients presenting with ventricular tachycardia (VT) or supraventricular wide complex tachycardia (SWCT). At present, the Vereckei aVR and Brugada algorithms are the most widely recognized and frequently relied upon wide complex tachycardia (WCT) differentiation criteria by NCs. This study aimed to determine the diagnostic efficacy of the Vereckei aVR and Brugada algorithms when applied by NCs.

Methods: In a blinded fashion, three internal medicine residents prospectively interpreted WCTs using the Vereckei aVR and Brugada algorithms. The diagnostic performance of each method was evaluated according to their agreement with the correct rhythm diagnosis.

Results: Two-hundred sixty-nine WCTs (160 VT, 109 SWCT) from 186 patients were independently interpreted by each participant (807 separate interpretations per algorithm). The aVR and Brugada algorithms accurately classified 546 out of 807 (67.7%) and 622 out of 807 (77.1%) interpreted WCTs, respectively. Overall sensitivity and specificity of the aVR algorithm for VT was 92.1% and 31.8%, respectively. Overall sensitivity and specificity of the Brugada algorithm for VT was 89.4% and 59.0%, respectively. Both algorithms yielded modestly favorable overall positive predictive values (aVR 66.5%; Brugada 76.2%) and negative predictive values (73.3%; Brugada 79.1%).

Conclusion: Non-cardiologist algorithm users correctly identified most "actual" VTs, but did not sufficiently revise VT probability to conclusively distinguish VT and SWCT. Newer WCT differentiation methods are needed to improve NC's ability to accurately differentiate WCTs.
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http://dx.doi.org/10.1016/j.jelectrocard.2018.09.015DOI Listing
October 2019

Clinical Significance of Early Repolarization in Long QT Syndrome.

JACC Clin Electrophysiol 2018 09 29;4(9):1238-1244. Epub 2018 Aug 29.

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

Objectives: This study sought to determine the prevalence of early repolarization pattern (ERP) within a large cohort of patients with long QT syndrome (LQTS) and examine the correlation and clinical significance of ERP with symptomatic status and subsequent risk of breakthrough cardiac events (BCEs).

Background: The electrocardiographic ERP is associated with an increased risk of arrhythmic events and sudden cardiac death.

Methods: ERP was defined as an end-QRS notch or slur on the downslope of a prominent R-wave with a J point ≥0.1 mV in 2 or more contiguous leads of the 12-lead electrocardiogram, excluding V1 to V3. A patient was considered previously symptomatic if they had a suspected LQTS-triggered cardiac event prior to diagnosis. BCEs were defined as LQTS-attributable syncope/seizures, aborted cardiac arrest, appropriate ventricular fibrillation-terminating implantable cardioverter-defibrillator shocks, and sudden cardiac death following diagnosis and institution of a LQTS-directed treatment program.

Results: In this study, 528 patients (57% female) with genotype-confirmed LQTS (283 with LQT1, 193 with LQT2, and 52 with LQT3) were reviewed from which 2,618 electrocardiograms were analyzed over a median follow-up of 6.7 (interquartile range, 3.6 to 10 years) years. Eighty-two (15.5%; female 51%) patients were identified as having ERP; 40 (50%) of these ERP-positive patients showed persistent ERP. One hundred twenty-four patients (23.5%) were classified as previously symptomatic LQTS and 39 (7.2%) experienced a subsequent BCE. ERP was not associated with either symptomatic status (p = 0.62) or BCE (p = 0.61).

Conclusions: Although ERP is common in LQTS, this extensive study suggests that the presence of concomitant ERP does not correlate with either those with a history of LQTS-triggered events prior to diagnosis or those with subsequent BCEs from their treated LQTS substrate.
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http://dx.doi.org/10.1016/j.jacep.2018.06.007DOI Listing
September 2018

His Bundle (Conduction System) Pacing: A Contemporary Appraisal.

Card Electrophysiol Clin 2018 09;10(3):461-482

Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA. Electronic address:

The His bundle (conduction system) is an attractive target for physiologic pacing because it uses the native conduction system. Although the potential benefits of conduction system pacing were recognized in the 1970s, in the past 2 decades, it has grown in interest as a potentially preferred method of ventricular stimulation in appropriate patients. This review provides an appraisal of conduction system pacing, with focus on anatomy, physiology, tools, and techniques as well as an appraisal of current published data and thoughts on future directions.
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http://dx.doi.org/10.1016/j.ccep.2018.05.015DOI Listing
September 2018

Lateral Percutaneous Epicardial Access With a Novel Technique.

JACC Clin Electrophysiol 2018 Aug;4(8):1115-1116

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address:

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http://dx.doi.org/10.1016/j.jacep.2018.04.012DOI Listing
August 2018

Inappropriate Sinus Tachycardia: Current Challenges and Future Directions.

J Innov Card Rhythm Manag 2018 Jul 15;9(7):3239-3243. Epub 2018 Jul 15.

Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.19102/icrm.2018.090706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252682PMC
July 2018

The efficacy and safety of electroanatomic mapping-guided endomyocardial biopsy: a systematic review.

