Superior approach from the pocket for atrioventricular junction ablation performed at the time of conduction system pacing implantation

Abstract

BackgroundConduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve outcomes in patients with symptomatic, refractory atrial fibrillation (AF). Superior approach (SA) from the pocket via axillary or subclavian vein has been proposed as an alternative to the conventional femoral venous access (FA) to perform AVJA.ObjectiveTo assess the feasibility and safety of SA for AVJA performed simultaneously with CSP, and to compare this approach with FA.MethodsA prospective, observational study, enrolling consecutive patients with symptomatic, refractory AF undergoing simultaneous CSP and AVJA.ResultsA total of 107 patients were enrolled: in 50, AVJA was primarily attempted with SA, in 69 from FA. AVJA with SA was successful in 38 patients (76.0%), while in 12 patients, a subsequent FA was required. AVJA from FA was successful in 68 patients (98.5%), while in one patient, a left‐sided approach via femoral artery was required. Compared with FA, SA was associated with a significantly longer duration of ablation (238.0 ± 218.2 vs. 161.9 ± 181.9 s; p = .035), a significantly shorter procedure time (28.1 ± 19.8 vs. 19.8 ± 16.8 min; p = .018), an earlier ambulation (2.7 ± 3.2 vs. 19.8 ± 0.1 h; p < .001), and an earlier discharge from procedure completion (24.0 ± 2.7 vs. 27.1 ± 5.1 h; p < .001). After a median follow‐up of 12 months, the rate of complications was similar in the two groups (2.0% in SA, 4.3% in FA; p = .483).ConclusionSimultaneous CSP and AVJA with SA is feasible, with a safety profile similar to FA. Compared to FA, this approach reduces the procedure times and allows earlier ambulation and discharge.

“Ablate and Pace” with Conduction System Pacing: Concomitant versus Delayed Atrioventricular Junction Ablation

“…Given the low reported lead dislodgement rates in CSP, and especially in LBBAP [17,18,25,29], and given the possibility of implanting a backup lead for the sake of safety (especially in HBP), several operators perform CSP implantation and AVJA simultaneously in the same procedure. This strategy has been evaluated in several studies, showing that it is feasible and safe [14][15][16][17][18][19][20]. However, no previous study has compared the single-procedure strategy with the two-procedure one.…”

“…During the follow-up, data on the occurrence of procedure-related complications (defined below), refs. [10,16,21,25,[28][29][30], procedure-related hospitalizations, AVJA out-comes, and pacing parameters were prospectively recorded in a secure electronic data management system.…”

“…Procedure-related complications were defined as any adverse event related to implantation and AVJA, intra-or post-procedural, including cardiac tamponade, device infection (systemic or local infection), device malfunction, pneumothorax, pocket hematoma, lead dislodgement, lead failure, and CSP lead deactivation. CSP lead deactivation was defined as the deactivation of the lead due to loss of capture, excessive increase of capture threshold (leading to a premature battery depletion), or phrenic nerve stimulation irresolvable by reprogramming [10,16].…”

“…Given the potential risk of lead malfunction (mainly related to dislodgement) during the first weeks after device implantation in patients becoming PM-dependent after AVJA, ablation is routinely performed 4-6 weeks after device implantation to allow lead stabilization [6,13]. However, previous studies enrolling patients undergoing A&P with CSP have shown that performing AVJA simultaneously with the implantation procedure is feasible and safe [9][10][11][12][14][15][16][17][18][19][20]. This approach is potentially advantageous as it avoids the need for a new hospitalization, and allows the benefits of the A&P strategy to be provided already at the time of implantation.…”