Tushar V Salukhe

Royal Brompton and Harefield NHS Foundation Trust, Harefield, England, United Kingdom

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Publications (41)259.23 Total impact

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    ABSTRACT: Recent evidence supports left atrial appendage closure (LAAC) as a cost-effective alternative to warfarin. However these findings, based on clinical trial populations, may not be generalisable to clinical practice. The cost-impact of a real world experience of LAAC compared with warfarin, dabigatran, rivaroxaban, apixaban, aspirin and no therapy in patients with nonvalvular atrial fibrillation (NVAF) is unknown.
    Europace 10/2014; 16 Suppl 3:iii17. DOI:10.1093/europace/euu240.3 · 3.05 Impact Factor
  • Hitesh C Patel, Tushar V Salukhe
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    ABSTRACT: Renal denervation is increasingly being adopted as a treatment option in patients with resistant hypertension. The long-term safety of this procedure is unknown. Though the procedure interrupts the sympathetic nerves at the renal level, it also has effects on other organ beds, notably the heart and vasculature. These effects have been purported to be clinically beneficial and thus formed a rationale for examining the role of renal denervation in other conditions, including heart failure, arrhythmia, obstructive sleep apnoea and the metabolic syndrome. There is a theoretical concern that attenuating the renal sympathetic nerves might cause orthostatic hypotension or syncope. From the limited data available from hypertension trials, the procedure has not been associated with excessive episodes of syncope and this is supported by mechanistic tilt table data in asymptomatic patients. Ultimately, the safety of this technique will only be established once we have larger phase III/IV studies.
    International journal of cardiology 01/2014; 172(1). DOI:10.1016/j.ijcard.2013.12.163 · 6.18 Impact Factor
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    ABSTRACT: -The role of subsequent atrial tachycardias (AT) in the context of persistent atrial fibrillation (AF) remains undetermined. This study evaluated the prognostic role of subsequent ATs for arrhythmia recurrences following catheter ablation of persistent AF. -A total of 110 patients with persistent AF (63±9 y, 22 female, 61 long-lasting persistent AF) underwent pulmonary vein isolation followed by electrogram-guided ablation. After AF terminated to AT, patients were separated by the randomization protocol to receive either direct cardioversion (group A) or further ablation of subsequent ATs to sinus rhythm (SR) (group B). After a mean follow-up (FU) of 20.1±13.3 months after the first procedure, significantly more group B patients were in SR as compared to patients in group A (30 (57%) vs. 18 (34%), p=0.02). Moreover, recurrences of AF were significantly less frequent of group B than in group A patients (10 (19%) vs. 26 (49%), p=0.001). After the last procedure (FU 34.0±6.4 months), significantly more group B patients were free of AF as compared to patients of group A (49 (92%) vs. 39 (74%), p=0.01). The proportion of AT recurrences did not differ between the two groups after the first and final procedure. The strongest predictor for an arrhythmia free survival after a single procedure was randomization to the procedural endpoint of termination to SR by elimination of subsequent ATs (p=0.004). -Catheter ablation of subsequent ATs increases freedom from AF but not AT, suggesting a contributing role of subsequent ATs in the mechanisms of persistent AF. Clinical Trial Registration-URL: http://www.clinicaltrials.gov; Unique identifier: NCT01896570.
    Circulation Arrhythmia and Electrophysiology 10/2013; 6(6). DOI:10.1161/CIRCEP.113.001019 · 5.95 Impact Factor
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    ABSTRACT: Ivabradine, an I(f) current blocker, has shown promising results in treatment of postural orthostatic tachycardia syndrome (POTS). There is a subgroup of vasovagal syncope (VVS) patients, who demonstrate sinus tachycardia before collapse on tilt testing mimicking some features of POTS. These patients may also respond to ivabradine therapy.University Hospital Syncope Clinic where ivabradine was prescribed in a prospective fashion on humanitarian grounds between October 2008 and December 2011.METHODS AND RESULTS: Twenty-five patients of mean age 33±years presenting syncope in all and palpitation in 23, duration 9±years underwent tilt testing with reproduction of usual symptoms including tachycardia preceding collapse. Ivabradine was prescribed in doses of 5-20 mg/day, mean 10.7 mg, as once or twice daily medication. The response to treatment was classified as deterioration in none, no change in 5, improvement in 10, and symptoms abolished in 8 patients. Side effects were minimal; one patient required discontinuation.CONCLUSION: In this pilot study of ivabradine, in patients with VVS, of patients who demonstrated sinus tachycardia before collapse on tilt, 72% reported a marked benefit or complete resolution of symptoms. The drug was well tolerated. A randomized controlled trial against placebo is justified.
