bluuebunny/crossref_metadata_2025 huggingface dataset:
Improved prognosis with integrated care management including early rhythm control and healthy lifestyle modification in patients with concurrent atrial fibrillation and diabetes mellitus
Authors: Ahn H J , Lee S R , Choi E K , Lee S W , Han K D , Oh S , Gregory L I P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with concurrent atrial fibrillation (AF) and diabetes mellitus (DM) [AF-DM] have a high risk of cardiovascular and diabetes-related complications, but are less engaged in a comprehensive treatment approach.

Purpose

We evaluated the association of early rhythm control (ERC), lifestyle modification (LSM), and a combination of ERC and LSM with cardiovascular or diabetes-related complication risk in patients with AF-DM.

Methods

From the National Health Information Database, 47,940 patients diagnosed with AF-DM in 2009–2016 were included. We defined ERC as rhythm control therapy within two years of AF diagnosis and LSM as adherence to ≥2 of the healthy behaviors among non-current smoking, non-drinking, and regular exercise. We compared the primary (ischemic stroke) and secondary (macro- and microvascular complications, glycemic emergency, and all-cause death) outcomes in four groups: non-ERC and non-LSM (group 1), LSM only (group 2), ERC only (group 3), and both ERC and LSM (group 4).

Results

Of total, 10,617 (22%), 26,730 (55.8%), 2,903 (6.1%), and 7,690 (16.0%) were classified into groups 1 to 4, in sequence. The mean duration from AF diagnosis to ERC was 25.6±75.5 days. During 4.0 (interquartile range: 2.5–6.2) years’ follow-up, groups 2 and 3 were associated with 23% and 33% lower risks of stroke than group 1, respectively. Group 4 was associated with the lowest risk of stroke: hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51–0.67, p<0.001. Regarding secondary outcomes, the lowest risks were also observed in group 4; macro- and microvascular complications, glycemic emergency, and all-cause death had HRs (95% CIs) of 0.63 (0.56–0.70), 0.88 (0.82–0.94), 0.72 (0.62–0.84), and 0.80 (0.73–0.87), respectively, all p<0.001.

Conclusions

For AF-DM patients, ERC and LSM exert a synergistic effect in preventing cardiovascular and diabetes-related complications with the greatest lowered risk of stroke. A comprehensive treatment approach should be pursued in AF-DM patients.
Impact of concomitant proton pump inhibitor during oral anticoagulant treatment
Authors: Lee K N , Kim D Y , Roh S Y , Kim H Y , Hwang K S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Proton pump inhibitor is commonly used for gastroprotective effect in patients with a combination of antiplatelets and anticoagulants. However, data quantifying the concomitant proton pump inhibitor for clinical adverse outcomes other than gastrointestinal bleedings of oral anticoagulant is lacking.

Purpose

We aimed to explore the effect of concomitant proton pump inhibitor on the effectiveness and safety of oral anticoagulant in patients with atrial fibrillation.

Methods

The medical records were retrospectively reviewed from four tertiary referral hospitals between January 1, 2012, and December 31, 2020. Concomitant use of drug was quantified as the overlapping proportion over the duration of oral anticoagulant therapy. Primary endpoint was the time to occurrence of ischemic stroke, systemic embolism, intracardiac thrombus, major bleeding events, or death.

Results

Data were analyzed for 20,750 episodes with oral anticoagulant and atrial fibrillation (median [IQR] age, 71 [63-78] years; female, 42.5%; warfarin, 37.3%; median [IQR] CHA2DS2-VASc score, 3 [2-5]). The risk of primary endpoint was greatest in the group of persistent use (80% or more of overlapping proportion) of proton pump inhibitor among the other groups with less overlapping proportion (adjusted hazard ratio, 1.88; 95% confidence interval, 1.63–2.16; P for groups, <0.001). Concomitant proton pump inhibitor was not associated with the risk of major bleeding from the gastrointestinal tract.

Conclusion

Among patients with atrial fibrillation receiving oral anticoagulant, concomitant use of proton pump inhibitor increased the rate of thromboembolism, major bleeding, or death in proportion of overlapping period.
Racial differences in atrial fibrillation-related strokes and mortality
Authors: Kang D S , Yang P S , Kim D H , Jang E S , Yu H T , Kim T H , Sung J H , Pak H N , Lee M H , Lip G Y , Joung B Y
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background and Aims

Adverse outcomes associated with atrial fibrillation (AF) in Asians have not been fully elucidated. In a patient-level comparative analysis of UK Biobank and Korean National Health Insurance Service-Health Screening data, we evaluated the race-specific associations of AF with stroke and mortality.

Methods

This study enrolled 425,805 Asians (mean [SD] age, 56.0 [9.3] years; 55.3% of men) and 372,851 Whites (mean [SD] age, 57.1 [8.0] years; 47.6% of men). The main outcomes were total, ischemic, and hemorrhagic strokes and all-cause death.

Results

During the follow-up period (mean [SD], 7.3 [1.4] years in Asians; 11.7 [1.5] years in Whites), the incident rates (IR) of AF per 1000 person-years were 2.6 (95% CI, 2.5–2.7) in Asians and 4.4 (95% CI, 4.3–4.5) in Whites. The IR of total, ischemic, and hemorrhagic strokes were greater in Asians with AF than in Whites with AF. The rate difference (IR of the outcome in those with AF minus IR of the outcome in those without AF) for total stroke was 15.2 (95% CI, 13.4–17.0) in Asians and 4.5 (95% CI, 4.0–5.0) in Whites. For ischemic and hemorrhagic strokes, the rate differences were 2.5- to 3.5-fold higher in Asians than in Whites. Asians had a rate difference of 26.3 (95% CI, 24.2–28.4) for all-cause death, whereas Whites had a rate difference of 20.7 (95% CI, 19.7–21.7).

