Publications by authors named "William Whang"

107 Publications

Anhedonic Depression Is Not Associated With Risk of Recurrent Major Adverse Cardiac Events and All-Cause Mortality in Acute Coronary Syndrome Patients.

Ann Behav Med 2021 Oct 12. Epub 2021 Oct 12.

Center for Personalized Health, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.

Background: Depression after acute coronary syndrome (ACS) is common and increases risks of adverse outcomes, but it remains unclear which depression features are most associated with major adverse cardiac events (MACE) and all-cause mortality (ACM).

Purpose: To examine whether a subtype of depression characterized by anhedonia and major depressive disorder (MDD) predicts 1-year MACE/ACM occurrence in ACS patients compared to no MDD history. We also consider other depression features in the literature as predictors.

Methods: Patients (N = 1,087) presenting to a hospital with ACS completed a self-report measure of current depressive symptoms in-hospital and a diagnostic interview assessing MDD within 1 week post-hospitalization. MACE/ACM events were assessed at 1-, 6-, and 12-month follow-ups. Cox regression models were used to examine the association of the anhedonic depression subtype and MDD without anhedonia with time to MACE/ACM, adjusting for sociodemographic and clinical covariates.

Results: There were 142 MACE/ACM events over the 12-month follow-up. The 1-year MACE/ACM in patients with anhedonic depression, compared to those with no MDD, was somewhat higher in an age-adjusted model (hazard ratio [HR] = 1.63, p = .08), but was not significant after further covariate adjustment (HR = 1.24, p = .47). Of the additional depression features, moderate-to-severe self-reported depressive symptoms significantly predicted the risk of MACE/ACM, even in covariate-adjusted models (HR = 1.72, p = .04), but the continuous measure of self-reported depressive symptoms did not.

Conclusion: The anhedonic depression subtype did not uniquely predict MACE/ACM as hypothesized. Moderate-to-severe levels of total self-reported depressive symptoms, however, may be associated with increased MACE/ACM risk, even after accounting for potential sociodemographic and clinical confounders.
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http://dx.doi.org/10.1093/abm/kaab092DOI Listing
October 2021

Prognostic Value of Electrocardiographic QRS Diminution in Patients Hospitalized With COVID-19 or Influenza.

Am J Cardiol 2021 Nov 9;159:129-137. Epub 2021 Aug 9.

Icahn School of Medicine at Mount Sinai Hospital: Mount Sinai Heart, New York, New York. Electronic address:

During the clinical care of hospitalized patients with COVID-19, diminished QRS amplitude on the surface electrocardiogram (ECG) was observed to precede clinical decompensation, culminating in death. This prompted investigation into the prognostic utility and specificity of low QRS complex amplitude (LoQRS) in COVID-19. We retrospectively analyzed consecutive adults admitted to a telemetry service with SARS-CoV-2 (n = 140) or influenza (n = 281) infection with a final disposition-death or discharge. LoQRS was defined as a composite of QRS amplitude <5 mm or <10 mm in the limb or precordial leads, respectively, or a ≥50% decrease in QRS amplitude on follow-up ECG during hospitalization. LoQRS was more prevalent in patients with COVID-19 than influenza (24.3% vs 11.7%, p = 0.001), and in patients who died than survived with either COVID-19 (48.1% vs 10.2%, p <0.001) or influenza (38.9% vs 9.9%, p <0.001). LoQRS was independently associated with mortality in patients with COVID-19 when adjusted for baseline clinical variables (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.9 to 33.8, p <0.001), presenting and peak troponin, D-dimer, C-reactive protein, albumin, intubation, and vasopressor requirement (OR 13.8, 95% CI 1.3 to 145.5, p = 0.029). The median time to death in COVID-19 from the first ECG with LoQRS was 52 hours (interquartile range 18 to 130). Dynamic QRS amplitude diminution is a strong independent predictor of death over not only the course of COVID-19 infection, but also influenza infection. In conclusion, this finding may serve as a pragmatic prognostication tool reflecting evolving clinical changes during hospitalization, over a potentially actionable time interval for clinical reassessment.
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http://dx.doi.org/10.1016/j.amjcard.2021.07.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349698PMC
November 2021

How does the level of pulmonary venous isolation compare between pulsed field ablation and thermal energy ablation (radiofrequency, cryo, or laser)?

Europace 2021 Jun 21. Epub 2021 Jun 21.

Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029, USA.

Aims: We studied the extent/area of electrical pulmonary vein isolation (PVI) after either pulsed field ablation (PFA) using a pentaspline catheter or thermal ablation technologies.

Methods And Results: In a clinical trial (NCT03714178), paroxysmal atrial fibrillation (PAF) patients underwent PVI with a multi-electrode pentaspline PFA catheter using a biphasic waveform, and after 75 days, detailed voltage maps were created during protocol-specified remapping studies. Comparative voltage mapping data were retrospectively collected from consecutive PAF patients who (i) underwent PVI using thermal energy, (ii) underwent reablation for recurrence, and (iii) had durably isolated PVs. The left and right PV antral isolation areas and non-ablated posterior wall were quantified. There were 20 patients with durable PVI in the PFA cohort, and 39 in the thermal ablation cohort [29 radiofrequency ablation (RFA), 6 cryoballoon, and 4 visually guided laser balloon]. Pulsed field ablation patients were younger with shorter follow-up. Left atrial diameter and ventricular systolic function were preserved in both cohorts. There was no significant difference between the PFA and thermal ablation cohorts in either the left- and right-sided PV isolation areas, or the non-ablated posterior wall area. The right superior PV isolation area was smaller with PFA than RFA, but this disappeared after propensity score matching. Notch-like normal voltage areas were seen at the posterior aspect of the carina in the balloon sub-cohort, but not the PFA or RFA cohorts.

Conclusion: Catheter-based PVI with the pentaspline PFA catheter creates chronic PV antral isolation areas as encompassing as thermal energy ablation.
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http://dx.doi.org/10.1093/europace/euab150DOI Listing
June 2021

Assessment of Catheter Ablation or Antiarrhythmic Drugs for First-line Therapy of Atrial Fibrillation: A Meta-analysis of Randomized Clinical Trials.

JAMA Cardiol 2021 Jun;6(6):697-705

Helmsley Center for Cardiac Electrophysiology, Mount Sinai Hospital, New York, New York.

Importance: Early rhythm control of atrial fibrillation (AF) with either antiarrhythmic drugs (AADs) or catheter ablation has been reported to improve cardiovascular outcomes compared with usual care; however, the optimal therapeutic modality to achieve early rhythm control is unclear.

Objective: To assess the safety and efficacy of AF ablation as first-line therapy when compared with AADs in patients with paroxysmal AF.

Data Sources: PubMed/MEDLINE, Scopus, Google Scholar, and various major scientific conference sessions from January 1, 2000, through November 23, 2020.

Study Selection: Randomized clinical trials (RCTs) published in English that had at least 12 months of follow-up and compared clinical outcomes of ablation vs AADs as first-line therapy in adults with AF. The quality of individual studies was assessed using the Cochrane risk of bias tool. Six RCTs met inclusion criteria, including 1212 patients.