    Europace 09/2013; 16(2). DOI:10.1093/europace/eut226 · 3.05 Impact Factor
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    ABSTRACT: BACKGROUND: Contact force (CF) sensing technology allows real time CF measurement during catheter ablation. We hypothesised that the use of CF technology during pulmonary vein isolation (PVI) for atrial fibrillation (AF) would translate into lower acute pulmonary vein (PV) reconnection rates. METHODS AND RESULTS: Symptomatic AF patients were treated in two groups, 'unblinded' and 'blinded', each containing 20 patients undergoing first time PVI. An irrigated radiofrequency CF sensing catheter was used in both groups. In the 'unblinded' group, the operator could view the CF value during mapping and ablation in real time. In the 'blinded group', the operator was 'blinded' to this information during the procedure, although the data were recorded. All 80 PVs were successfully isolated with exit and entrance block re-tested after 1h with adenosine. There was a significant association between blinding and the rate of acute PV reconnection. 17/80 (21%) of the PVs in the blinded subjects had a reconnection while 3/80 (4%) of the PVs in the unblinded subjects had a reconnection (p=0.001). Blinding the operator resulted in lower mean CF overall (11.6g (10.5, 12.9g) vs. 14.4g (13.3, 15.7g); p=0.002). Sites where applied CF was significantly lower than others were usually the sites where reconnection occurred: these were the ridge between the left upper PV and appendage, and the right carina. CONCLUSIONS: CF data identified key areas where CF was poor. These were the areas of acute reconnection. Availability of real time CF information during PVI was associated with a significantly lower acute pulmonary vein reconnection rate.
    International journal of cardiology 12/2012; 168(2). DOI:10.1016/j.ijcard.2012.11.072 · 6.18 Impact Factor
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    ABSTRACT: Patients can expect a cure from atrial fibrillation (AF) with ablation. Procedural safety and success depend on patient comfort, compliance, and immobility. This is difficult to achieve with benzodiazepine and opiate boluses that are the mainstay of current practice. We sought to determine the safety and efficacy of propofol infusion sedation administered to patients without assisted ventilation for AF ablation. Procedural data from 1000 consecutive patients undergoing AF ablation were analysed. Sedation with 2% propofol was used in all procedures without assisted ventilation and was administered, monitored, and controlled by electrophysiologists. Primary outcome measures were adverse sedative affects including (i) respiratory depression (SpO(2)< 90% for >20 s) and (ii) persistent hypotension [systolic blood pressure (SBP)<90 mmHg at minimum sedation level]. Secondary endpoints included full recovery within 60 min and procedural complications. Of 1000 ablations, 506 ablations were performed for persistent and 494 for paroxysmal AF. Average patient age was 60.1 ± 11.3 years (72.3% male). Propofol was commenced in all patients at a mean infusion rate of 18.5 ± 4.8 mL/h with a mean baseline SBP of 140.3 ± 19.9 mmHg. Mean procedure time was 148.7 ± 57.7 min. Adverse sedative effects necessitating cessation of propofol and switch to midazolam bolus sedation occurred in 15.6% of patients (13.6% due to persistent hypotension, 1.9% due to respiratory depression, and 0.1% due to hypersalivation). Patients who had persistent hypotension were older (62.9 ± 11.2 vs. 60.0 ± 11.4 years, P= 0.011) and more likely to be female (39.5 vs. 23.7%, P< 0.001) than those who tolerated propofol. Patient age correlated to maximum blood pressure drop with propofol (R(2)= 0.101, P< 0.001) and inversely correlated to mean propofol infusion rate (R(2)= 0.066, P< 0.001). No procedures were abandoned due to adverse effects of sedation. All patients recovered within 60 min. Serious procedural complications, unrelated to sedation, occurred in 0.5%, all of whom had pericardial tamponade successfully treated with percutaneous pericardiocentesis. Sedation with 2% propofol infusion administered by cardiologists without assisted ventilation is safe, effective, and practical for use in AF ablation without serious or residual complications. In this setting, persistent hypotension is the most common acute adverse effect requiring cessation of propofol in ∼14%.