Conclusion

Despite the higher incidence of AF in Whites, the outcomes of AF-related rates of total, ischemic, and hemorrhagic strokes and all-cause death was greater in Asians than Whites.
Integration of preprocedural computed tomography scan findings into atherosclerotic cardiovascular disease risk estimation in patients with atrial fibrillation scheduled for catheter ablation
Authors: Verhaert D V M , Kerperien M , Habibi Z , Westra S W , Lankveld T A R , Chaldoupi S M , Den Uijl D , Luermans J G L M , Schotten U , Knackstedt C , Vernooy K , Linz D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) and atherosclerosis often coexist due to a shared risk profile. Prior to an AF ablation, computed tomography (CT) scans are routinely performed to assess pulmonary vein anatomy. Often coronary plaques are described as incidental findings. According to current guidelines, patients with coronary plaques on CT are classified as being at very high risk of developing cardiovascular atherosclerotic events, potentially resulting in a redefinition of treatment targets for comorbidities.

Purpose

This study estimated individual 10-year risks of developing atherosclerotic cardiovascular disease (CVD) events according to the 2021 ESC guideline on CVD prevention before and after the integration of CT-derived coronary plaque information in the risk assessment of AF patients scheduled for catheter ablation.

Methods

Consecutive AF patients scheduled for catheter ablation were included in the ISOLATION registry (NCT04342312). Patients were excluded from this subanalysis if no preprocedural CT was performed. Each patient was classified as being at low-to-moderate, high, or very high risk of developing CVD in the coming 10 years according to the 2021 ESC guideline on CVD prevention (Figure 1). This classification was based on previous CVD, chronic kidney disease, diabetes mellitus, or the Systematic Coronary Risk Estimation 2 (SCORE2) or SCORE2-Older Persons (SCORE2-OP) risk estimation. The impact of pre-AF ablation CTs on CVD risk was assessed by comparing risk classifications excluding and including information on coronary plaques on CT.

Results

A total of 1022 patients (age 64 ±9, 664 [65%] male, 686 [67%] paroxysmal AF) was included. Overall CVD risk was high, with 86% of patients at a high (n=190, 19%) or very high (n=693, 68%) 10-year risk of developing CVD events. Coronary plaques were observed in 59% (n=606) of pre-AF ablation CTs. Integration of the CT-derived information on coronary plaques resulted in reclassification of 364 patients (36%) towards the very high risk category (Figure 2). Previous CVD events were observed in 161 very high risk patients (16%).

Conclusion

In AF patients scheduled for catheter ablation, integration of the information on coronary plaques derived from the pre-AF ablation CT resulted in reclassification of one in three patients towards the very high risk category, which impacted treatment targets for lipid levels and blood pressure.
Is epicardial adipose tissue, quantified before cardiac surgery by computed tomography, able to predict postoperative atrial fibrillation?
Authors: Perrotta L , Genovese F , Pradella S , Bugetti M , Ricciardi G , Girasole T , Bambagioni G , Checchi L , Bevilacqua S , Gabrielli E , Letteriello M , Miele V , Stefano P L , Pieragnoli P , Michelucci A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery (CS) associated with prolonged hospitalization and increased risk of future adverse events. Epicardial adipose tissue (EAT), defined as adipose tissue between the myocardium and the visceral pericardium, has been recently recognized as a potential contributor to AF pathogenesis.

Purpose

to evaluate the role of EAT, measured by preoperative CT, in predicting the occurrence of POAF after CS.

Methods

All patients without prior AT/AF history who underwent CS at our centre were prospectively enrolled and retrospectively analyzed. All the included patients had performed a cardiac CT for the evaluation of the pre-operative coronary arteries. Baseline and surgical characteristics were systematically collected along with pre-operative echocardiographic parameters (LA diameter and area; EF) and CT EAT values. For the evaluation of the EAT we selected the area delimited superiorly from the center of the right pulmonary artery and inferiorly to the end of the pericardial sac. The adipose tissue between the myocardium and the pericardium was manually delimited and the total EAT volume was expressed in mL (total EATV; Fig. 1). Also the thickness (mm) of the EAT at the level of the free wall of the right ventricle (RV EAT) and posterior to the left atrium in a 4-chamber plane (LA EAT) were reported. All the measured EAT were indexed for BSA. Multivariate logistic regression analysis was used to identify independent predictors of the study endpoint: the occurrence POAF during the early postoperative period.

Results

A total of 117 patients (age 65±15 years old; M= 71%) were enrolled. Soon after surgery, POAF was observed in 55 patients (47%). Patients with POAF were significantly older, with higher comorbidities burden (diabetes; CHA2DS2-VASc score ≥1) than patients without POAF. No other significant differences for clinical features or surgical procedures were observed. Echocardiographic and CT parameters did not significantly differ between the two groups however older patients who developed POAF had elevated levels of indexed total EATV (96.1±46.6 cm3/m2) (Fig.2). At multivariate logistic regression analysis the only indipendent predictor of POAF remained age (OR: 1.053; 95% CI: 1.018-1.089; p=0.003).

Conclusions

Advanced age is a recognized risk factor for POAF following CS in patients without prior AF history. Older patients who developed POAF had elevated EAT values, however our study did not evidence any link between EAT and POAF.
Novel inflammatory biomarkers in postural orthostatic tachycardia syndrome
Authors: Nawaz S , Larsson A , Hamrefors V , Ruge T , Sutton R , Olshansky B , Fedorowski A , Johansson M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder characterized by excessive orthostatic tachycardia and orthostatic intolerance. While traditional inflammatory biomarkers tend to be normal, a subclinical inflammatory process may be present in POTS.