Data Extraction And Synthesis: Two investigators independently extracted data. Reporting was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. Analysis was performed using a random-effects model with the Mantel-Haenszel method, and results are presented as 95% CIs.

Main Outcomes And Measures: Main outcomes were safety and efficacy of AF ablation as first-line therapy when compared with AADs. Trials were evaluated as having low risk of selection and attrition biases, high risk of performance bias, and with unclear risk for detection biases due to unblinding and open-label designs.

Results: A total of 6 RCTs involving 1212 patients with AF were included (609 were randomized to AF ablation and 603 to drug therapy; mean [SD] age, 56 [11] years). Compared with AADs, catheter ablation use was associated with reductions in recurrent atrial arrhythmia (32.3% vs 53%; risk ratio [RR], 0.62; 95% CI, 0.51-0.74; P < .001; I2 = 40%), with a number needed to treat with ablation to prevent 1 arrhythmia of 5. Use of ablation was also associated with reduced symptomatic atrial arrhythmia (11.8% vs 26.4%; RR, 0.44; 95% CI, 0.27-0.72; P = .001; I2 = 54%) and hospitalization (5.6% vs 18.7%; RR, 0.32; 95% CI, 0.19-0.53; P < .001) with no significant difference in serious adverse events between the groups (4.2% vs 2.8%; RR, 1.52; 95% CI, 0.81-2.85; P = .19).

Conclusions And Relevance: In this meta-analysis of randomized clinical trials including first-line therapy of patients with paroxysmal AF, catheter ablation compared with antiarrhythmic drugs was associated with reductions in recurrence of atrial arrhythmias and hospitalizations, with no difference in major adverse events.
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http://dx.doi.org/10.1001/jamacardio.2021.0852DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082432PMC
June 2021

Atrial Fibrillation in Patients Hospitalized With COVID-19: Incidence, Predictors, Outcomes, and Comparison to Influenza.

JACC Clin Electrophysiol 2021 09 24;7(9):1120-1130. Epub 2021 Feb 24.

Department of Cardiovascular Medicine, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objectives: The goal of this study is to determine the incidence, predictors, and outcomes of atrial fibrillation (AF) or atrial flutter (AFL) in patients hospitalized with coronavirus disease-2019 (COVID-19).

Background: COVID-19 results in increased inflammatory markers previously associated with atrial arrhythmias. However, little is known about their incidence or specificity in COVID-19 or their association with outcomes.

Methods: This is a retrospective analysis of 3,970 patients admitted with polymerase chain reaction-positive COVID-19 between February 4 and April 22, 2020, with manual review performed of 1,110. The comparator arm included 1,420 patients with influenza hospitalized between January 1, 2017, and January 1, 2020.

Results: Among 3,970 inpatients with COVID-19, the incidence of AF/AFL was 10% (n = 375) and in patients without a history of atrial arrhythmias it was 4% (n = 146). Patients with new-onset AF/AFL were older with increased inflammatory markers including interleukin 6 (93 vs. 68 pg/ml; p < 0.01), and more myocardial injury (troponin-I: 0.2 vs. 0.06 ng/ml; p < 0.01). AF and AFL were associated with increased mortality (46% vs. 26%; p < 0.01). Manual review captured a somewhat higher incidence of AF/AFL (13%, n = 140). Compared to inpatients with COVID-19, patients with influenza (n = 1,420) had similar rates of AF/AFL (12%, n = 163) but lower mortality. The presence of AF/AFL correlated with similarly increased mortality in both COVID-19 (relative risk: 1.77) and influenza (relative risk: 1.78).

Conclusions: AF/AFL occurs in a subset of patients hospitalized with either COVID-19 or influenza and is associated with inflammation and disease severity in both infections. The incidence and associated increase in mortality in both cohorts suggests that AF/AFL is not specific to COVID-19, but is rather a generalized response to the systemic inflammation of severe viral illnesses.
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http://dx.doi.org/10.1016/j.jacep.2021.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904279PMC
September 2021

Barriers and financial impact of same-day discharge after atrial fibrillation ablation.

Pacing Clin Electrophysiol 2021 04 15;44(4):711-719. Epub 2021 Mar 15.

Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Same-day discharge (SDD) after atrial fibrillation (AF) ablation is increasingly being considered. This study examined the barriers and financial impact associated with SDD in a contemporary cohort of patients undergoing elective AF ablation.

Methods: A single center retrospective review was conducted of the 249 first case-of-the-day outpatient AF ablations performed in 2019 to evaluate the proportion of patients that could have undergone SDD. Barriers to SDD were defined as any intervention that prevented SDD by 8 p.m. The financial impact of SDD was based on savings from avoidance of the overnight hospital stay and revenue related to management of chest pain facilitated by a vacant hospital bed.

Results: SDD could have occurred in 157 patients (63%) without change in management and in up to 200 patients (80%) if avoidable barriers were addressed. Barriers to SDD included non-clinical logistical issues (43%), prolonged post-procedure recovery (42%) and minor procedural complications (15%). On multivariate analysis, factors associated with barriers to SDD included increasing age (P = .01), left ventricular ejection fraction ≤ 35% (P = .04), and severely dilated left atrium (P = .04). The financial gain from SDD would have ranged from $1,110,096 (assuming discharge of 63% of eligible patients) to $1,480,128 (assuming 80% discharge) over the course of a year.

Conclusions: Up to 80% of patients undergoing outpatient AF ablation were amenable to SDD if avoidable delays in care had been anticipated. Based on reduced hospital operating expenses and increased revenue from management of individuals with chest pain, this would translate to a financial savings of ∼$1.5 million.
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http://dx.doi.org/10.1111/pace.14217DOI Listing
April 2021

Transcatheter embolic coils to treat peridevice leaks after left atrial appendage closure.

Heart Rhythm 2021 05 4;18(5):717-722. Epub 2021 Feb 4.

Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

Background: Left atrial appendage closure (LAAC) has proven to be an effective alternative to long-term oral anticoagulation in the prevention of thromboembolic events in patients with atrial fibrillation. In a minority of patients, inadequate seal may result in persistent peridevice flow and inability of the appendage to fully thrombose, thereby representing a potential source for thromboembolism.

Objective: The purpose of this study was to study the use of endovascular coiling of the appendage to address persistent peridevice leak in patients undergoing LAAC with the Watchman device.

Methods: This is a retrospective single-center analysis involving patients who underwent placement of a LAAC device and returned for endovascular coiling to address persistent device leak between 2018 and 2020. Baseline characteristics, procedural outcomes, and follow-up echocardiograms were analyzed to demonstrate the feasibility and safety of this technique.

Results: Patients (N = 20) were identified with a mean leak size of 3.8 ± 1.3 mm (range 2.5-7 mm), all of whom had a non-thrombosed appendage. Acute procedural success was achieved in 95% of patients. Complete or significant reduction in flow beyond the LAAC device was achieved in 61% and 33% of patients, respectively. The 1 procedure-related adverse event was a pericardial effusion before coil deployment, requiring percutaneous drainage.

