Cardiac Rhythm Management
Articles Articles 2013 May

Letter from the Editor

DOI: 10.19102/icrm.2013.040501

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Dear Readers,

We certainly have a very interesting set of articles for this month’s issue of the Journal!

I was particularly interested in the very striking images provided by Dr. Rafael and colleagues with the “rogue lead” from an externalized St. Jude Riata cable. This definitely was a lead extraction case that I am glad was not on my schedule to do!

In this issue we also include the “First US Case of a Transformer Break with Loss of Shock Therapy and Rapid Battery Depletion in the Boston Scientific INCEPTA ICD.” In addition, we have a nice review of the role of remote magnetic navigation in catheter ablation, the role of adenosine in facilitating accessory pathway conduction, and several fascinating case reports.

Among all of these interesting articles this month, I would like to focus my comments on the articles submitted by Dr. Hamden and colleagues describing the cost analysis of a syncope clinic and from our colleagues at the Massachusetts General Hospital titled “Surgical Left Atrial Appendage Ligation and Anticoagulation.”

I must confess that treating patients with syncope has always been a challenge for me. Certainly, the elderly patient who presents to the emergency room with complete heart block and syncope is an extremely easy case to manage. However, cases like this are the minority of what I see day to day.

Typically, the cases I see in my clinic are the younger patients with no clearly identifiable cause of syncope with possible borderline prolonged QTc, or the elderly patients with multiple medical comorbidities where it is not clear if they actually passed out or if it was just a mechanical fall. In each situation, either the patient or the family is very concerned and anxiety levels are typically exceedingly high. Answers to the cause of syncope can often be elusive, creating further frustration for the patient, family, and the cardiologist.

To help address this clinical challenge that all of us regularly face, I specifically asked my good friend Dr. Hamden to share his wisdom and experience with us. While working at the University of Utah Hospital, Dr. Hamden organized and created a multidisciplinary syncope center. Under his passion for treating patients with syncope, this program was incredibly successful and was a great asset to our community. Putting his new MBA degree to work, he has also provided a detailed financial analysis of this syncope clinic in the article. We are truly sorry that he left Utah and wish him well in his new role as Chief of Cardiology at the University of Wisconsin School of Medicine.

In this article, Dr. Hamden demonstrates how creating a specialized clinic to treat such a challenging condition can both provide fantastic patient care and be profitable to hospitals. As you read this article, I would ask you to consider whether or not the addition of a new multidisciplinary specialty clinic would make sense for you at your hospital. With the emphasis on improving quality and preventing unnecessary hospitalizations as part of health-care reform in the United States, multidisciplinary specialized clinics, such as the one described by Hamden and coworkers, will become more commonplace. Indeed, we are seeing the formation of many of these multidisciplinary specialty clinics at our own institution, particularly in the area of structural heart disease management, surgical/catheter atrial fibrillation ablation, hypertension, and left atrial appendage management.

On the subject of left atrial appendage management, I thoroughly enjoyed the article from our good friends at Massachusetts General Hospital. How many times have we seen a case where supposedly the left atrial appendage was excised at the time of surgery only to see a large left atrial appendage stump at the time of a transesophageal echo or while we are mapping the left atrium during a catheter ablation procedure?

This is truly a clinical conundrum and an area of concern for me. Many surgeons promote that they can prevent atrial fibrillation strokes by eliminating the left atrial appendage. While most surgeons will tell you that they never leave a left atrial “stump,” even in the best of hands, at least one in three left atrial appendage elimination surgeries are incomplete. Is a residual left atrial “stump” following surgery more or less thrombogenic than just leaving the appendage alone?

What do I do in my clinical practice? When trying to determine whether or not a patient still requires anticoagulation following surgical left atrial appendage elimination, I generally perform a transesophageal echo. If the appendage is completely eliminated, then I consider this patient “equivalent” to the Watchman data where percutaneous left atrial appendage occlusion was shown to be comparable to warfarin. Thus, if the surgery was complete, I typically do not use anticoagulation in these patients. In contrast, if there is still a “stump” following surgery, then I treat this patient as if they never had left atrial appendage surgery.

I trust that you will agree with me that the articles presented in this issue of the Journal will truly be of benefit to you and your patients. As always, I welcome any comments that you might have or articles you would like to submit to the Journal!

Warm regards,

John Day, MD, FHRS, FACC
The Journal of Innovations in Cardiac Rhythm Management
Director of Heart Rhythm Services
Intermountain Medical Center
Salt Lake City, UT