    Europace 03/2012; 14(3):325-30. DOI:10.1093/europace/eur328 · 3.05 Impact Factor
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    ABSTRACT: The aim of this study was to assess the role of a non-pharmacological approach on the frequency of traumatic injuries and syncope recurrence in patients with vasovagal syncope and normal hearts. We report the experience in our syncope centre with a standardized education and teaching protocol for patients with vasovagal syncope. The treatment of vasovagal syncope is often complex and discouraging. Besides medical options, behaviour modification is a main component of therapy but has no statistical evidence to support its use. Between January 1999 and September 2006, we prospectively enrolled all patients with vasovagal syncope. The patients were counselled about the benign nature of their disease. Specific recommendations were made according to a standardized education protocol established at our syncope centre. A pre-/post-study was conducted to investigate the effectiveness of our approach on syncope recurrence and frequency of injury as the study endpoints. Complete follow-up data were available from 85% of the study population (316 of 371) after a mean time of 710 ± 286 days (mean age 50 years; standard deviation ± 18 years, 160 female). Eighty-seven patients (27.5%) had a syncope recurrence with 22 suffering an injury during syncope. During the follow-up period, the syncope burden per month was significantly reduced from 0.35 ± 0.03 at initial presentation to 0.08 ± 0.02 (P< 0.001). The frequency of traumatic syncope was significantly lower at the time of recurrence compared with the initial presentation (25 vs. 42%; McNemar's test P= 0.02). A standardized education protocol significantly reduces traumatic injuries and syncope recurrence in patients with vasovagal syncope.
    Europace 11/2011; 14(3):410-5. DOI:10.1093/europace/eur341 · 3.05 Impact Factor
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    ABSTRACT: External biphasic electrical cardioversion (CV) is a standard treatment option for patients suffering from acute symptoms of atrial fibrillation (AF). Nevertheless, CV is not always successful, and thus strategies to increase the success rate are desirable. The purpose of this study was to evaluate the effect of intravenously administered K/Mg solution on the biphasic CV energy threshold and success rate to restore sinus rhythm (SR) in patients with AF. The study consisted of 170 patients with persistent AF. The patients were randomly assigned to undergo biphasic CV either with (n = 84) or without (n = 86) pretreatment with K/Mg solution. An energy step-up protocol of 75, 100, and 150 W (J) was used. Biphasic CV of AF was effective in 81 (96.4%) patients in the pretreatment and 74 (86.0%) patients in the control group (P = 0.005). The effective energy level required to achieve SR was significantly lower in the pretreated group (140.8 ± 26.9 J vs 182.5 ± 52.2 J, P = 0.02). No K/Mg-solution-associated side effects such as hypotension or bradycardia were observed. Administration of K/Mg solution positively influences the success rate of CV in patients with persistent AF. Furthermore, significantly less energy is required to successfully restore SR and therefore K/Mg pretreatment may facilitate SR restoration in patients undergoing CV for AF.