Conclusion: The clinical impact of residual peridevice leak post-Watchman implantation is a matter of continuing investigation. However, appendage coiling represents a new therapeutic tool to address this potential source for thromboembolism. Further studies should address the clinical impact of this technique, including the safety of discontinuing anticoagulation after successful coiling.
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http://dx.doi.org/10.1016/j.hrthm.2021.01.030DOI Listing
May 2021

Renal Sympathetic Denervation as Upstream Therapy During Atrial Fibrillation Ablation: Pilot HFIB Studies and Meta-Analysis.

JACC Clin Electrophysiol 2021 01 28;7(1):109-123. Epub 2020 Oct 28.

Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

Objectives: This study sought to determine the impact of adjunctive renal sympathetic denervation to catheter ablation in patients with atrial fibrillation (AF) and history of hypertension.

Background: There are limited data regarding the impact of upstream adjunctive renal sympathetic denervation (RSDN) to pulmonary vein isolation (PVI) in patients with symptomatic atrial fibrillation (AF) and hypertension.

Methods: The data for this study were obtained from 2 prospective randomized pilot studies, the HFIB (Adjunctive Renal Denervation to Modify Hypertension and Sympathetic tone as Upstream Therapy in the Treatment of Atrial Fibrillation)-1 (n = 30) and HFIB (Adjunctive Renal Denervation to Modify Hypertension and Sympathetic tone as Upstream Therapy in the Treatment of Atrial Fibrillation)-2 (n = 50) studies, and we performed a meta-analysis including all published studies comparing RSDN+PVI versus PVI alone up to January 25, 2020, in patients with AF and hypertension.

Results: At 24 months, AF recurrence occurred in 53% and 38% in the PVI and PVI+RSDN groups (p = 0.43) in the HFIB-1 study, respectively, and 27% and 25% in the PVI and PVI+RSDN groups (p = 0.80) in the HFIB-2 study, respectively. When combined in a meta-analysis including 6 studies (n = 725), adjunctive RSDN significantly decreased the risk of AF recurrence (risk ratio [RR]: 0.68; 95% confidence interval [CI]: 0.55 to 0.83; p = 0.0002; I = 0%) when compared with PVI. Six renal artery complications occurred in the HFIB-1 study and none occurred in the HFIB-2 study with RSDN. However, in the meta-analysis, there were no significant differences in overall complications between both groups (RR: 1.43; 95% CI: 0.63 to 3.22; p = 0.40; I = 7%). When compared with baseline, RDSN significantly reduced the systolic blood pressure (-12.1 mm Hg; 95% CI: -20.9 to -3.3 mm Hg; p < 0.007; I = 99%) and diastolic blood pressure (-5.60 mm Hg; 95% CI: -10.05 to -1.10 mm Hg; p = 0.01; I = 98%) on follow-up.

Conclusions: The pilot HFIB-1 and HFIB-2 studies did not demonstrate a benefit with RSDN as an adjunctive upstream therapy during PVI. However, in the meta-analysis, adjunctive RSDN to PVI appears to be safe, and improves clinical outcomes in AF patients with a history of hypertension.
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http://dx.doi.org/10.1016/j.jacep.2020.08.013DOI Listing
January 2021

Malignant Arrhythmias in Patients With COVID-19: Incidence, Mechanisms, and Outcomes.

Circ Arrhythm Electrophysiol 2020 11 7;13(11):e008920. Epub 2020 Oct 7.

Department of Cardiovascular Medicine, Helmsley Electrophysiology Center (M.K.T., D.M., E.C., P.S., I.K., M.B., W.W., M.A.M., S.C., J.S.K., N.L., A.S., S.R.D., V.Y.R.), Icahn School of Medicine at Mount Sinai, New York, NY.

Background: Patients with coronavirus disease 2019 (COVID-19) who develop cardiac injury are reported to experience higher rates of malignant cardiac arrhythmias. However, little is known about these arrhythmias-their frequency, the underlying mechanisms, and their impact on mortality.

Methods: We extracted data from a registry (NCT04358029) regarding consecutive inpatients with confirmed COVID-19 who were receiving continuous telemetric ECG monitoring and had a definitive disposition of hospital discharge or death. Between patients who died versus discharged, we compared a primary composite end point of cardiac arrest from ventricular tachycardia/fibrillation or bradyarrhythmias such as atrioventricular block.

Results: Among 800 patients with COVID-19 at Mount Sinai Hospital with definitive dispositions, 140 patients had telemetric monitoring, and either died (52) or were discharged (88). The median (interquartile range) age was 61 years (48-74); 73% men; and ethnicity was White in 34%. Comorbidities included hypertension in 61%, coronary artery disease in 25%, ventricular arrhythmia history in 1.4%, and no significant comorbidities in 16%. Compared with discharged patients, those who died had elevated peak troponin I levels (0.27 versus 0.02 ng/mL) and more primary end point events (17% versus 4%, =0.01)-a difference driven by tachyarrhythmias. Fatal tachyarrhythmias invariably occurred in the presence of severe metabolic imbalance, while atrioventricular block was largely an independent primary event.

Conclusions: Hospitalized patients with COVID-19 who die experience malignant cardiac arrhythmias more often than those surviving to discharge. However, these events represent a minority of cardiovascular deaths, and ventricular tachyarrhythmias are mainly associated with severe metabolic derangement. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04358029.
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http://dx.doi.org/10.1161/CIRCEP.120.008920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668347PMC
November 2020

Syncope and presyncope in patients with COVID-19.

Pacing Clin Electrophysiol 2020 10 12;43(10):1139-1148. Epub 2020 Sep 12.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.

Introduction: Recent studies have described several cardiovascular manifestations of COVID-19 including myocardial ischemia, myocarditis, thromboembolism, and malignant arrhythmias. However, to our knowledge, syncope in COVID-19 patients has not been systematically evaluated. We sought to characterize syncope and/or presyncope in COVID-19.

Methods: This is a retrospective analysis of consecutive patients hospitalized with laboratory-confirmed COVID-19 with either syncope or presyncope. This "study" group (n = 37) was compared with an age and gender-matched cohort of patients without syncope ("control") (n = 40). Syncope was attributed to various categories. We compared telemetry data, treatments received, and clinical outcomes between the two groups.

Results: Among 1000 COVID-19 patients admitted to the Mount Sinai Hospital, the incidence of syncope/presyncope was 3.7%. The median age of the entire cohort was 69 years (range 26-89+ years) and 55% were men. Major comorbidities included hypertension, diabetes, and coronary artery disease. Syncopal episodes were categorized as (a) unspecified in 59.4% patients, (b) neurocardiogenic in 15.6% patients, (c) hypotensive in 12.5% patients, and (d) cardiopulmonary in 3.1% patients with fall versus syncope and seizure versus syncope in 2 of 32 (6.3%) and 1 of 33 (3.1%) patients, respectively. Compared with the "control" group, there were no significant differences in both admission and peak blood levels of d-dimer, troponin-I, and CRP in the "study" group. Additionally, there were no differences in arrhythmias or death between both groups.

Conclusions: Syncope/presyncope in patients hospitalized with COVID-19 is uncommon and is infrequently associated with a cardiac etiology or associated with adverse outcomes compared to those who do not present with these symptoms.
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http://dx.doi.org/10.1111/pace.14047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461520PMC
October 2020

Follow-up imaging after left atrial appendage closure.