J Interv Card Electrophysiol 2018 Oct 12;53(1):63-71. Epub 2018 Jul 12.

Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55906, USA.

Purpose: Electroanatomic mapping (EAM) has been utilized as a modality to improve the sensitivity of endomyocardial biopsy (EMB). We sought to systematically review published medical literature on the efficacy and safety of EAM-guided EMB.

Methods: We searched Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central, Scopus, and Web of Science for studies where EAM was used for EMB. Data abstracted included demographics, indications, final diagnoses, histology findings, and technical details of biopsy extraction. Test characteristics including sensitivity (Se), specificity (Sp), and area under curve (AUC) were calculated on a per-patient and per-biopsy level.

Results: Seventeen studies (9 case series, 8 case reports) were included in this systematic review. EAM-guided EMB was performed in 148 patients and results of 207 individual biopsies were available for analysis. The most common indications for EAM-guided EMB were suspected arrhythmogenic right ventricular cardiomyopathy (ARVC), myocarditis, and cardiac sarcoidosis (CS). The pooled sensitivity and specificity for EAM-guided EMB for the diagnosis of cardiomyopathies (ARVC, myocarditis, CS, and other specific diagnoses) were 92 and 58% on per-biopsy analysis and 100 and 39% on per-patient analysis. Among the individual components of abnormal EGMs, abnormal unipolar EGM had the best AUC on per-biopsy (0.81, 95% CI 0.68-0.90) and per-patient analysis (0.84, 95% CI 0.68-0.92). EAM-guided EMB appears safe. Adverse events included 1 hemopericardium, 2 minimal asymptomatic pericardial effusions, and 1 femoral hematoma.

Conclusions: EAM-guided EMB is a safe and efficacious method and might improve test characteristics over conventional fluoroscopy-guided biopsy.
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http://dx.doi.org/10.1007/s10840-018-0410-7DOI Listing
October 2018

Percutaneous epicardial pacing using a novel transverse sinus device.

J Cardiovasc Electrophysiol 2018 09 6;29(9):1308-1316. Epub 2018 Jul 6.

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

Background: Transvenous lead implantation has multiple drawbacks and complications that can be overcome by epicardial lead placement. We aimed to design percutaneously implanted epicardial leads that are anchored through the transverse sinus (TS).

Methods And Results: We designed a novel multielectrode pacing device with four bipole electrode pairs. The device is advanced through the TS, with both ends externalized out of the pericardium. We tested the prototype in one proof-of-concept and 5 additional acute canine experiments. The TS device recorded ventricular and atrial electrograms. The median amplitude of near-field ventricular electrograms was 3.3 mA (IQR 2.0-4.3) and of near-field atrial electrograms was 2.1 mA (IQR 1.3-2.2). The median ventricular threshold (N  =  30) was 1.1 mA (IQR 0.7-3.1) at a median pulse width of 0.5 ms (IQR 0.5-0.5). The median atrial threshold (N  =  10) was 2.4 mA (IQR 1.1-7.8) at a median pulse width of 0.5 ms (IQR 0.5-0.9). Right and left ventricular and atrial pacing morphologies were noted while pacing electrodes adjacent to these chambers. Simultaneous left (LV) and right ventricular (RV) pacing showed reduction in QRS duration from 116 ms (RV) and 105 ms (LV) to 91 ms. On necropsy, the device was located in the TS in all animals. There were TS abrasions in one animal, and no other acute complications.

Conclusions: This study highlights a novel approach to epicardial pacing harnessing the unique anatomy of the transverse sinus as an anchoring point. Placement of this novel transverse sinus device was safe and feasible, with acceptable atrial and ventricular thresholds.
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http://dx.doi.org/10.1111/jce.13661DOI Listing
September 2018

Innovations in Clinical Cardiac Electrophysiology: Challenges and Upcoming Solutions in 2018 and Beyond.

J Innov Card Rhythm Manag 2017 Dec 15;8(12):2943-2955. Epub 2017 Dec 15.

Division of Cardiac Electrophysiology, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.19102/icrm.2017.081206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252723PMC
December 2017

MY APPROACH to the pregnant patient with a supraventricular tachycardia.

Trends Cardiovasc Med 2018 04 12;28(3):231-232. Epub 2017 Oct 12.

General Cardiology Fellow, Mayo Clinic, Rochester, MN. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2017.09.009DOI Listing
April 2018

Impact of atrial fibrillation on outcomes with motor vehicle accidents.

Int J Cardiol 2018 Jan 3;250:128-132. Epub 2017 Oct 3.

Mayo Clinic Division of Cardiovascular Diseases, Rochester, MN, United States. Electronic address:

Background: We examined the effect of AF a commonly encountered arrhythmia with significant morbidity on mortality following a motor vehicle accident (MVA) related hospitalization.

Methods: The Nationwide Inpatient Sample (NIS) was queried to identify patients with AF (ICD-9 CM 427.31) and MVA (ICD-9 CM E810.0-E819.9), considered separately and together, from 2003 through 2012. Baseline characteristics were identified and multilevel mixed model multivariate analysis was employed to verify the impact of AF on in-patient mortality in survivors.