    Journal of Cardiovascular Electrophysiology 08/2011; 23(1):54-9. DOI:10.1111/j.1540-8167.2011.02146.x · 3.48 Impact Factor
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    ABSTRACT: IntroductionVisualisation of the ablation-related atrial scar using delayed-enhanced MRI (DE-MRI) may reveal important underlying causes for atrial fibrillation (AF) recurrence following ablation. In order to develop and objective method for delineating ablation-scar we compared pre and post DE-MRI after Cryo-balloon lesion on the basis that a more predictable lesion set would be created for validation.Methods and Results12 patients undergoing cryoablation for PAF were enrolled in the study, and underwent pre-ablation DE-MRI scans. Pulmonary vein isolation (PVI) was confirmed in all patients at the end of the cryoablation procedure using a circular mapping catheter. Additional ablation by RF or Freezer Max was required to achieve PVI in 59%. No ablation was performed in any region other than the PV ostia. Post-ablation DE-MRI was performed at 3 months. An automatic segmentation of the LA was produced with custom software from the MRA sequence. The preablation and postablation free breathing late gadolinium enhanced sequence was registered to the MRA and the maximum intensity within the LA wall was projected onto the post ablation LA surface. The blood pool was identified automatically using custom software as the region 1 cm inside the wall of the LA, and its mean (BPM) and SD used as a baseline. To identify a universal threshold for scar, regions of brightest myocardium were initially selected in pre and post ablation MRIs. The brightest regions were 1.9±1.2 vs 8.7±3.1 SDs above the BPM in pre-and post-ablation MRIs respectively (p=0.001). A threshold of 5 SDs above the BPM was therefore programmed into our custom software to identify regions of scar for all patients. The ostial regions were defined as extending 1 cm both proximal and distal to the PV–LA junction, and selected manually for left and right sided veins prior to scar projection. (See Abstract 149 figure 1). The scar proportion within these regions was calculated using commercially available software ITK-SNAP. Total LA scar proportion was 0.2±0.02% vs 6.3±0.75% in pre and post ablation scans respectively. The increase in scar seen in the PV ostia was 24.6±1.38% compared with 2.6±1.28% in the rest of the LA (p=0.01) (See Abstract 149 figure 2).Comparison of pre-ablation and post-ablation %scar using fixed threshold.Conclusion We have demonstrated the feasibility an objective, automated method of DE-MRI analysis of left atrial ablation-scar. This technique will now need to be validated against clinical outcomes.
    Heart (British Cardiac Society) 06/2011; 97(1). DOI:10.1136/heartjnl-2011-300198.149 · 6.02 Impact Factor
  • Journal of Cardiovascular Electrophysiology 05/2011; 22(12):1399-401. DOI:10.1111/j.1540-8167.2011.02073.x · 3.48 Impact Factor
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    ABSTRACT: Stepwise ablation is an effective treatment for persistent atrial fibrillation (AF), although it often requires multiple procedures to eliminate recurrent arrhythmias. This study evaluated single- and multiple-procedure long-term success rates and potential predictors of a favorable single-procedure outcome of stepwise ablation for persistent AF. This study comprised 395 patients with persistent AF (duration 16 months) undergoing de novo catheter ablation using the stepwise approach. Procedural success was defined as the absence of any arrhythmia recurrence. Patient characteristics and electrophysiological parameters were analyzed with respect to single- and multiple-procedure outcomes. After a follow-up of 27 ± 7 months, 108 (27%) patients were free of arrhythmia recurrences with a single procedure. After 2.3 ± 0.6 procedures, 312 (79%) patients were free of arrhythmia with concomitant antiarrhythmic treatment in 38% (23% on β-blocker). Female gender, duration of persistent AF, and congestive heart failure were predictive for the outcome after first ablation. However, the strongest predictors for single-procedure success were longer baseline AF cycle length (CL) and procedural AF termination. Moreover, procedural AF termination during the index procedure also predicted a favorable outcome after the last procedure, while the existence of congestive heart failure was associated with an increased risk for eventual arrhythmia recurrences. Single-procedure long-term success is anticipated in approximately a quarter of patients undergoing de novo ablation of persistent AF. Baseline AFCL emerged as the strongest predictor of single-procedure success, while AF termination during index ablation predicts the overall outcome. However, an overall success rate of 79% is achievable with multiple procedures.