Heart Rhythm 2020 11 27;17(11):1848-1855. Epub 2020 Jun 27.

Cardiology Division, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

Background: Because device-related thrombus (DRT) portends a poor prognosis after left atrial appendage closure with the Watchman device, surveillance transesophageal echocardiography (TEE) is recommended at 45 days and 1 year. However, oral anticoagulants are just discontinued at 45 days, rendering this early TEE unlikely to detect DRT. Indeed, DRT is most likely to occur after instituting aspirin monotherapy.

Objective: The purpose of this study was to evaluate the alternative strategy of first TEE imaging (or computed tomography) at 4 months post-Watchman implantation.

Methods: After Food and Drug Administration approval, consecutive patients undergoing Watchman implantation at 2 centers received TEE or CT at 4 months and 1 year, along with a truncated drug regimen: 6 weeks of an oral anticoagulant (or clopidogrel in a subset) plus aspirin, then 6 weeks of dual antiplatelet therapy, and finally aspirin monotherapy.

Results: Of the 530-patient cohort (mean age 78.7±7.9 years; 65.5% (n = 347) male; CHADS-VASc score 4.5±1.4), 465 patients (87.7%) received 4-month imaging: 83.0% (440 of 530) TEE and 4.7% (25 of 530) computed tomography. Over a median follow-up of 12 months, 16 ischemic strokes (ISs), 8 transient ischemic attacks, and 1 systemic embolization occurred. Importantly, no IS occurred between 45 days and 4 months; the sole transient ischemic attack in this period (at ∼2 months) occurred 1 week after transcatheter aortic valve replacement. DRT was detected in 2.4% (11 of 465) at 4 months and 0.9% (2 of 214) at 1 year. No IS, but 1 leg embolization, was observed after DRT detection.

Conclusion: Delaying the first imaging post-Watchman implantation to 4 months was associated with no IS between 45 days and 4 months, the "vulnerable" period of this follow-up strategy.
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http://dx.doi.org/10.1016/j.hrthm.2020.06.024DOI Listing
November 2020

Ostial dimensional changes after pulmonary vein isolation: Pulsed field ablation vs radiofrequency ablation.

Heart Rhythm 2020 09 4;17(9):1528-1535. Epub 2020 May 4.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York; Cardiology Department, Homolka Hospital, Prague, Czech Republic. Electronic address:

Background: Pulmonary vein (PV) stenosis is an important potential complication of PV isolation using thermal modalities such as radiofrequency ablation (RFA). Pulsed field ablation (PFA) is an alternative energy that causes nonthermal myocardial cell death.

Objective: The purpose of this study was to compare the effect of PFA vs RFA on the incidence and severity of PV narrowing or stenosis.

Methods: Data were analyzed from 4 paroxysmal atrial fibrillation ablation trials using either PFA or RFA; because of absent CT scans or poor computed tomography scan quality, 73 of 153 patients (47.7%) were excluded. Baseline and 3-month cardiac computed tomography scans were reconstructed into 3-dimensional images, and the long and short axes of the PV ostia were quantitatively and qualitatively assessed in a randomized blinded manner by 2 physicians.

Results: A total of 299 PVs from 80 patients after either PFA (n = 37) or RFA (n = 43) were enrolled. PV ostial diameters decreased significantly less with PFA than with RFA (% change; long axis: 0.9% ± 8.5% vs -11.9% ± 16.3%; P < .001 and short axis: 3.4% ± 12.7% vs -12.9% ± 18.5%; P < .001). After a combined quantitative/qualitative analysis, mild (30%-49%), moderate (50%-69%), or severe (70%-100%) PV narrowing was observed, respectively, in 9.0% (15 of 166), 1.8% (3 of 166), and 1.2% (2 of 166) of PVs in the RFA cohort but in none of the PVs after PFA (P < .001). Overall, PV narrowing/stenosis was present in 0% and 0% vs 12.0% and 32.5% of PVs and patients who underwent PFA and RFA, respectively.

Conclusion: This study indicates that unlike after RFA, the incidence and severity of PV narrowing/stenosis after PV isolation is virtually eliminated with PFA.
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http://dx.doi.org/10.1016/j.hrthm.2020.04.040DOI Listing
September 2020

Automated Noncontact Ultrasound Imaging and Ablation System for the Treatment of Atrial Fibrillation: Outcomes of the First-in-Human VALUE Trial.

Circ Arrhythm Electrophysiol 2020 03 12;13(3):e007917. Epub 2020 Feb 12.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, NY (M.K.T., W.W., S.R.D., V.Y.R.).

Background: Catheter ablation for atrial fibrillation (AF) using point-by-point radiofrequency energy or single-application one-shot balloons is either technically challenging or have limited ability to accommodate variable patient anatomy to achieve acute and durable pulmonary vein (PV) isolation. A novel ablation system employs low intensity collimated ultrasound (LICU)-guided anatomic mapping and robotic ablation to isolate PVs. In this first-in-human, single-center, multioperator trial, VALUE trial (VytronUS Ablation System for Treatment of Paroxysmal Atrial Fibrillation; NCT03639597) in patients with paroxysmal atrial fibrillation, this LICU system was evaluated to determine its safety, effectiveness in PV isolation, and freedom from recurrent atrial arrhythmias.

Methods: In the enrolled 52 patients with paroxysmal atrial fibrillation, ultrasound M-mode-based left atrial anatomies were successfully created, and ablation was performed under robotic control along an operator-defined lesion path. The LICU system software advanced over the course of the study: the last 13 patients were ablated with enhanced software.

Results: Acute PV isolation was achieved in 98% of PVs-using LICU-only in 77.3% (153/198) of PVs and requiring touch-up with a standard radiofrequency ablation catheter in 22.7% (45/198) PVs. The touch-up rate decreased to 5.8% (3/52) in patients undergoing LICU-ablation with enhanced software. Freedom from atrial arrhythmia recurrence was 79.6% (39/49 patients) at 12 months or 92.3% (12/13 patients) with the enhanced software. Major adverse events occurred in 3 patients (5.8%): one had transient diaphragmatic paralysis, one vascular access complication, and one had transient ST-segment elevation from air-embolism, without sequelae.

Conclusions: In this first-in-human study, low- intensity collimated ultrasound-guided anatomic mapping and robotic ablation allows PV isolation with good chronic safety; PV isolation success is improving with device enhancements. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03639597.
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http://dx.doi.org/10.1161/CIRCEP.119.007917DOI Listing
March 2020

RADAR: A Multicenter Food and Drug Administration Investigational Device Exemption Clinical Trial of Persistent Atrial Fibrillation.

Circ Arrhythm Electrophysiol 2020 01 16;13(1):e007825. Epub 2020 Jan 16.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (S.C., S.R.D., W.W., V.Y.R.).

Background: Pulmonary vein isolation is insufficient to treat all patients with persistent atrial fibrillation (AF), and effective adjunctive ablation strategies are needed. Ablation of AF drivers holds promise, but current technologies to identify drivers are limited by spatial resolution. In a single-arm, first-in-human, investigator-initiated Food and Drug Administration Investigational Device Exemption study, we used a novel system for real-time, high-resolution identification of AF drivers in persistent AF.