Results: Of an estimated 2,978,630 MVA admissions reported, 79,687 (2.6%) hospitalizations also had a diagnosis of AF. The in-hospital mortality was 2.6% in MVA alone and 7.6% in MVA and AF. In multivariate analysis, after adjustment for age, gender, Charlson Comorbidity Index (CCI), the Trauma Mortality Prediction Model (TMPM), and hospital characteristics, AF was independently associated with in-hospital mortality [Odds ratio (OR) 1.52, confidence interval (CI) 1.41-1.69, P value<0.0001]. In patients with MVA and AF, increasing age, CCI, and TMPM were associated with higher mortality. Female gender is associated with lower mortality (OR 0.84, CI 0.81-0.88, P -0.0016). Most patients with MVA and AF had a CHADS2 score of 2 (34.6%). Mortality and transfusion rates were higher in MVA and AF patients compared to patients with MVA alone across all CHADS2 scores.

Conclusion: In patients with a MVA, the presence of AF is an independent risk factor for in-hospital mortality.
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http://dx.doi.org/10.1016/j.ijcard.2017.10.002DOI Listing
January 2018

Impact of acute left ventricular apical thrombus on cardioversion for atrial fibrillation.

Echocardiography 2017 Nov 24;34(11):1708-1711. Epub 2017 Sep 24.

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

Among patients undergoing cardioversion for atrial fibrillation, the presence of left ventricular thrombus is a relatively uncommon and challenging clinical dilemma. While left atrial appendage thrombus is a contraindication to cardioversion, there is paucity of data regarding the safety of cardioversion in with the presence of left ventricular apical thrombus. Also, thrombus characteristics such as protrusion and mobility on echocardiography are known risk factors for systemic embolism. In this article, we present a case highlighting the management of atrial fibrillation in the setting of left ventricular dysfunction, acute heart failure, and echocardiographic evidence of acute left ventricular apical thrombus.
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http://dx.doi.org/10.1111/echo.13706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351065PMC
November 2017

Response by Vaidya et al to Letter Regarding Article, "Burden of Arrhythmia in Pregnancy".

Circulation 2017 07;136(2):244-245

From Departments of Medicine (V.R.V., P.A.F., M.M., S.K., P.A.N., Y.-M.C., B.G., S.J.A., A.J.D.), Pediatric and Adolescent Medicine (S.J.A.), and Physiology and Biomedical Engineering (S.J.A.), and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (P.A.N.), Mayo Clinic, Rochester, MN; Department of Cardiovascular Heart and Circulation, Mount Sinai's St Luke Roosevelt Hospital Center, New York City, NY (S.A.); Leonard M. Miller School of Medicine, University of Miami, FL (N.P.); Department of Heart and Vascular (Cardiology), The Everett Clinic, WA (A.B.); Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, NJ (N.P., K.A.); Section of Neonatology, Department of Pediatrics, University of Washington, Seattle (Z.B.); and Stanford University School of Medicine, CA (M.P.T.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.028571DOI Listing
July 2017

The effect of mitral valve surgery on ventricular arrhythmia in patients with bileaflet mitral valve prolapse.

Indian Pacing Electrophysiol J 2016 Nov - Dec;16(6):187-191. Epub 2016 Oct 24.

Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Electronic address:

Background: Bileaflet mitral valve prolapse (biMVP) is associated with frequent ventricular ectopy (VE) and malignant ventricular arrhythmia. We examined the effect of mitral valve (MV) surgery on VE burden in biMVP patients.

Methods: We included 32 consecutive patients undergoing MV surgery for mitral regurgitation secondary to biMVP between 1993 and 2012 at Mayo Clinic who had available pre- and post-operative Holter monitoring data. Characteristics of patients with a significant reduction in postoperative VE (group A, defined as >10% reduction in VE burden compared to baseline) were compared with the rest of study patients (group B).

Results: In the overall cohort, VE burden was unchanged after the surgery (41 interquartile range [16, 196] pre-surgery vs. 40 interquartile range [5186] beats/hour [bph] post-surgery; P = 0.34). However, in 17 patients (53.1%), VE burden decreased by at least 10% after the surgery. These patients (group A) were younger than the group B (59 ± 15 vs. 68 ± 7 years; P = 0.04). Other characteristics including pre- and postoperative left ventricular function and size were similar in both groups. Age <60 years was associated with a reduction in postoperative VE (odds ratio 5.8; 95% confidence interval, 1.1-44.7; P = 0.03). Furthermore, there was a graded relationship between age and odds of VE reduction with surgery (odds ratio 1.9; 95% confidence interval 1.04-4.3 per 10-year; P = 0.04).

Conclusions: MV surgery does not uniformly reduce VE burden in patients with biMVP. However, those patients who do have a reduction in VE burden are younger, perhaps suggesting that early surgical intervention could modify the underlying electrophysiologic substrate.
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http://dx.doi.org/10.1016/j.ipej.2016.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5219837PMC
October 2016
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