    Heart rhythm: the official journal of the Heart Rhythm Society 04/2011; 8(9):1391-7. DOI:10.1016/j.hrthm.2011.04.012 · 4.56 Impact Factor
  • Richard Sutton, Tushar Salukhe
    Europace 03/2011; 13(3):306-7. DOI:10.1093/europace/euq497 · 3.05 Impact Factor
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    ABSTRACT: Catheter ablation (CA) is considered the treatment of choice for patients with atrioventricular nodal reentrant tachycardia (AVNRT). However, there is a tendency to avoid CA in the elderly because of a presumed increased risk of periprocedural atrioventricular (AV) nodal block. The purpose of this prospective registry was to assess age-related differences in the efficacy and safety of CA within a large population with AVNRT. A total of 3,234 consecutive patients from 48 German trial centers who underwent CA of AVNRT between March 2007 and May 2010 were enrolled in this study. The cohort was divided into three age groups: <50 years (group 1, n = 1,268 [39.2%]; median age = 40 [30.0-45.0] years, 74.1% women), 50-75 years old (group 2, n = 1,707 [52.8%]; 63.0 [58.0-69.0] years, 63.0% women), and > 75 years old (group 3, n = 259 [8.0%]; 79.0 [77.0-82.0] years, 50.6% women). CA was performed with radiofrequency current (RFC) in 97.7% and cryoablation technology in 2.3% of all cases. No differences were observed among the three groups with regard to primary CA success rate (98.7% vs. 98.8 % vs. 98.5%; P = .92) and overall procedure duration (75.0 minutes [50.0-105.0]; P = .93). Hemodynamically stable pericardial effusion occurred in five group 2 (0.3%) and two group 3 (0.8%) patients but in none of the group 1 (P <.05) patients. Complete AV block requiring permanent pacemaker implantation occurred in two patients in group 1 (0.2%) and six patients in group 2 (0.4%) but none in group 3 (P = 0.41). During a median follow-up period of 511.5 days (396.0-771.0), AVNRT recurrence occurred in 5.7% of all patients. Patients >75 years (group 3) had a significantly longer hospital stay (3.0 days [2.0-5.0]) compared with group 1 (2.0 days [1.0-2.0]) or group 2 (2.0 days [1.0-3.0]) patients (P <.0001). CA of AVNRT is highly effective and safe and does not pose an increased risk for complete AV block in patients over 75 years of age, despite a higher prevalence of structural heart disease. Antiarrhythmic drug therapy is often ineffective in this age group; thus, CA for AVNRT should be considered the preferred treatment even in elderly patients.
    Heart rhythm: the official journal of the Heart Rhythm Society 02/2011; 8(7):981-7. DOI:10.1016/j.hrthm.2011.02.008 · 4.56 Impact Factor
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    ABSTRACT: Pulmonary veins (PVs) usually drain into the left atrium (LA) and are frequently targeted for electrical isolation, since it became evident that PVs may trigger and maintain paroxysmal atrial fibrillation (AF). We present a patient with right-sided PVs anomalously connecting to the right atrium with lack of electrical PV-atrial connection. Therefore, isolation of the left veins was performed resulting in freedom from AF as shown during a midterm follow-up. These findings indicate that PV connection to the LA may be a prerequisite for the arrhythmogenic properties of the PVs causing AF.
    Pacing and Clinical Electrophysiology 11/2010; 35(3):e69-72. DOI:10.1111/j.1540-8159.2010.02962.x · 1.75 Impact Factor
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    ABSTRACT: Vasovagal syncope is a common cause of recurrent syncope. Clinically, these episodes may present as an isolated event with an identifiable trigger, or manifest as a cluster of recurrent episodes warranting intensive evaluation. The mechanism of vasovagal syncope is incompletely understood. Diagnostic tools such as implantable loop recorders may facilitate the identification of patients with arrhythmia mimicking benign vasovagal syncope. This review focuses on the management of vasovagal syncope and discusses the non-pharmacological and pharmacological treatment options, especially the use of midodrine and selective serotonin reuptake inhibitors. The role of cardiac pacing may be meaningful for a subgroup of patients who manifest severe bradycardia or asystole but this still remains controversial.
    World Journal of Cardiology (WJC) 10/2010; 2(10):308-15. DOI:10.4330/wjc.v2.i10.308 · 2.06 Impact Factor
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    ABSTRACT: To prevent atrial fibrillation (AF) recurrence after catheter ablation, pulmonary venous isolation (PVI) at an antral level is more effective than segmental ostial ablation. Cryoablation around the pulmonary venous (PV) ostia for AF therapy is potentially safer compared to radiofrequency ablation (RFA). The aim of this study was to investigate the efficacy of a strategy using a large cryoablation balloon to perform antral cryoablation with 'touch-up' ostial cryoablation for PVI in patients with paroxysmal and persistent AF. Paroxysmal and persistent AF patients undergoing their first left atrial ablation were recruited. After cryoballoon therapy, each PV was assessed for isolation and if necessary, treated with focal ostial cryoablation until PVI was achieved. Follow-up with Holter monitoring was performed. Clinical outcomes of the cryoablation protocol were compared, with consecutive patients undergoing PVI by RFA. 124 consecutive patients underwent cryoablation. 77% of paroxysmal and 48% of persistent AF subjects were free from AF at 12 months after a single procedure. Over the same time period, 53 consecutive paroxysmal AF subjects underwent PVI with RFA and at 12 months, 72% were free from AF at 12 months (p=NS). There were too few persistent AF subjects (n=8) undergoing solely PVI by RFA as a comparison group. Procedural and fluoroscopic times during cryoablation were significantly shorter than RFA. PV isolation can be achieved in less than 2 h by a simple cryoablation protocol with excellent results after a single intervention, particularly for paroxysmal AF.