Methods: Patients with persistent or long-standing persistent AF underwent ablation using the RADAR (Real-Time Electrogram Analysis for Drivers of Atrial Fibrillation) system in conjunction with a standard electroanatomical mapping system. After pulmonary vein isolation, electrogram and spatial information was streamed to the RADAR system and analyzed to identify driver domains to target for ablation.

Results: Across 4 centers, 64 subjects were enrolled: 73% male, age, 64.7±9.5 years; body mass index, 31.7±6.0 kg/m; left atrium size, 54±10 mm, with persistent/long-standing persistent AF in 53 (83%)/11 (17%), prior AF ablation (re-do group) in 26 (41%). After 12.6±0.8 months follow-up, 68% remained AF-free off all antiarrhythmics; 74% remained AF-free and 66% remained AF/atrial tachycardia/atrial flutter-free on or off AADs (antiarrhythmic drugs). AF terminated with ablation in 35 patients (55%) overall and in 23/38 (61%) of de novo ablation patients. For patients with AF termination during ablation, 82% remained AF-free and 74% AF/atrial tachycardia/atrial flutter-free during follow-up on or off AADs. Patients undergoing first-time ablation generally had higher rates of freedom from AF than the re-do group.

Conclusions: This novel technology for panoramic mapping of AF drivers showed promising results in a persistent/long-standing persistent AF population. These data provide the scientific basis for a randomized trial.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03263702; IDE#G170049.
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http://dx.doi.org/10.1161/CIRCEP.119.007825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970579PMC
January 2020

Net Clinical Benefit of Left Atrial Appendage Closure Versus Warfarin in Patients With Atrial Fibrillation: A Pooled Analysis of the Randomized PROTECT-AF and PREVAIL Studies.

J Am Heart Assoc 2019 12 22;8(23):e013525. Epub 2019 Nov 22.

Mount Sinai Heart The Zena and Michael A. Wiener Cardiovascular Institute, and The Marie-Josée and Henry R. Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai New York NY.

Background The PROTECT-AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy) trials demonstrated noninferiority of left atrial appendage closure (LAAC) to warfarin for the composite end point of stroke, systemic embolism, or cardiovascular death. This study aims to quantify the net clinical benefit (NCB) of LAAC versus warfarin, accounting for differences in clinical impact of different event types. Methods and Results We performed a post hoc analysis of the PROTECT-AF and PREVAIL trials, which randomized atrial fibrillation patients to LAAC or warfarin in a 2:1 fashion. The trials enrolled patients in the United States and Europe between 2005 and 2012 with paroxysmal, persistent, or permanent atrial fibrillation and CHADS risk scores ≥1. Relative to an index weight for death (1.0), events were assigned weights based on their disabling effect: (1) stroke event weights were based on modified Rankin scores in the base case analyses, and (2) major bleed (0.05) and pericardial effusion (0.05). NCB was calculated as the sum of weight-adjusted events per 100 patient-years. Among 1114 randomized subjects, the NCB of LAAC was 1.42% per year (95% CI 0.01-2.82, =0.04) and a relative risk of 0.74 (95% CI 0.56-1.00). NCB point estimates favored warfarin early in follow-up, but trended in favor of LAAC after 1 to 2 years. The benefit of LAAC was preserved across subgroups, with particular benefit observed in the subgroup of prior stroke and without diabetes mellitus. Conclusions This analysis demonstrates long-term NCB of LAAC with Watchman over warfarin therapy, as the upfront risk of periprocedural events is counterbalanced over time by reduced bleeding events and mortality. Clinical Trial Registration UR: http://www.clinicaltrials.gov. Unique identifiers: NCT01182441 and NCT00129545.
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http://dx.doi.org/10.1161/JAHA.119.013525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6912972PMC
December 2019

Recurrent atrial fibrillation/flutter detection after ablation or cardioversion using the AliveCor KardiaMobile device: iHEART results.

J Cardiovasc Electrophysiol 2019 11 25;30(11):2220-2228. Epub 2019 Sep 25.

Department of Medicine - Cardiology, Columbia University Irving Medical Center, New York, New York.

Objective: This study evaluated the impact of daily ECG (electrocardiogram) self-recordings on time to documented recurrent atrial fibrillation (AF) or atrial flutter (AFL) and time to treatment of recurrent arrhythmia in patients undergoing catheter radiofrequency ablation (RFA) or direct current cardioversion (DCCV) for AF/AFL.

Background: AF recurrence rates after RFA and DCCV are 20% to 45% and 60% to 80%, respectively. Randomized trials comparing mobile ECG devices to standard of care have not been performed in an AF/AFL population after treatment.

Methods: Of 262 patients consented, 238 were randomized to either standard of care (123) or to receive the iHEART intervention (115). Patients in the intervention group were provided with and trained to use an AliveCor KardiaMobile ECG monitor, and were instructed to take and transmit daily ECG recordings. Data were collected from transmitted ECG recordings and patients' electronic health records.

Results: In a multivariate Cox model, the likelihood of recurrence detection was greater in the intervention group (hazard ratio = 1.56, 95% confidence interval [CI]: 1.06-2.30, P = .024). Hazard ratios did not differ significantly for RFA and DCCV procedures. Recurrence during the first month after ablation strongly predicted later recurrence (hazard ratio = 4.53, 95% CI: 2.05-10.00, P = .0006). Time from detection to treatment was shorter for the control group (hazard ratio = 0.33, 95% CI: 0.57-2.92, P < .0001).

Conclusions: The use of mobile ECG self-recording devices allows for earlier detection of AF/AFL recurrence and may empower patients to engage in shared health decision-making.
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http://dx.doi.org/10.1111/jce.14160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819233PMC
November 2019

Does Left Atrial Appendage Closure Reduce Mortality? A Vital Status Analysis of the Randomized PROTECT AF and PREVAIL Clinical Trials.

J Atr Fibrillation 2018 Dec 31;11(4):2119. Epub 2018 Dec 31.

Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Compared with warfarin, left atrial appendage closure (LAAC) reduced mortality in an analysis of the PROTECTAF and PREVAIL trials. However, these data were limited by patient drop-out.We sought to estimatethe mortality benefit with LAACusing updated vital status information.In PROTECT AF and PREVAIL, 227 of 1114 randomized subjects failed to complete 5-year follow-up. Centers were manually queried for updated vital status on 76 subjects (33%).During median follow-up 5.0 years (interquartile range 3.8, 5.1), 112 of 732 LAAC subjects (15.3%) and 79 of 382 controls (20.7%) died. The hazard ratio for all-cause mortality with LAAC compared with warfarin was 0.70 (95% CI 0.53-0.94, p=0.017).Subgroup analyses suggested that subjects <75 years and those with higher CHA2DS2-VASc score, history of transient ischemic attack or stroke, and permanent AF derived particular benefit, although interaction terms were not significant.The number needed to treat(NNT) with LAAC to prevent one death over 5 years was 16 (95% CI 10-82). Despite competing mortality risks in this elderly cohort, updated vital status data from PROTECT AF and PREVAIL revealed that LAAC was associated with 30% improved survival compared with warfarin, with an NNT of 16.
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http://dx.doi.org/10.4022/jafib.2119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533844PMC
December 2018

Catheter Ablation for Atrial Tachycardia in Adults With Congenital Heart Disease: Electrophysiological Predictors of Acute Procedural Success and Post-Procedure Atrial Tachycardia Recurrence.

