During VT ablation procedures, ECS should be considered for specific mapping and targeted ablation. Once recognized, these structures can be successfully targeted for ablation without valve damage.

Risk of CIN with CRT implantations was substantial. Increased volume of radiocontrast used for LV lead placement was associated with substantially increased risk of CIN. Minimal contrast use was associated with decreased procedural times without adverse impact on adequacy of lead placement.

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Radiofrequency ablation is increasingly used as an option to optimally manage patients with symptomatic atrial fibrillation. Presently, ablationists strive to improve success rates, particularly with persistent atrial fibrillation, while simultaneously attempting to reduce complications. A well-recognized complication with atrial fibrillation ablation is injury to the phrenic nerve giving rise to diaphragmatic paresis and patient discomfort.Phrenic nerve damage may occur when performing common components of atrial fibrillation ablation including pulmonary and superior vena caval isolation. The challenge for ablationists is to successfully target the arrhythmogenic substrate while avoiding this complication. In order to do this, a thorough knowledge of phrenic nerve anatomy, points in the ablation procedure where nerve damage is more likely, and an understanding of the presently utilized techniques to avoid this complication is required. In addition, when this complication does arise, prompt recognition of its occurrence, knowledge of the natural history, and available methods for management are needed.In this review, we discuss the underlying anatomic principles, techniques of avoiding phrenic nerve damage, and presently available methods of diagnosing and managing this complication.

Radiofrequency ablation for atrial fibrillation is being increasingly used to treat patients with symptomatic arrhythmia. The procedure is complex and associated with significant complications including thromboembolism, stroke, and bleeding. Despite significant advances in catheter design, online cardiac imaging, and greater operator experience, both stroke and major vascular complications continue to be problematic. Increasing the duration and intensity of anticoagulation has been the primary modality used to decrease thromboembolism. However, these measures increase the likelihood and severity of bleeding-related complications. The optimal method of anticoagulation along with the adjunctive use of technology to decrease vascular complications and mechanically prevent cerebral embolization is unknown. In this paper, we review the present methods used by ablationists to decrease the likelihood of thromboembolism during atrial fibrillation. We then describe methods used to decrease bleeding and vascular complications at access sites as well as cardiac perforation. We briefly discuss newer techniques to decrease endovascular complications including epicardial ablation and the use of temporarily implanted vascular protection devices.Finally, we describe the best option or combination of approaches that attempt to balance the risks of thromboembolism and bleeding during AF ablation..

Background and Purpose: With the surge of critically ill COVID-19 patients, neurology and neurosurgery residents and advanced practice providers (APPs) were deployed to intensive care units (ICU). These providers lacked relevant critical care training. We investigated whether a focused video-based learning curriculum could effectively teach high priority intensive care topics in this unprecedented setting to these neurology providers. Methods: Neurocritical care clinicians led a multidisciplinary team in developing a 2.5-hour lecture series covering the critical care management of COVID-19 patients. We examined whether provider confidence, stress, and knowledge base improved after viewing the lectures. Results: A total of 88 residents and APPs participated across 2 academic institutions. 64 participants (73%) had not spent time as an ICU provider. After viewing the lecture series, the proportion of providers who felt moderately, quite, or extremely confident increased from 11% to 72% (60% difference, 95% CI 49-72%) and the proportion of providers who felt nervous/stressed, very nervous/stressed, or extremely nervous/stressed decreased from 78% to 48% (38% difference, 95% CI 26-49%). Scores on knowledge base questions increased an average of 2.5 out of 12 points (SD 2.1; p < 0.001). Conclusion: A targeted, asynchronous curriculum on critical care COVID-19 management led to significantly increased confidence, decreased stress, and improved knowledge among resident trainees and APPs. This curriculum could serve as an effective didactic resource for neurology providers preparing for the COVID-19 ICU.