Purpose

We aimed to analyse novel inflammatory biomarkers in POTS patients: Growth Differentiation Factor 15 (GDF15), Neutrophil Gelatinase Associated Lipocalin (NGAL), Intercellular Adhesion Molecule 1 (ICAM-1), Tumour Necrosis Factor Receptor 1 (TNFR1) and Tumour Necrosis Factor Receptor 2 (TNFR2) and compared them to healthy controls. These inflammatory biomarkers have been shown to be independent predictors of major adverse cardiovascular events in other populations.

Methods

An age- and sex-matched case-control study included 65 patients verified to have POTS by positive head-up tilt-testing and cardiovascular autonomic tests, and 65 healthy controls (mean age: 31.1 vs 31.5 years, 84% females) with negative active standing tests and no history of syncope, orthostatic intolerance, or endocrine disease. High-sensitivity chemiluminescence sandwich immunoassay was used to measure plasma levels of inflammatory biomarkers in a blinded fashion. Descriptive statistics compared groups and a univariate ANOVA was employed. Biomarker values were log-transformed. A score incorporating all biomarkers was generated to see if the totality of biomarkers discriminated POTS patients from controls.

Results

Baseline characteristics are displayed in Table 1. Mean levels of GDF15 (p=0.01), NGAL (p=0.003), ICAM-1 (p=0.04) and TNFR1 (p=0.03) were significantly higher in POTS vs controls, whereas TNFR2 (p=0.04) was significantly lower in POTS (p=0.04). The product of four upregulated biomarkers divided by TNFR2 produced a receiver operator curve (ROC) with an area under the curve (AUC) of 0.703 (p<0.001) (Fig.1).

Conclusion

POTS patients had increased GDF15, NGAL, TNFR1 and ICAM-1 levels and reduced TNFR2 levels suggesting underlying, yet undefined, subclinical inflammatory processes involving neutrophil and endothelial activation.
Spontaneous variation of ventriculoatrial interval after tachycardia induction: determinants and usefulness in the diagnosis of supraventricular tachycardias with long ventriculoatrial interval
Authors: Duran-Bobin O , Hernandez J , Morinigo J L , Sanchez Garcia M , Portales-Fernandez J , Gonzalez-Juanatey C , Cruz A , Oterino A , Bravo L , Sanchez P L , Jimenez-Candil J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Determining the mechanism of supraventricular tachycardias with prolonged ventriculoatrial (VA) intervals is sometimes a challenge, because the usual diagnostic manoeuvers based on pacing during the ongoing tachycardia cannot be performed or do not offer diagnostic accuracy.

Purpose

To analyse the determinants, time course and diagnostic accuracy (atypical atrioventricular nodal reentrant tachycardias [AVNRT] versus orthodromic reentrant tachycardias through an accessory pathway [ORT]) of spontaneous VA intervals variation in patients with narrow QRS tachycardias and prolonged VA.

Methods

A total of 156 induced tachycardias were studied (44 with atypical AVNRT and 112 with ORT). Two sets of 10 measurements were performed for each patient: after tachycardia induction and one minute later. VA and VV intervals were determined.

Results

Among patients with AVNRT, there was a marked variability in the VA intervals after induction (Mn-VA: mean beat-to-beat variation of VA; MX-VA: maximum of the beat-to-beat VA variation). Figure 1. No significant differences were found in the variability of the VA interval between slow-slow versus fast-slow atypical AVNRTs (p>0.5 in all comparisons). And, even though the variability of the VA interval at one minute continued to be considerable, it tended to decrease after induction. However, as shown in Figure 1, in subjects with ORT, no relevant beat-to-beat changes in the duration of the VA intervals were seen, neither after induction nor at one minute later. The values of VA interval variability in ORT with septal versus free-wall accessory pathways were similar. Additionally, in 9 (20%) patients with atypical AVNRT and in 11 (10%) with ORT the Dif-VA increased from induction to one minute, with the maximum increment being of 29 ms and 6 ms, respectively. The difference between the longest and the shortest VA interval (Dif-VA) correlates significantly with the diagnosis of atypical AVNRT (C coefficient=0.95 and 0.85 after induction and at one minute, respectively; p<0.001). A Dif-VA ≥15 ms presents a sensitivity and specificity for atypical AVNRT of 50% and 99%, respectively after induction, and of 27% and 100% one minute later. Figure 2. We found a robust and significant correlation between the fluctuations of VV and VA intervals in atypical AVNRTs (Coefficient Rho: 0.56 and 0.76, after induction and at one minute, respectively; p<0.001 for both) but not in ORTs.

Conclusions

The analysis of VA interval variability after induction and at one minute later correctly discriminates atypical AVNRT from ORT in almost all cases. Such variability of VA intervals is related to the fluctuations of VV intervals in atypical AVRNTs but not in ORTs.
Wave speed guided point-by-point cavo-tricuspid isthmus ablation to reduce ablation and fluoroscopy in typical atrial flutter
Authors: Rodriguez O R , Zaraket F Z , Gonzalez C G , Casteigt B C , Jimenez J J , Valles Gras E
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Ablation procedures for cavo-tricuspid isthmus (CTI) dependent typical atrial flutter (AFL) have traditionally been performed with conventional electrophysiology mapping guided by fluoroscopy. Three-dimensional electroanatomical mapping (EAM) systems have routinely been used to guide ablation of more complex arrhythmias, but in recent years, have been used for simple ablations with the aim of reducing irradiation. High voltage regions in the CTI have been described as a target in order to minimize procedure times, but there is a lack of knowledge regarding the utility of slow conduction zones for this purpose.