JACC Clin Electrophysiol 2019 Apr 30;5(4):438-447. Epub 2019 Jan 30.

Cardiac Electrophysiology Unit, Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York. Electronic address:

Objectives: This study sought to determine the electrophysiological predictors of acute procedural success and of post-ablation recurrence of atrial tachyarrhythmias (ATs) in our adult congenital heart disease (ACHD) population undergoing catheter ablation for treatment of AT.

Background: Catheter ablation is frequently performed to treat persistent AT in ACHD. The predictors of post-ablation AT recurrence have not been well studied in the ACHD population.

Methods: The authors performed a retrospective study of all catheter ablations for treatment of AT performed in ACHD patients between December 1, 2005, and July 20, 2017, at Columbia University Medical Center. Pre-specified clinical and procedural data of interest and the time from ablation to recurrence were determined by chart and procedure report review.

Results: A total of 140 patients (mean age: 45 years) underwent catheter ablation for 182 AT. Of the AT, 179 (93%) were intra-atrial macro-re-entrant tachycardia, and 12 (7%) had a focal origin. The presence of a single mechanism was a predictor of acute procedural success that could be achieved in 89% of the patients. At a median of 49.9 months, 62 patients (44%) had recurrent AT. Time to recurrence was significantly shorter (12.5 months) for recurrent AT in 13 of the 20 patients with previous Fontan procedure. By multivariable analysis, acute procedural success was a positive predictor and prior surgical maze procedure was a negative predictor of AT-free survival. Of the 62 patients with recurrent AT, 42 (68%) had a second catheter ablation procedure, and in 22 of these, the AT mechanism was different than previously observed.

Conclusions: Catheter ablation for AT in ACHD patients is an effective method of arrhythmia control. More than 1 AT mechanism per patient is common. Acute procedural success is a predictor of freedom from AT recurrence. The majority of patients achieve multiple arrhythmia-free years.
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http://dx.doi.org/10.1016/j.jacep.2018.10.011DOI Listing
April 2019

Septal accessory pathway and the value of para-Hisian entrainment.

HeartRhythm Case Rep 2019 Feb 11;5(2):78-79. Epub 2018 Jun 11.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.

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http://dx.doi.org/10.1016/j.hrcr.2018.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379302PMC
February 2019

Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials.

Ann Intern Med 2019 01 25;170(1):41-50. Epub 2018 Dec 25.

Mount Sinai Hospital, New York, New York (M.K.T., J.G., W.W., S.S., J.S.K., M.A.M., N.L., A.S., A.G., S.C., S.R.D., V.Y.R.).

This article has been corrected. The original version (PDF) is appended to this article as a Supplement.

Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist and are associated with increased morbidity and mortality risk.

Purpose: To compare benefits and harms between catheter ablation and drug therapy in adult patients with AF and HF.

Data Sources: ClinicalTrials.gov, PubMed, Web of Science (Clarivate Analytics), EBSCO Information Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from 1 January 2005 to 1 October 2018.

Study Selection: Randomized controlled trials (RCTs) published in English that had at least 6 months of follow-up and compared clinical outcomes of catheter ablation versus drug therapy in adults with AF and HF.

Data Extraction: 2 investigators independently extracted data and assessed study quality.

Data Synthesis: 6 RCTs involving 775 patients met inclusion criteria. Compared with drug therapy, AF ablation reduced all-cause mortality (9.0% vs. 17.6%; risk ratio [RR], 0.52 [95% CI, 0.33 to 0.81]) and HF hospitalizations (16.4% vs. 27.6%; RR, 0.60 [CI, 0.39 to 0.93]). Ablation improved left ventricular ejection fraction (LVEF) (mean difference, 6.95% [CI, 3.0% to 10.9%]), 6-minute walk test distance (mean difference, 20.93 m [CI, 5.91 to 35.95 m]), peak oxygen consumption (Vo2max) (mean difference, 3.17 mL/kg per minute [CI, 1.26 to 5.07 mL/kg per minute]), and quality of life (mean difference in Minnesota Living with Heart Failure Questionnaire score, -9.02 points [CI, -19.75 to 1.71 points]). Serious adverse events were more common in the ablation groups, although differences between the ablation and drug therapy groups were not statistically significant (7.2% vs. 3.8%; RR, 1.68 [CI, 0.58 to 4.85]).

Limitation: Results driven primarily by 1 clinical trial, possible patient selection bias in the ablation group, lack of patient-level data, open-label trial designs, and heterogeneous follow-up length among trials.

Conclusion: Catheter ablation was superior to conventional drug therapy in improving all-cause mortality, HF hospitalizations, LVEF, 6-minute walk test distance, Vo2max, and quality of life, with no statistically significant increase in serious adverse events.

Primary Funding Source: None.
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http://dx.doi.org/10.7326/M18-0992DOI Listing
January 2019

Predictors and rates of recurrence of atrial arrhythmias following catheter ablation in adults with congenital heart disease.

Congenit Heart Dis 2019 Mar 19;14(2):207-212. Epub 2018 Nov 19.

Division of Cardiology, Department of Medicine, Schneeweiss Adult Congenital Heart Center, Columbia University Medical Center, New York, New York.

Background: Catheter ablation is commonly performed to treat atrial arrhythmias in adult congenital heart disease (ACHD). Despite the frequency of ablations in the ACHD population, predictors of recurrence remain poorly defined.

Objective: We sought to determine predictors of arrhythmia recurrence in ACHD patients following catheter ablation for atrial arrhythmias.

Methods: We performed a retrospective study of all catheter ablations for atrial arrhythmias performed in ACHD patients between January 12, 2005 and February 11, 2015 at our institution. Prespecified exposures of interest and time from ablation to recurrence were determined via chart review.

Results: Among 124 patients (mean age: 45 years) who underwent catheter ablation, 96 (77%) were treated for macro-reentrant atrial tachycardia, 10 (7%) for focal atrial tachycardia, 9 (7%) for atrial fibrillation, 7 (6%) for atrioventricular nodal reentrant tachycardia, and 2 (2%) for atrioventricular reentrant tachycardia. 15 (12%) required transseptal/transbaffle puncture. Fifty-one percent of patients recurred with a median time to recurrence of 1639 days. By univariate and multivariable analysis, body mass index (BMI) and Fontan status were the only variables associated with recurrence. Dose-dependent effect was observed with overweight (HR = 2.37, P = .012), obese (HR = 2.67, P = .009), and morbidly obese (HR = 4.23, P = .003) patients demonstrating an increasing risk for arrhythmia recurrence postablation. There was no significant different in recurrence rates by gender, age, non-Fontan diagnosis, or need for transseptal puncture.

Conclusions: In our cohort of ACHD patients, BMI was a significant risk factor for arrhythmia recurrence postablation, independent of Fontan status. These findings may help guide treatment decisions for persistent arrhythmias in the ACHD population.
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http://dx.doi.org/10.1111/chd.12695DOI Listing
March 2019

Mitral isthmus ablation: A hierarchical approach guided by electroanatomic correlation.

