CLINICAL ABSTRACTS
Methods: Lead extraction operative notes and perioperative documentation
OPTIMAL TECHNIQUES FOR LATE GADOLINIUM-ENHANCED MRI:
COMPARISON OF DELAY TIME, SLICE THICKNESS, AND MULTIPLANAR
RECONSTRUCTION VS MAXIMUM INTENSITY PROJECTION FOR ASSESSMENT
OF FIBROSIS IN ATRIAL FIBRILLATION
I.M. Khurram, R. Beinart, V. Zipunnikov, H. Calkins, S. Nazarian,
S.L. Zimmerman
Johns Hopkins University, Baltimore, MD.
Background: Left atrial (LA) late gadolinium enhancement (LGE) mag-
netic resonance imaging (MRI) has varying protocols, which may limit
interstudy comparisons. This study evaluates whether changes in image
acquisition and reconstruction parameters affect quantification of LA
LGE MRI.
Methods: A total of 200 LGE MRI scans were prepared using various
techniques from 5 subjects. 3D respiratory and ECG-gated LGE images
were acquired at 15, 20, 25, and 30 minutes after contrast. Multiplanar
reconstructions (MPR) and maximum intensity projections (MIP) were
created from 3D data at various slice thicknesses. LA LGE was quantified
with image intensity ratio (IIR, atrial wall signal intensity divided by blood
pool). Mean IIR was calculated for the entire LA as a metric of LGE burden.
Additionally, in 42 consecutive preablation patients, local IIR values
from 3.5-mm MPR and MIP reconstructions were separately registered to
LA electroanatomic voltage maps (EAM) obtained prior to ablation
procedure.
Results: Multitime point LGE-MRI showed a rise in baseline mean IIR of
0.5% ⫾ 0.1% per minute (P o.001) in MPR and a rise of 0.6% ⫾ 0.1% (P
o.001) for MIP using regression analysis (Figure A). The MPR- and MIP-
based mean IIRs diverged, showing change of –0.3% for MPR and þ1.1%
for MIP for 1-mm increase in slice thickness (P o.001 for both; Figure B).
A total of 4428 EAM points were registered to local LA wall IIRs from both
MPR and MIP techniques. An increase of a single unit of IIR was related to
drop in 1.20 mV with MPR and 1.25 mV with MIP (P o.001 for both).
Conclusions: Variations in timing of acquisition, image reconstruction
methods, and slice thickness result in changes in LA LGE quantity.
A HYBRID APPROACH TO INTRAVENOUS LEAD MANAGEMENT: THE
UNC EXPERIENCE
R. Macfie, A. Kiser
University of North Carolina, Chapel Hill, NC.
Background: Since November 2010, physicians at the University of North
Carolina (UNC) have taken a unique approach to cardiovascular implantable
electronic device (CIED) lead extraction: the cardiac surgeon and electro-
physiologist (EP) collaborate to extract and reimplant leads. This study
compares this new shared technique with EP-only and surgeon-only
extraction.
1547-5271/$-see front matter B 2013 Published by Elsevier Inc. on behalf of Heart Rhythm Society.
from 2007–2012 were reviewed. In the standard and surgeon-only
approaches the respective EP or surgeon performs the entire procedure. In
the hybrid approach the cardiac surgeon does the lead extraction and the EP
completes the reimplantation; both physicians are engaged for the
entire case.
Results: Over the study period 28 patients underwent hybrid extraction, 35
underwent standard extraction, and 8 patients underwent surgeon-only
extraction. Patients undergoing hybrid lead extraction had a significantly
higher rate of invasive pressure monitoring (89% vs 6%, P o.05); use of
transesophageal echocardiography (TEE) (61% vs 3%, P o.05); and use of
general anesthesia (100% vs 63%, P o.05) compared to those undergoing
standard extraction. Use of a laser was more common when the surgeon
performed the extraction (78% vs 23%, P o.05), suggesting increased case
complexity. A major complication occurred in the hybrid group where a
swift sternotomy resolved the issue. There was a trend toward decreased
postoperative complications in patients undergoing hybrid extractions.
Surgeon-only extractions were significantly more likely to involved invasive
pressure monitoring, TEE, general anesthesia, and prolonged hospital stays.
The institution of hybrid lead management has contributed to 118% case
growth in lead extractions.
Conclusions: This review suggests that a hybrid, collaborative approach to
intravenous CIED lead management can provide excellent patient outcomes
and practice growth.
LONE T-WAVE ALTERNANS VS T-WAVE ALTERNANS COUPLED WITH
MECHANICAL ALTERNANS CARRY DIFFERENT RISKS
L. Tereshchenko1, R. Kim2, O. Cingolani1, I. Wittstein1, R. McLean1,
L. Han2, K. Cheng2, E. Robinson1, J. Brinker1, R. Berger1, C. Henrikson1,
S. Schulman1
1
Johns Hopkins University SOM, Baltimore, MD, 2Johns Hopkins
University, Baltimore, MD.
Background: T-wave alternans (TWA) and mechanical alternans (MA) can
be coupled. The goal of this study was to compare outcomes in patents with
MA and TWA.
Methods: A prospective cohort study was conducted in the intensive
cardiac care unit and enrolled 133 patients (59.6 ⫾ 15.7 years; 65% men)
admitted with acute heart failure (HF). Surface ECG and peripheral arterial
blood pressure waveform via arterial line were recorded continuously.
MA and TWA were measured by enhanced modified moving average
method. All-cause death or heart transplant served as a combined primary
endpoint.
Results: MA was observed in 28 patients (25%), whereas TWA was
detected in 33 patients (33%). If present, MA was tightly coupled with
TWA. Mitral flow deceleration time was shorter (127 ⫾ 61 ms vs 172 ⫾ 80
ms, P ¼ .030), and left atrial systolic diameter was larger (5.1 ⫾ 1.3 mm vs
4.4 ⫾ 0.9 mm, P ¼ .020) in patients with MA compared to those without.
Mean TWA amplitude was larger in patients with both TWA and MA
compared to patients with lone TWA (median 37 [interquartile range 26–61]
mV vs 22 [21–23] mV, P ¼ .045). After adjustment for New York Heart
Association HF class, MA was associated with the primary endpoint (HR
2.3, 95% confidence interval 1.15–4.59, P ¼ .018), whereas all lone TWA
patients remained alive. Univariate Kaplan-Meier survival analysis showed
the worst survival in patients with both MA and TWA at baseline, whereas
patients without alternans had an intermediate probability of survival
(Figure 1). All patients with lone TWA remained free from the primary
endpoint.
http://dx.doi.org/10.1016/j.clinthera.2013.07.340