Methods

In a prospective cohort of patients undergoing 3D EAM assisted AFL ablation, we evaluated a novel strategy (NS) based on omnipolar vectors, using both wave speed and voltage information to focus radiofrequency (RF) lesions (see figure), and compared with a recent retrospective cohort of patients undergoing voltage-guided ablation (VG).

Results

A group of 26 consecutive patients with mean age 68±12 years and 88% male, underwent NS ablation, and were compared to 23 patients undergoing VG ablation, with no differences among patient characteristics. Of the 26 patients in group NS, 16 (53.9%) were successfully ablated targeting only 2 sites, representing the 2 most confluent areas of low wave speed and high voltage. A total of 24 (92.5%) were ablated successfully with targeting all sites of low wave speed. Only a single patient in the NS group required the completion of a classic CTI line. Average fluoroscopy time and radiation dose were lower in the NS group compared to VG group (1.1±2.4 min 19.5±41.7 mGray vs 8.2±10.2 min and 64.4±76.5 mGray, p=0.0014 and p=0.013, respectively). Furthermore, RF time trended towards reduction in the NS group.

Conclusions

A strategy based on targeting only areas of low wave speed is effective, limiting the need to complete a traditional CTI line, and reducing fluoroscopy in patients undergoin CTI ablation.
Outcomes of cavotricuspid isthmus-dependent fLutter ablation: randomized study comparing single vs multiple catheter procedures. The SIMPLE study
Authors: Falasconi G , Penela D , Chauca A , Fernandez-Armenta J , Pavon R , Acosta J , Lozano J M , Soto-Iglesias D , Marti-Almor J , Bellido A , Ordonez A , Viveros D , Alderete J , Francia P , Berruezo A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation is recommended as first-line therapy for patients with symptomatic typical atrial flutter (AFl). Although the conventional multi-catheter approach is the standard of care for cavotricuspid isthmus (CTI) ablation, a single-catheter approach was recently described as a feasible alternative.

Purpose

The present study sought to compare safety, efficacy, and efficiency of single vs multi-catheter approach for AFl ablation.

Methods

In this randomized multicentre study, consecutive patients referred for AFl ablation (n= 253) were enrolled and randomized to multiple vs single-catheter approach for CTI ablation. In the single-catheter arm CTI block was confirmed analyzing PR interval (PRI) on the surface ECG as previously described by Madaffari and colleagues: briefly, PRI defined as the time between the pacing spike and the onset of the QRS complex, was measured on the surface ECG during atrial pacing (10 V, 1.5 ms) at a stable cycle length from the tip of the ablation catheter placed at 5 o’clock (medial to CTI line), 7 o’clock (lateral to CTI line), and 9 o’clock position. CTI block was assumed when: (i) the PRI at 7 o’clock was >80ms longer than that at pacing sites of 5, and (ii) the PRI at 9 o’clock was shorter than the PRI at 7 o’clock (Figure 1). Procedural and follow-up data were collected and compared between the two arms.

Results

128 and 125 patients were assigned to the single-catheter and to the multi-catheter arms, respectively. In the single-catheter arm, procedure time was singificantly shorter (37±25 vs 48±27 minutes, p=0.002), required less fluoroscopy time (430±461 vs 712±628 seconds, p<0.001) and less radiofrequency time (428±316 vs 643±519 seconds, p<0.001), achieving a higher first-pass CTI block rate [55 (45%) vs 37 (31%), p=0.044], compared with the multi-catheter arm. After a median follow-up of 12 months, 11 (4%) patients experienced AFl recurrences [5 (4%) in the single-catheter arm and 6 (5%) in the multi-catheter arm, P=0.99]. No differences were found in arrhythmia-free survival between arms (log-rank= 0.71). Results are summarized in Figure 2.

Conclusions

Recurrence-free survival of the single-catheter approach for typical AFl ablation is not inferior to the conventional multiple-catheter approach, reducing procedure, fluoroscopy and radiofrequency time.
National sudden cardiac death autopsy database highlighting sudden arrhythmic death and cardiomyopathies, applying diagnostic criteria and expanding the concept of the molecular autopsy
Authors: Westaby J , Zullo E , Cox S , Sheppard M N
Published: May 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Cardiac Risk in the Young

Background

Sudden cardiac death (SCD) is defined as natural unexpected death in witnessed cases occurring <1 hour and in unwitnessed cases as last seen alive <24hours. SCD due to ischaemic heart disease (IHD) is frequent in older age groups, in younger people genetic cardiac causes including channelopathies and cardiomyopathies are more frequent.

Purpose

To present the causes of SCD from a large pathology registry.

Methods

Cases were examined macroscopically and microscopically by two expert cardiac pathologists. Criteria used are presented in figure 1.

Results

The hearts from 7214 SCD cases were examined between 1994-2021. Sudden arrhythmic death syndrome (SADS), a morphologically normal heart, which can be underlain by the channelopathies, is most common (3821, 53%) followed by the cardiomyopathies (1558, 22%), then IHD (670, 9%). Valve disease (225, 3%), congenital heart disease (213, 3%) and myocarditis/sarcoidosis (206, 3%) are the next most common. Hypertensive heart disease (185, 3%), aortic disease (129, 2%), vascular disease (97, 1%) and conduction disease (40, 1%) are smaller proportions (figure 2).