Heart Rhythm 2019 04 10;16(4):632-637. Epub 2018 Oct 10.

Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York, New York. Electronic address:

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http://dx.doi.org/10.1016/j.hrthm.2018.10.005DOI Listing
April 2019

Esophageal Deviation During Atrial Fibrillation Ablation: Clinical Experience With a Dedicated Esophageal Balloon Retractor.

JACC Clin Electrophysiol 2018 08 30;4(8):1020-1030. Epub 2018 May 30.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

Objectives: The goal of this study was to determine the safety and feasibility of a novel esophageal balloon retractor (DV8) for MED during PVI.

Background: The authors previously showed that mechanical esophageal deviation (MED) is feasible using an off-the-shelf metal stylet to allow uninterrupted ablation along the posterior left atrium during pulmonary vein isolation (PVI). Although it is an attractive strategy to avoid esophageal thermal injury, this technique was hampered by both the propensity for oropharyngeal trauma from the stiff stylet and the limited lateral esophageal displacement.

Methods: In 200 consecutive patients undergoing atrial fibrillation ablation, the DV8 balloon retractor was used for MED; contrast was instilled into the esophagus to accurately delineate the trailing esophageal edge. Deviation was performed to maximize the distance from the trailing esophageal edge to the closest point of the ablation line (MED) and correlated to occurrences of luminal esophageal temperature elevation.

Results: In patients undergoing MED during a first-ever PVI of 304 vein pairs, the MED during right and left PVI were 21.2 ± 8.7 mm and 15.5 ± 6.8 mm, respectively. Deviation of at least 5 mm of MED was achievable in 97.7%. Luminal esophageal temperature increases universally occurred (100%) at MED <5 mm, less often (28%) at MED 5 to 20 mm, and rarely (1.9%) at MED >20 mm. There were no esophageal complications, but 2 patients experienced oropharyngeal bleeding due to trauma related to device placement.

Conclusions: MED with the balloon retractor safely moved the esophagus away from the site of energy delivery during atrial fibrillation ablation.
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http://dx.doi.org/10.1016/j.jacep.2018.04.001DOI Listing
August 2018

Real-time optical spectroscopic monitoring of nonirrigated lesion progression within atrial and ventricular tissues.

J Biophotonics 2019 04 26;12(4):e201800144. Epub 2018 Dec 26.

Department of Electrical Engineering, Columbia University, New York, NY.

Despite considerable advances in guidance of radiofrequency ablation (RFA) therapy for the treatment of cardiac arrhythmias, success rates have been hampered by a lack of tools for precise intraoperative evaluation of lesion extent. Near-infrared spectroscopic (NIRS) techniques are sensitive to tissue structural and biomolecular properties, characteristics that are directly altered by radiofrequency (RF) treatment. In this work, a combined NIRS-RFA catheter is developed for real-time monitoring of tissue reflectance during RF energy delivery. An algorithm is proposed for processing NIR spectra to approximate nonirrigated lesion depth in both atrial and ventricular tissues. The probe optical geometry was designed to bias measurement influence toward absorption enabling enhanced sensitivity to changes in tissue composition. A set of parameters termed "lesion optical indices" are defined encapsulating spectral differences between ablated and unablated tissue. Utilizing these features, a model for real-time tissue spectra classification and lesion size estimation is presented. Experimental validation conducted within freshly excised porcine cardiac specimens showed strong concordance between algorithm estimates and post-hoc tissue assessment.
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http://dx.doi.org/10.1002/jbio.201800144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353711PMC
April 2019

Posttraumatic stress disorder in patients who rule out versus rule in for acute coronary syndrome.

Gen Hosp Psychiatry 2018 Jul - Aug;53:101-107. Epub 2018 May 16.

Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th St, New York, NY 10032, USA.

Objective: Many patients who present to the emergency department (ED) with acute coronary syndromes (ACS) develop posttraumatic stress disorder (PTSD) due to the experience. Less is known about risk for PTSD in patients who rule out for ACS. Our objective was to compare the risk of developing PTSD among patients who rule out versus rule in for ACS.

Methods: We enrolled a consecutive sample of 1000 patients presenting to an emergency department (ED) with symptoms of a probable ACS. We assessed presenting ACS symptoms in the ED. We determined whether presenting symptoms were due to a confirmed ACS or another etiology by chart review. We assessed PTSD by telephone 1 month after discharge using the PTSD Checklist specific for the suspected ACS event (PCL-S). We used logistic regression to determine the association of ruling out versus ruling in for ACS with a positive PTSD screen (PCL-S ≥ 32), adjusting for demographics, comorbidities, depression, trauma history, and pre-existing PTSD.

Results: Approximately two-thirds of patients (68.2%) ruled out for ACS. Compared to confirmed ACS patients, patients who ruled out had similar presenting symptoms, and similar risk of screening positive for PTSD (18.9% versus 16.8%; p = 0.47; adjusted OR 1.18, 95% CI 0.69-2.00; p = 0.55).

Conclusions: ED presentation with ACS symptoms was sufficient to trigger a positive PTSD screen whether the etiology was due to a life-threatening ACS or another etiology. Patients who present with ACS symptoms should be considered for interventions to prevent PTSD after hospitalization, regardless of symptom etiology.
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http://dx.doi.org/10.1016/j.genhosppsych.2018.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6291417PMC
November 2018

Association of positive well-being with reduced cardiac repolarization abnormalities in the First National Health and Nutrition Examination Survey.

Int J Cardiol 2018 Aug 2;265:246-250. Epub 2018 May 2.

Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States; Division of Cardiology, Department of Medicine, Atlanta Veterans Affairs Medical Center, Atlanta, GA, United States. Electronic address:

Background: The mechanisms by which psychological factors may influence possibly arrhythmia risk are not known. We hypothesized that psychological wellness, measured by the General Well-Being Schedule (GBWS), is associated with less repolarization heterogeneity as measured by T-axis. We also explored whether T-axis was a mediator in the relationship of GWBS with adverse cardiac outcomes.

Methods: We studied 5533 adults aged 25-74 years without a history of CVD from NHANES I (National Health and Nutrition Examination Survey) (1971-75). Frontal T-axis was obtained through 12-lead ECG and characterized as normal (15° to 75°), borderline (-15° to 15° or 75° to 105°) or abnormal (>105° or <-15°).

Results: The mean ± SD age was 43.1 ± 11.5 years and 55% were women. A 1-SD increase in GWBS score associated with a 23% reduced odds of abnormal T-axis (p < 0.001) and 11% lower hazard of composite CHD hospitalization and death (p = 0.02). When adjusting for sociodemographic factors, health behaviors, and CHD risk factors, the association was minimally changed and remained statistically significant. Additional adjustment for T-axis did not change the relationship with outcomes.

Conclusion: General well-being is independently associated with less abnormal frontal T-axis and CHD events in otherwise healthy individuals.
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http://dx.doi.org/10.1016/j.ijcard.2018.04.135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994381PMC
August 2018

Evaluating the Utility of mHealth ECG Heart Monitoring for the Detection and Management of Atrial Fibrillation in Clinical Practice.

J Atr Fibrillation 2017 Feb-Mar;9(5):1546. Epub 2017 Feb 28.