    Heart (British Cardiac Society) 09/2010; 96(17):1379-84. DOI:10.1136/hrt.2009.192419 · 6.02 Impact Factor
    This article is viewable in ResearchGate's enriched format
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    ABSTRACT: Termination of persistent atrial fibrillation (AF) can be achieved through ablation, with the majority of patients terminating to an atrial tachycardia (AT) and fewer directly to sinus rhythm (SR). We aimed to identify potential predictors for the existence of a substrate for AT on termination to SR. We assessed 95 persistent AF patients (age, 60+/-10 years) who underwent catheter ablation to the end point of AF termination. Forty patients terminated directly to SR (SRterm) and 55 to ATs (ATterm). Compared with the ATterm group, the SRterm group were younger (56+/-10 versus 63+/-9 years, P=0.001), had shorter durations of AF before ablation (9+/-26 versus 14+/-20 months, P<0.001), smaller left atrial diameters (41+/-5 versus 45+/-5 mm, P=0.015), and longer baseline AF cycle lengths (178+/-23 versus 159+/-31 ms, P=0.005). However, AF cycle length was the sole independent predictor of direct termination to SR. The most frequent AF termination site in SRterm patients was the pulmonary veins (53%), whereas in ATterm patients this was within the left atrium (58%). After follow-up of 12+/-6 months, there was a trend toward a greater proportion of patients in SR among those who terminated directly to SR after a single procedure. The most frequent type of recurrence was paroxysmal AF in SRterm patients and AT in ATterm patients. Patients who terminate to SR through ablation without an intermediate AT are characterized by a less altered arrhythmogenic substrate. Baseline AF cycle lengths emerged as a sole independent predictor of a substrate for consecutive arrhythmias.
    Circulation Arrhythmia and Electrophysiology 08/2010; 3(4):351-60. DOI:10.1161/CIRCEP.110.945279 · 5.95 Impact Factor
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    ABSTRACT: Atrial tachycardias (AT) often occur after ablation of long-lasting persistent AF (CAF) and are difficult to treat conservatively. This study evaluated mechanisms and success rates of conventional mapping and catheter ablation of recurrent ATs occurring late after stepwise ablation of CAF. A total of 320 patients underwent de novo ablation of CAF using a stepwise ablation approach in 2006 to 2007 at our institution. This study comprised patients who presented with recurrent ATs at their first redo procedure after initial de novo CAF ablation. All procedures were guided by conventional mapping techniques exclusively. Sixty-one patients (63+/-10 years, 14 women) presented with their clinical AT at their redo procedure 7.7+/-4.4 months after initial de novo CAF ablation. A total of 133 ATs (2.2+/-0.9 per patient) were mapped. Forty-four (72%) were due to reentry; 17 (28%) were focal ATs. Reentry ATs were mainly characterized as roof and perimitral flutter (43% and 34%, respectively). Focal ATs mainly originated from the great thoracic veins (pulmonary veins: 41%, coronary sinus: 23%). Forty-five (74%) patients had conduction recovery of at least 1 pulmonary vein (mean, 1.2+/-0.8). Overall, 124 (93%) ATs could be ablated successfully. The mean procedure duration was 181+/-59 minutes, with a mean fluoroscopy time of 45+/-21 minutes. After a mean follow-up of 21+/-4 months, 50 (82%) patients were free of any arrhythmia recurrences after a single redo procedure. Although late recurrent ATs may have complex mechanisms, catheter ablation guided exclusively by conventional techniques is highly effective with excellent acute and long-term success rates.