Discussion

This is the largest SCD cohort with autopsy findings ever reported from one country. SADS and cardiomyopathies predominate. This study highlights the importance of the autopsy in SCD which is a significant public health concern in all age groups. Knowing the true incidence in our population will improve risk stratification and develop preventative strategies for family members. There is now a national pilot study integrating molecular autopsy into the assessment of SCD victims.
Long-term follow-up of idiopathic ventricular fibrillation: A 30-year experience from our hospital
Authors: Rattanawong P , Rayfield C , Kenyon C , Seri A , Yinadsawaphan T , Srivathsan K
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Idiopathic ventricular fibrillation (IVF) is responsible for 5-7% of sudden cardiac arrests in the absence of substrate for ventricular arrhythmia, structural diseases, or primary arrhythmic syndromes. The characteristics, management, and prognosis of these patients are unclear.

Purpose

To investigate the clinical features, management, and prognosis of IVF in our hospital healthcare system

Methods

Mayo Database Explorer software was used to identify IVF patients from our hospital electronic medical records between 1990 to 2022 in 5 states. The medical records were manually reviewed.

Results

A total of 132 patients were initially diagnosed with IVF. During the 9.2±6.8 years mean follow-up, 36 [27.3%] patients were later diagnosed with structural diseases or primary arrhythmic syndromes (dilated cardiomyopathy [41.7%], Long QT syndrome [27.8%], catecholaminergic polymorphic ventricular tachycardia [8.3%], Brugada syndrome [5.6%], mitral valve-related arrhythmia [5.6%], and short QT syndrome [2.8%]). Among the rest of the 96 patients with true IVF (mean age 38.4±15.7 years, male 59.4%, Caucasian 80.2%, hypertension 28.1%, diabetes 8.3%), 91 (94.8%) patients presented with out-of-hospital cardiac arrest and 88 (91.7%) patients had a history of syncope. Early repolarization and fragmented QRS were noted in 32 (33.3%) and 28 (29.1%) patients, respectively. Defibrillators were implanted in 92 (95.8%) patients. Genetic testing was performed in 35 (36.5%) patients, and possible associated mutations were found in 13 (37.1%) patients. An Electrophysiology study was conducted in 55 (57.3%) patients, and ventricular fibrillation was induced in 17 (30.9%) patients. The medical management with antiarrhythmic drugs was selected in 60 (62.5%) patients, and the catheter ablation ± anti-arrhythmic drugs was selected in 36 (37.5%) patients. The recurrence of ventricular fibrillation during 9.2±6.8 years of mean follow-up was significantly higher in the ablation strategy group (p=0.0003) (Figure 1).

Conclusions

We reported the largest cohort of IVF patients from a single healthcare system. Early repolarization and fragmented QRS were common in IVF. The possible associated mutations were found in one-third of IVF who underwent genetic testing. The ventricular fibrillation recurrences were significantly higher in the catheter ablation strategy group.
Sinus rate and QRS duration on lead V1 predict major events in Brugada syndrome
Authors: Laporte P , Vaglio M , Denjoy I , Maison-Blanche P , Badilini F , Leenhardt A , Extramiana F
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Ministère de la Santé Française

Background

Arrhythmic risk stratification remains a major challenge in asymptomatic Brugada patients. Many studies have evaluated risk stratification performance based on a single or a few ECG-derived parameters measured manually. We aimed to assess the predictive value of multi ECG parameters measured automatically in patients with Brugada syndrome.

Materials and Methods

We performed a prospective, multicenter cohort study including Brugada patients with at least one available type 1 ECG (either spontaneously or drug-induced) between January 2005 and November 2021. Paper ECG were first digitized and then automatically analyzed using the Glasgow and Bravo algorithms (included in the logiciel CalECG). Clinical data and Brugada related events at diagnosis and during follow-up were collected. Sudden cardiac death, aborted cardiac arrest and appropriate ICD therapy in the VF zone were considered as major events. The predictive value of clinical and ECG parameters for symptomatic status was assessed using uni- and multivariate Cox models.

Results

ECGs from 301 Brugada patients (77% male, mean age at diagnosis 43 years, follow-up 7±5.6 years) were analyzed. Brugada-related symptoms (cardiac syncope or major event) occurred in 23% of patients before diagnosis and 11% during follow-up (incidence: 1.57%/year).

After multivariate Cox analysis, only 2 baseline ECG (without Ajmaline) parameters were significantly associated with major events: RR interval (HR=1.01 (95%CI [1-1.01]), p=0.002) and QRS duration in lead V1 (HR=1.04 (95%CI [1-1.07]), p=0.038).

QRS prolongation in lead V1 >113 ms (AUROC 0.69 (95% CI [0.58-0.8])) was associated with a 3-fold increased risk of major event (HR =3.49 (95% CI [1.72-7.09]), p=0.001).

Conclusion

Many previously described ECG parameter were not associated with major event in Brugada patients after multi-parameter evaluation. Sinus rate and QRS duration on lead V1 were independent risk factor. These results need to be validated on an external cohort. The predictive value of ECG parameters in Brugada syndrome should be assessed using automated multiparametric quantification.
Ventricular tachycardia predicts all-cause mortality and non-sudden cardiac death in non-ischaemic cardiomyopathy
Authors: Omara S , Godsk T S , Koeber L , Thune J J , Pehrson S , Tedrow U B , Ebert M , Carbucicchio C , Berruezo A , Vaseghi M , Deneke T , Wijnmaalen A P , Stevenson W G , Nielsen J C , Zeppenfeld K
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The DCM-VT study was partially supported by an investigator-initiated grant (IIS-310) from Biosense Webster (a Johnson & Johnson company). The DANISH study was supported by unrestricted grants from Medtronic, St. Jude Medical, TrygFonden, and the Danish Heart Foundation.