Senior Faculty.

Background: Little attention has focused on the integration of mobile health (mHealth) technology with self-management approaches to improve the detection and management of atrial fibrillation (AF) in clinical practice.

Objective: The objective of this study was to investigate the differences between mHealth and usual care over a 6-month follow-up period among patients with a known history of atrial fibrillation.

Methods: A pilot cohort from within the larger ongoing randomized trial, iPhone® Helping Evaluate Atrial fibrillation Rhythm through Technology (iHEART), was evaluated to determine differences in detection of AF and atrial flutter (AFL) recurrence rates (following treatment to restore normal rhythm) between patients undergoing daily smartphone ECG monitoring and age and gender matched control patients. SF-36v2 QoL assessments were administered at baseline and 6 months to a subset of the patients undergoing daily ECG monitoring. Differences between groups were assessed by t-test, Fisher's exact test, and Cox proportional hazard models.

Results: Among the 23 patients with smartphone ECG monitors (16 males and 7 females, mean age 55 ± 10), 14 (61%) had detection of recurrent AF/AFL versus 30% of controls. During the follow-up period, patients given smartphone ECG monitors were more than twice as likely to have an episode of recurrent AF/AFL detected (hazard ratio: 2.55; 95% CI: 1.06 - 6.11; p = 0.04). Among the 13 patients with baseline and 6 month QoL assessments, significant improvements were observed in the physical functioning (p = 0.009), role physical (p = 0.007), vitality (p = 0.03), and mental health domains (p = 0.02).

Conclusions: Cardiac mHealth self-monitoring is a feasible and effective mechanism for enhancing AF/AFL detection that improves quality of life.
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http://dx.doi.org/10.4022/jafib.1546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673393PMC
February 2017

Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Indications, Strategies, and Outcomes-Part II.

J Am Coll Cardiol 2017 Dec;70(23):2924-2941

Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

In contrast to ventricular tachycardia (VT) that occurs in the setting of a structurally normal heart, VT that occurs in patients with structural heart disease carries an elevated risk for sudden cardiac death (SCD), and implantable cardioverter-defibrillators (ICDs) are the mainstay of therapy. In these individuals, catheter ablation may be used as adjunctive therapy to treat or prevent repetitive ICD therapies when antiarrhythmic drugs are ineffective or not desired. However, certain patients with frequent premature ventricular contractions (PVCs) or VT and tachycardiomyopathy should be considered for ablation before ICD implantation because left ventricular function may improve, consequently decreasing the risk of SCD and obviating the need for an ICD. The goal of this paper is to review the pathophysiology, mechanism, and management of VT in the setting of structural heart disease and discuss the evolving role of catheter ablation in decreasing ventricular arrhythmia recurrence.
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http://dx.doi.org/10.1016/j.jacc.2017.10.030DOI Listing
December 2017

Catheter Ablation of Ventricular Tachycardia in Structurally Normal Hearts: Indications, Strategies, and Outcomes-Part I.

J Am Coll Cardiol 2017 Dec;70(23):2909-2923

Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

Catheter ablation of ventricular tachycardia (VT) is being increasingly performed; yet, there is often confusion regarding indications, outcomes, and how to identify those patient populations most likely to benefit. The management strategy differs between those with structural heart disease and those without. For the former, an implantable cardioverter-defibrillator (ICD) is typically required due to an elevated risk for sudden cardiac death, and catheter ablation can be used as adjunctive therapy to treat or prevent repetitive ICD therapies. In contrast, VT or premature ventricular contractions in the setting of a structurally normal heart carries a low risk for sudden cardiac death; accordingly, there is typically no indication for an ICD. In these patients, catheter ablation is considered for symptom management or to treat tachycardiomyopathy and is potentially curative. Here, the authors discuss the pathophysiology, mechanism, and management of VT that occurs in the setting of a structurally normal heart and the role of catheter ablation.
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http://dx.doi.org/10.1016/j.jacc.2017.10.031DOI Listing
December 2017

Electrocardiographic Findings in National Basketball Association Athletes.

JAMA Cardiol 2018 01;3(1):69-74

Division of Cardiology, Columbia University Medical Center, New York, New York.

Importance: While it is known that long-term intensive athletic training is associated with cardiac structural changes that can be reflected on surface electrocardiograms (ECGs), there is a paucity of sport-specific ECG data. This study seeks to clarify the applicability of existing athlete ECG interpretation criteria to elite basketball players, an athlete group shown to develop significant athletic cardiac remodeling.

Objective: To generate normative ECG data for National Basketball Association (NBA) athletes and to assess the accuracy of athlete ECG interpretation criteria in this population.

Design, Setting, And Participants: The NBA has partnered with Columbia University Medical Center to annually perform a review of policy-mandated annual preseason ECGs and stress echocardiograms for all players and predraft participants. This observational study includes the preseason ECG examinations of NBA athletes who participated in the 2013-2014 and 2014-2015 seasons, plus all participants in the 2014 and 2015 NBA predraft combines. Examinations were performed from July 2013 to May 2015. Data analysis was performed between December 2015 and March 2017.

Exposures: Active roster or draft status in the NBA and routine preseason ECGs and echocardiograms.

Main Outcomes And Measures: Baseline quantitative ECG variables were measured and ECG data qualitatively analyzed using 3 existing, athlete-specific interpretation criteria: Seattle (2012), refined (2014), and international (2017). Abnormal ECG findings were compared with matched echocardiographic data.

Results: Of 519 male athletes, 409 (78.8%) were African American, 96 (18.5%) were white, and the remaining 14 (2.7%) were of other races/ethnicities; 115 were predraft combine participants, and the remaining 404 were on active rosters of NBA teams. The mean (SD) age was 24.8 (4.3) years. Physiologic, training-related changes were present in 462 (89.0%) athletes in the study. Under Seattle criteria, 131 (25.2%) had abnormal findings, compared with 108 (20.8%) and 81 (15.6%) under refined and international criteria, respectively. Increased age and increased left ventricular relative wall thickness (RWT) on echocardiogram were highly associated with abnormal ECG classifications; 17 of 186 athletes (9.1%) in the youngest age group (age 18-22 years) had abnormal ECGs compared with 36 of the 159 athletes (22.6%) in the oldest age group (age 27-39 years) (odds ratio, 2.9; 95% CI, 1.6-5.4; P < .001). Abnormal T-wave inversions (TWI) were present in 32 athletes (6.2%), and this was associated with smaller left ventricular cavity size and increased RWT. One of the 172 athletes (0.6%) in the lowest RWT group (range, 0.24-0.35) had TWIs compared with 24 of the 163 athletes (14.7%) in the highest RWT group (range, 0.41-0.57) (odds ratio, 29.5; 95% CI, 3.9-221.0; P < .001).

Conclusions And Relevance: Despite the improved specificity of the international recommendations over previous athlete-specific ECG criteria, abnormal ECG classification rates remain high in NBA athletes. The development of left ventricular concentric remodeling appears to have a significant influence on the prevalence of abnormal ECG classification and repolarization abnormalities in this athlete group.
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http://dx.doi.org/10.1001/jamacardio.2017.4572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833528PMC
January 2018
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