    Circulation Arrhythmia and Electrophysiology 04/2010; 3(2):160-9. DOI:10.1161/CIRCEP.109.899021 · 5.95 Impact Factor
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    ABSTRACT: It is current practice to withhold implantable cardioverter defibrillators (ICD) from patients with severe heart failure because their deaths are judged as non-sudden and therefore assumed not to be preventable by ICD. If this was true, there should be a trend towards reduced preventability of deaths in the severe heart failure subgroups within existing randomised control ICD trials. We tested the prevailing assumption that patients with most severe heart failure would not benefit from ICD implantation. METHODS Six trials were identified enrolling 7873 patients, with 2734 patients randomly assigned to receive an ICD. Reduction in mortality in the ICD arm varied between 5.6% and 31%. All six trials provided data separated into higher and lower ejection fraction subgroups. Five trials provided data separated into higher and lower New York Heart Association (NYHA) class patient subgroups. For patients subcategorised by NYHA class, there was a non-significant difference in z-score (p=0.922) between patients with mild to moderate and severe heart failure. Similarly, subgrouping by left ventricular ejection fraction (LVEF) revealed no significant difference between z-scores (p=0.170). Both observations suggest no attenuation of benefit of ICD implantation in patients with higher NYHA class or lower LVEF. There is no evidence within the existing trial populations of a tendency for the relative risk reduction to be smaller in patients with severe heart failure. The prevailing assumption that severe heart failure patients are less likely to benefit from ICD therapy must be questioned.
    Heart (British Cardiac Society) 04/2010; 96(8):599-603. DOI:10.1136/hrt.2009.179515 · 6.02 Impact Factor
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    ABSTRACT: A robotic navigation system (RNS, Hansen™) has been developed as an alternative method of performing ablation for atrial fibrillation (AF). Despite the growing application of RNS-guided pulmonary vein isolation (PVI), its consequences and mechanisms of subsequent AF recurrences are unknown. We investigated the acute procedural success and persistence of PVI over time after robotic PVI and its relation to clinical outcome. Sixty-four patients (60.7 ± 9.8 years, 53 male) with paroxysmal AF underwent robotic circumferential PVI with 3-dimensional left atrial reconstruction (NavX™). A voluntary repeat invasive electrophysiological study was performed 3 months after ablation irrespective of clinical course. Robotic PVI was successful in all patients without complication (fluoroscopy time: 23.5 [12-34], procedure time: 180 [150-225] minutes). Fluoroscopy time demonstrated a gradual decline but was significantly reduced after the 30th patient following the introduction of additional navigation software (34 [29-45] vs 12 [9-17] minutes; P < 0.001). A repeat study at 3 months was performed in 63% of patients and revealed electrical conduction recovery in 43% of all PVs. Restudied patients without AF recurrence (n = 28) showed a significantly lower number of recovered PVs (1 (0-2) vs 2 (2-3); P = 0.006) and a longer LA-PV conduction delay than patients with AF recurrences (n = 12). Persistent block of all PVs was associated with freedom from AF in all patients. At 3 months, 67% of patients were free of AF, while reablation of recovered PVs led to an overall freedom from AF in 81% of patients after 1 year. Robotic PVI for PAF is safe, effective, and requires limited fluoroscopy while yielding comparable success rates to conventional ablation approaches with PV reconduction as a common phenomenon associated with AF recurrences.
    Journal of Cardiovascular Electrophysiology 04/2010; 21(10):1079-84. DOI:10.1111/j.1540-8167.2010.01773.x · 3.48 Impact Factor

Publication Stats

726 Citations
259.23 Total Impact Points


  • 2003–2014
    • Royal Brompton and Harefield NHS Foundation Trust
      Harefield, England, United Kingdom
    • Royal Berkshire NHS Foundation Trust
      Reading, England, United Kingdom
  • 2011
    • University Medical Center Hamburg - Eppendorf
      • Department of Cardiology, Electrophysiology
      Hamburg, Hamburg, Germany
  • 2010–2011
    • University of Hamburg
      • Department of Cardiology, Electrophysiology
      Hamburg, Hamburg, Germany
  • 2008–2011
    • Imperial College Healthcare NHS Trust
      • Division of Cardiology Cardiothoracic and Thoracic Surgery
      Londinium, England, United Kingdom
  • 2005–2010
    • Imperial College London
      • International Centre for Circulatory Health
      Londinium, England, United Kingdom
  • 2003–2006
    • The Heart Lung Center
      Londinium, England, United Kingdom
  • 2004
    • Heart Research Institute (UK)
      Norwich, England, United Kingdom
    • National Heart, Lung, and Blood Institute
      Maryland, United States