Background

Endstage heart failure, ventricular tachycardia (VT) and sudden cardiac death (SCD) are sequels of non-ischaemic cardiomyopathies (NICM). Implantable cardioverter defibrillators (ICDs) can terminate VT and prevent SCD but mortality benefit has been limited in recent trials suggesting that VT may also be associated with non-sudden cardiovascular death (NSCVD).

Purpose

To assess the effect of VT on all-cause mortality and NSCVD in NICM patients with ICDs.

Methods

Two multicenter cohorts of NICM patients were merged for analysis: (1) patients randomized to ICD in the DANISH trial, which included patients with NICM, LVEF ≤35% and no prior VT and (2) the DCM-VT study cohort, which included consecutive NICM patients with any LVEF referred for ablation of sustained VT. Predictors for the primary composite outcome of all-cause death and heart transplant (death/HTx) and for the secondary outcome of NSCVD were assessed. In addition, propensity score matching was performed using the parameters age, gender, LVEF and eGFR. Finally, survival following VT occurrence was compared between DANISH and DCM-VT patients.

Results

A total of 828 patients (556 DANISH, 272 DCM-VT) were followed for a median of 3.9 years (2.1 – 5.8). DANISH patients had a median LVEF of 25% (20 – 30) and DCM-VT patients 35% (27 – 43). A total of 148 patients (DANISH 16.4%, DCM-VT 21.0%) experienced death/HTx and NSCVD occurred in 78 patients (7.7%, 12.9%, respectively). In multivariable analysis history of VT at inclusion was a significant predictor of the primary outcome with an adjusted hazard ratio (HRa) of 3.81 (95% CI 2.33 - 6.24) as were age [HRa 1.02 per year (1.01 - 1.04)], LVEF [HRa 0.96 per 1% increase (0.94 - 0.98)] and reduced eGFR [HRa 1.71 (1.15 – 2.53 )]. History of VT predicted NSCVD with an HRa of 7.54 (3.97 - 14.33). After matching, history of VT still predicted death/HTx [HR 4.12 (2.48 - 6.82)] and NSCVD [HR 6.92 (3.30 - 14.52)]. Risk of death/HTx, as well as NSCVD, for DANISH patients was similar to DCM-VT patients after they experienced their first VT event [HRa 0.90 (0.48 - 1.69) and HRa 1.07 (0.56 - 2.06) resp.].

Conclusions

VT occurrence appears to be an important predictor of non-sudden CV death as well as all-cause death in NICM patients independent of other markers of heart failure severity. VT may be a marker of progressive disease and remodelling that could be incorporated into risk-stratification to help predict deterioration and need for HTx.
Using the 3D architecture of scar to predict life-threatening ventricular arrythmias - still a long way to go
Authors: Amador R , Bello A R , Freitas P , Guerreiro S , Abecasis J , Coutinho Santos A , Saraiva C , Galvao Santos P , Moscoso Costa F , Carvalho M S , Carmo P , Cavaco D , Morgado F , Ferreira A M , Adragao P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Late gadolinium enhancement (LGE) has been proposed as an independent predictor of ventricular arrhythmias.

Purpose

The purpose of this study was to assess if myocardial scar characterization could enhance the risk stratification for life-threatening arrhythmias and sudden cardiac death (SCD).

Methods

We included patients with an indication for ICD or CRT-D implantation who underwent cardiac magnetic resonance for clinical proposes since February/2018 and in whom a 3D-LGE dataset was obtained. Patients with channelopathies (n=2) or inappropriate imaging quality (imaging artifacts; n=7) were excluded. Scar characterization using ADAS software was performed in 3D-LGE datasets in all but 5 patients, where 2D datasets were used. The primary endpoint was the composite of appropriate ICD therapy (classified as ATP or shock) or SCD.

Results

A total of 75 patients were analysed (mean age 63 ± 13 years; 83% male; mean LVEF 31 ± 13%; 50 patients with ischemic and 25 with non-ischemic cardiomyopathy; 14 patients received a device in the setting of secondary prevention). During a median follow-up of 1.4 years (IQR 0.7 – 2.4 years) there were 15 events (12 appropriate ICD therapies [8 shocks and 4 ATP] and 3 SCD). No statistically significant differences were found between patients with or without events in terms of scar mass, border zone (BZ) mass, BZ channels (BZC), BZC mass, number of channels detected, and scar heterogeneity (BZ mass / scar mass ratio) - all p values > 0.2 – Figure. Restricting the analysis to only primary prevention cases yielded similar results. Overall, 11 patients did not show any channel. Two of these experienced an arrhythmic event, yielding a negative predictive value of 80% (95% CI 75-83%) for the absence of channels.

Conclusion

In this cohort with still relatively limited follow-up duration, no single parameter reflecting scar tissue characterization was able to predict appropriate device therapies or sudden cardiac death.
Clinical significance of conduction velocity orientation vectors on cardiac mapping surfaces
Authors: Rodriguez Padilla J , Anderson R , Joens C , Masse S , Bhaskaran A , Niri A , Lai P , Ali Azam M , Lee G , Vigmond E , Nanthakumar K
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): This work was supported by the Lefoulon Delalande Foundation

OBJECTIVE

Electroanatomical maps using automated conduction velocity (CV) algorithms are now being calculated using 2D mapping tools. The basis of substrate-based functional assessment is to detect slow zones or slow CV of which isochronal late activation mapping (ILAM) is now commonly performed. We studied the accuracy of mapping surface 2D CV, compared to the 3D vectors, and the influence of mapping resolution in non-scarred animal and human heart models.