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INTRODUCTION: Non-Hodgkin lymphomas (NHL) are characterized by dysregulation of pathways controlling cell proliferation and apoptosis. Proteosome inhibitors and mTOR inhibitors target these pathways and have single-agent activity in NHL, though their safety and efficacy when used in combination requires further study. We conducted a prospective, phase I dose-escalation study to determine the safety, efficacy and maximum tolerated dose (MTD) of everolimus in combination with bortezomib in patients (pts) with relapsed/refractory NHL. METHODS: Eligibility criteria included: (1) relapsed or relapsed/refractory NHL with no limit on prior therapy; (2) measurable disease by standard radiographic findings (or monoclonal protein assessment for pts with lymphoplasmacytic lymphoma (LPL)); (3) ECOG PS ≤ 2 and adequate organ function. Hematologic parameters initially include platelets > 100,000 but subsequent amendments permitted >75,000. Dose levels for bortezomib were 0.7, 1, or 1.3 mg/m2 given either IV or SC on d1, 4, 8, and 11 every 21 days. Everolimus was given orally 5 mg every other day (qod) or daily (qd), or 10 mg qd. Dose levels were increased using a standard 3 x 3 design (see table). Pts were assessed for response after every 2 cycles and maintained on treatment continuously until disease progression, death, intolerance to treatment or patient choice. RESULTS: 28 pts were enrolled from July 2008 to June 2014. The median age was 65 (range, 40–86) years and 20/28 (61%) were male. Diagnoses included: follicular lymphoma (FL, 9), mantle cell lymphoma, (MCL, 5), diffuse large B-cell lymphoma (5), small lymphocytic lymphoma (SLL, 2), T-cell lymphoma, NOS (1), nodal marginal zone lymphoma (2), anaplastic large cell lymphoma (1), LPL (1), and splenic marginal zone lymphoma (SMZL, 1). Median number of prior therapies was 3 (range, 1-5) with no pts previously receiving bortezomib. Median number of cycles of therapy on study was 3 (range, 1-41). Hematologic toxicities included anemia (36 grade I/II, 6 grade III), neutropenia (10 grade I/II, 2 grade III), and lymphopenia (14 grade I/II, 3 grade III). Thrombocytopenia (44 grade I/II, 6 grade III) was the AE most commonly leading to treatment interruptions. Non-hematologic grade III toxicities included: cardiac (n=1), fatigue (n=1), skin infection (n = 1), low testosterone (n = 1), pneumonia (n=1), LFT elevation (n=4), hyperglycemia (n=1), hypercalcemia (n=1), electrolyte abnormalities (n=2), muscle weakness (n=1), syncope (n=1), herniated disc (n=1), flu-like symptoms (n=1). There were two grade IV toxicities: hyperkalemia (n=1) and secondary malignancy (n=1). Escalation of everolimus to 10 mg qd with bortezomib 1.3 mg/m^2 on d1, 4, 8 and 11 (dose level 5) resulted in dose-limiting thrombocytopenia requiring protocol amendment to declare the MTD to be dose level 4: 5 mg everolimus qd with 1.3 mg/m2 bortezomib d1, 4, 8, and 11 every 21 days. Of 24 response-evaluable pts there was 1 complete response in an MCL patient and 3 partial responses (2 MCL, 1 FL) for an overall response rate of 17%. There were 9 pts with stable disease (5 FL, 1 MCL, 1 SLL and 1 SMZL) and 11 pts had progressive disease. All but one patient have discontinued treatment. Reasons for discontinuation included disease progression (15), adverse event (10) or patient choice (2). CONCLUSIONS: The combination of everolimus and bortezomib results in dose limiting thrombocytopenia at maximal single agent doses. Everolimus at 5 mg qd can be safely combined with standard dose bortezomib (1.3 mg/m2 d1, 4, 8 and 11 q 21d). This combination has modest clinical activity in heavily pre-treated aggressive and follicular NHL. Notable responses were found in 3 of 5 MCL patients, warranting further investigation of this combination for mantle cell lymphoma. Abstract 4482. Table:Dose levels, toxicities, treatment length and responses of relapsed/refractory NHL patients treated with bortezomib + everolimusDose levelNEverolimus(mg)Bortezomib1(mg/m2)Grade III/IV Adverse EventsMean # CyclesResponse Hematologic Non-Hematologic135 qod0.702242 PR, 1 SD235 qod1.02331 PR, 1 SD, 1 PD375 qd1.041052 SD, 3 PD, 2NE465 qd1.35751 SD, 3 PD, 2NE25910 qd1.35291 CR, 3 SD, 4 PD, 1 NEAbbreviations: CR, complete response; PR, partial response, PD, progressive disease; NE, not-evaluableNotes: (1). Bortezomib at indicated dose on d1, 4, 8, 11 q21 days, (2) patient still on treatment Disclosures Hill: Novartis: Research Funding; Millenium: Research Funding. Off Label Use: Bortezomib and everolimus are both off-label for the treatment of most NHL.. Smith:Novaartis: Research Funding; Millenium: Research Funding.