Methods

Two models were used: a healthy porcine Langendorff model with transmural needle electrodes and a computer stimulation model of the ventricles built from an MRI-segmented, excised human heart. Local activation times (LAT) within the 3D volume of the mesh were used to calculate true 3D CVs (direction and velocity) for different pixel resolutions ranging between 500 mm – 4 mm (3D CVs). CV was also calculated for endocardial surface-only LATs (2D CV).

Results

In the experimental model, surface (2D) CV was faster on the epicardium (0.509 m/s) compared to the endocardium (0.262 m/s, Figure 1). In stimulation models, 2D CV significantly exceeded 3D CVs across all mapping resolutions and increased as resolution decreased (Figure 2). 3D and 2D left ventricle CV at 500mm resolution increased from 429.2±189.3 mm/s to 527.7±253.8 mm/s (P<0.01), respectively with modest correlation (R=0.64). Decreasing the resolution to 4mm significantly increased 2D CV and weakened the correlation (R=0.46). The majority of CV vectors were not parallel (<30°) to the mapping surface providing a potential mechanistic explanation for erroneous LAT-based CV over-estimation.

Conclusion

Ventricular CV is overestimated when using 2D LAT-based CV calculation of the mapping surface and is significantly compounded by mapping resolution. These findings have implications for the current methodology of functional substrate assessment with ILAM and surface CV assessment.
Clinical trial report: the electrocardiographic response to ajmaline provocation in healthy subjects
Authors: Ensam B , Scrocco C , Batchvarov V , Behr E
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

The Robert Lancaster Memorial Fund sponsored by McColl’s Research Group

Background

The electrocardiographic (ECG) response to diagnostic ajmaline provocation (AP) testing has been studied extensively in clinical cohorts. However, the healthy ECG response has not been described. We undertook a trial examining ECG changes in response to AP in a cohort of systematically recruited asymptomatic Caucasian healthy subjects with no family history of sudden death and normal baseline ECG and echocardiogram.

Methods

Applicants responded to a national recruitment advertisement and completed an online medical questionnaire. Those fulfilling inclusion criteria were invited to undergo further evaluation with eligible subjects undergoing a diagnostic ajmaline challenge (1mg/kg, max. 100mg over 5 minutes). A continuous ECG was recorded in the standard and high right precordial lead (HRPL) position. Automated analysis of conventional and novel ECG measurements were made at baseline and at peak drug effect, which was defined as the point of maximum QRS duration (excluding precordial leads).

Results

One hundred healthy Caucasian subjects underwent AP. The mean age was 26.84 years (SD ± 8.01 years) and 52% were male. A drug induced type 1 Brugada pattern (DI-T1BP) was observed in 3/100 (3%) of the cohort. We performed a paired comparison of ECG measures at baseline versus peak drug effect (Table 1).

AP had a similar effect on global QRS duration and global PR interval, with both increasing by 28%, mean ∆ 25.66ms and mean ∆ 43.36ms respectively. Changes in S wave parameters in lead II were pronounced, with a 97% increase in S wave duration and a 101% increase in S wave negative amplitude. ST-J point elevation in the anterior, inferior, and lateral regions was comparable, with a 57%, 51% and 57% increase in ST-J amplitude respectively.

AP had a greater effect on cardiac conduction in females compared to males (Table 2). In contrast, changes in STJ point amplitude and combined and segmented QRST segment area were greater in males.

Conclusion

The healthy ECG response to AP elicits a pronounced effect on cardiac conduction, more so in females compared to males, whilst changes in STJ point amplitude and QRST area were greater in male subjects. The DI-T1BP is part of the healthy response to AP.
Noninvasive stratification of ventricular substrate by electrocardiographic imaging
Authors: Reventos-Presmanes J , Hernandez-Romero I , Invers-Rubio E , Ferro E , Garre P , Borras R , Tolosana J M , Guasch E , Arbelo E , Porta-Sanchez A , Vazquez S , Guichard J B , Climent A M , Mont L , Roca-Luque I
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Abnormalities of cardiac activation and conduction velocity (CV) are known pro-arrhythmogenic factors. Electrocardiographic imaging (ECGI) is presented as a non-invasive tool for arrhythmogenic substrate analysis. However, electrocardiographic features such propagation activation patterns, and CV are unknown in healthy subjects. In this study, ECGI technology has been evaluated for ventricular tissue stratification in patients with and without structural heart disease.

Methods

Nineteen patients were included in the study. The healthy ventricles group (Panel A) included 10 patients (8 males, 57 ± 6 years, NYHA = I and LVEF 61 ± 5 %) with normal baseline QRS and normal values of ventricular morphology, function and perfusion assessed by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). The structural heart disease group (Panel B) included 9 patients (9 males, 66±6 years, NYHA 2±1 and LVEF 26±5%) with ischemic cardiomyopathy (ICM) confirmed by LGE-CMR and indication for ablation due to ventricular tachycardia. For each patient, fibrotic areas were identified by ventricular segmentation of the LGE-CMR and ventricles were regionalized in 16 regions. Epicardial electrograms were noninvasively reconstructed by ECGI, late activation time (LAT) and CV maps were calculated to study electrocardiographic features.

Results

– Ventricles with fibrosis secondary to ICM revealed heterogenous activation patters and higher activation time distribution compared to healthy ventricles (120 ms vs 80 ms; p<0.01). Density distribution of CV was evaluated in the 0-200 cm/s interval, patients with healthy ventricular tissue showed homogenous CV distribution whereas ICM patients presented higher concentration in the slow CV region with a maximum peak around 75 cm/s. Moreover, CV values were significantly lower in fibrotic myocardium present in patients with structural heart disease compared to healthy myocardium (77 ± 40 cm/s vs 114 ± 46 cm/s; p<0.01), Panel C anterior view. Non-fibrotic regions in the ischemic ventricle group, Panel C inferior view, presented similar CV distributions to healthy ventricular tissue (114 ± 46 cm/s vs 120 ± 48 cm/s; p = 0.14).

Conclusions

ECGI can noninvasively identify fibrotic tissue by analysing ventricular activation and CV patterns. ECGI could be a potential early tool to identify patients at risk of sudden cardiac death.
Impact of cardiac magnetic resonance channels to localize deceleration zones during VT ablation
Authors: Vazquez-Calvo S , Garre P , Ferro E , Guichard J B , Falzone P , Arbelo E , Tolosana J M , Guasch E , Mont L , Porta-Sanchez A , Brugada J , Ortiz-Perez J T , Roca-Luque I
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance has demonstrated to accurately identify voltage conduction channels and it is nowadays an important tool to analyze the arrhythmic substrate, to predict ventricular tachycardia (VT) events and to aid VT ablation. The characteristics of CMR channels (CMR-CCs) that predicts the presence of deceleration zone (DZ) have not been explored.

Methods

Forty-four consecutive patients with scar-related VT undergoing ablation after CMR (October 2018-July 2021) were included (medium age 64.8±11.6 years; 95.5% male; 70.5% ischemic heart disease, mean ejection fraction of 32.3±7.8). Characteristics of CMR-CCs were analyzed and correlation with DZs both in baseline maps and remaps were performed. Patients were prospectively followed for VT recurrence for one year.

Results

Overall, 129 automatically detected CMR-CCs were analyzed (2.89±1.83 per patient; length: 52.72±65.44mm (0.18–376.73), CC mass: 1.76±2.46grams (0.01–14.59); protectedness 19.02±24.51% (0.01–143.51)). Overall, 73.6% of CMR-CCs were associated with a DZ: 58.1% CMR-CCs in baseline map and 15.5% with a DZs not observed initially but in remaps. The univariate analysis showed that channels associated with DZs were longer (61.83±73.43 vs. 29.96±32.55, OR 1.01, p0.004), with higher border zone mass (2.02±2.75 vs. 1.09±1.44, OR 1.28, p0.031) and more protectedness (21.90±27.23 vs. 11.46±14.20, OR1.02, p0.036). VT recurrence after one-year follow up was 21.95%.

Conclusions

Pre ablation CMR can accurately identify channels that correlates with DZs that could be targets for ablation, especially those CMR-CCs with higher length, border zone mass and protectedness. Additionally, some channels not related with DZ in the first map have a clear DZ after abolishing the first region of slow conduction, suggesting a very useful role of CMR to detect potential DZs.
Impact of pacing output and cycle length on QRS morphology in ablation of premature ventricular contractions (PACE-MAP-trial)
Authors: Van Den Bruck J , Woermann J , Sultan A , Filipovic K , Scheurlen C , Erlhoefer S , Dittrich S , Schipper J , Steven D , Lueker J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pace mapping is an established technique to localize the origin of premature ventricular contractions (PVC). The QRS morphology induced by endocardial pacing is compared with a previously recorded template of the target arrhythmia. Based upon historic in-vitro models pacing at the arrhythmia’s coupling interval (CI) and stimulation threshold has become the gold standard in pace mapping.

Purpose

There is a paucity of data supporting pacing at the CI and stimulation threshold as the gold standard for pace mapping. In this prospective study, we sought to assess systematically the impact of variations of pacing output and cycle length on the resulting QRS morphology during pace mapping in the context of PVC ablation.

Methods

All patients undergoing ablation of idiopathic PVC were prospectively enrolled in this study. Pace mapping was performed using four different parameter settings: (1) A predefined fixed burst at maximum output (10V/2ms), (2) fixed burst at stimulation threshold, (3) coupling interval at maximum output and (4) coupling interval at stimulation threshold. Pacing cycle length (PCL) of the fixed burst was defined as follows: For a CI≤450ms = PCL of CI+100ms and for a CI≥450 = PCL of CI-100ms. Using an automated waveform comparison algorithm (Bard® LabSystem™ PRO software; Boston Scientific, MA, USA), the resulting QRS complexes were matched with the clinical PVC, and with the gold standard. For every parameter setting the mean of the matching percentage of three QRS complexes entered the analysis.

Results

We report data of the first 47 consecutive patients (57±18 years, 64% male) enrolled in this ongoing study between May 2021 and September 2022. The pacing protocols were performed at 75 different sites: 6/75 epicardially via great cardiac vein, 38/75 in the RVOT, 23/75 in LVOT and 8/75 in the left ventricular cavity. When comparing the QRS morphologies resulting from the four different pace mapping settings with the clinical PVC, the univariate analysis revealed no difference between groups (p=0.9). Furthermore, there was no difference comparing the paced QRS morphologies at different output and cycle length to the gold standard of threshold pacing at coupling interval (p=0.9).

Conclusion

Variations of pacing output and stimulation cycle length during pace mapping does not affect QRS morphology during PVC ablation. Applying a modern automated waveform comparison tool, no advantage was observed when comparing with the gold standard. It is therefore reasonable to assume, that pace mapping can be performed using an easily applicable setting of a fixed burst at maximum pacing output.