bluuebunny/crossref_metadata_2025 huggingface dataset:
Hybrid therapy with ablation + subcutaneous ICD for secondary prevention of sudden cardiac death in ischemic heart disease
Authors: Maury P , Goldenberg I , Huang D , Aktas M , Sacher F , Clementy N , Mulpuru S , Friedman P , Meyer C , Tiefenbrun N , Mcnitt S , Zareba W , Nof E
Published: May 2024

Background

The aim of the prospective Ventricular Tachycardia Ablation- Subcutaneous ICD (VTAbl-SICD) Trial was to provide data on the efficacy and safety of a novel hybrid management strategy that combines VT ablation (VTAbl) with S-ICD implantation in patients who present with scar-related VT. The rate of appropriate therapy in patients with S-ICD may be a quite fairest surrogate of true residual sudden death (SD) risk compared to transvenous ICD (TV-ICD). More specific data on ischemic heart disease – the prominent cause of VT with the better results of VTAbl – may give arguments for questioning current practices in the future.

Methods

32 patients with post ischemic scar-related sustained VT/VF were included. Patients underwent VTAbl with subsequent (or previous prophylactic n=8) S-ICD implant and were followed for 2-years. We evaluate the occurrence of appropriate and ICD therapies once ablated, as well as cardiovascular (CV) readmissions or death. We also compared to 64 propensity-score matched patients implanted with a secondary prevention TV-ICD (enrolled in the Ranolazine in High-Risk Patients With Implanted Cardioverter-Defibrillators (RAID) trial).

Results

Mean age was 57±12 years (28 males, 87%) (53% hypertension, 31% diabetes and 47% congestive heart failure with NYHA 1.6±1). Mean LVEF was 39±9%.There were no major complications associated with the ablation and implant procedures. Propensity-score matched patients implanted with a secondary prevention TV-ICD displayed similar clinical characteristics.

At 16.5±8.6 months FU, appropriate ICD therapy occurred in 5 patients (15%) in the VTAbl-SICD group, significantly lower compared to the TV-ICD group (34 pts, 53%) (p<0.001). This corresponded to 2-year cumulative probability of 20% vs. 71% in the VTAbl-SICD vs. TV-ICD groups, respectively (log-rank p<0.001; Figure 1) and a significant 83% reduction in the risk of appropriate ICD therapy associated with VTAbl-SICD (HR= 0.17 [95% CI 0.07 - 0.39; p<0.001).

Two of the patients who received appropriate ICD therapy in the VTAbl-SICD group may have had unrecognized transient causes of VT (torsades de pointes or unrecognized ischemia), letting 3 out of 32 (10%) with possible aborted SD caused by VT recurrences. There were no cases of untreated symptomatic VT. The rate of CV readmissions was similar in the VTAbl-SICD (41%) vs. TV-ICD group (44%) (p=0.7), whereas mortality was significantly lower in the VTAbl-SICD- vs.TV-ICD- group (0% vs. 17%, respectively; p<0.001)

Conclusions

Our findings suggest that VT ablation in ischemic heart disease patients allow reaching a low residual true risk for SD, which should now be evaluated in terms of cost-effectiveness compared to ablation + S-ICD implantation. Concommitant S-ICD implantation seems to be a safe alternative to TV-ICD without ablation.Appropriate ICD therapy-free KM
Renal denervation for the management of refractory ventricular arrhythmias
Authors: Jacinto S , Teixeira A R , Santos H , Portugal G , Valente B , Lousinha A , Cunha P , Cacela D , Morais L , Santana A , Oliveira E , Ferreira R , Martins Oliveira M
Published: May 2024

Background

While catheter ablation (CA) has proven effective in managing ventricular arrhythmias (VA) associated with structural heart disease, a portion of patients continue to experience refractory VA despite medical treatment and multiple CA procedures. In such cases, additional techniques, such as autonomic neuromodulation, have been explored. Renal denervation (RDN), traditionally performed for the treatment of resistant arterial hypertension, inhibits the afferent renal sympathetic pathway, leading to reduced efferent sympathetic overactivation on a systemic level. Due to this mechanism, it has also been studied for the management of arrhythmias, including atrial fibrillation and VA, with favorable results.

Objective

To assess the effectiveness and safety of RDN for the management of refractory VA storms in high-risk patients.

Methods

A retrospective analysis of RDN procedures for electrical storms, conducted at a tertiary center between February 2020 and September 2023. We analyzed baseline patient characteristics, procedural details, and acute complications. Recurrence of VA after RDN was assessed at one and six months.

Results

A total of 7 patients underwent RDN for the treatment of refractory VA. The mean age was 56 ± 10 years (6 male). The primary diagnosis was ischemic cardiomyopathy (n=5), with a mean left ventricular ejection fraction (LVEF) of 20 ± 5%, and no history of resistant arterial hypertension. All patients had an implantable cardioverter-defibrillator (ICD) (two with concomitant resynchronization therapy). Five patients had undergone previous endocardial VA ablation. Of the two patients without prior VA ablation, one had a contraindication because of a large left ventricle thrombus, and the other was submitted to an electrophysiological study, but without inducible ventricular tachycardia. In the four weeks before RDN, patients exhibited a mean of 12 ± 18 sustained VA episodes, meeting the criteria for electrical storm (3 ≥ episodes in 24h). During the procedure, there was a mean of 7 ± 8 radiofrequency applications in the right renal artery and 6 ± 10 in the left renal artery. No acute complications were observed. One month after the procedure, VA episodes were reduced to a mean of 0 ± 1, with only two patients experiencing recurrent VA. After six months, the absence of VA recurrence remained consistent, with only one patient experiencing new episodes. There were no deaths during this period.

Conclusion

In our pilot study, RDN appeared to be a safe and effective treatment for the management of VA.VA episodes before and after RDN
STereotactic Arrhythmia Radioablation and its place in modern cardiac ElectroPhysiology: Results of an EHRA Survey
Authors: Kovacs B , Lehmann H I , Manninger M , Saguner A M , Futyma P , Duncker D , Chun J
Published: May 2024

Background

Stereotactic arrhythmia radioablation (STAR) is an emerging treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in particular in structural heart disease (SHD). However, the current role and envisioned future role of STAR is in clinical practice as viewed by Cardiologists is unknown.

Objective

To assess the current role of STAR, barriers to its use, and expected future role, within the cardiology community.

Methods

An online survey was created with the support of the EHRA Scientific Initiatives committee and distributed via newsletters and social media. The survey consisted of 20 multiple-choice questions with a focus on baseline demographics, awareness / access, current use, and the future role of STAR.

Results

A total of 129 international participants completed the survey, mean age was 43±11 years, 25 (16.4%) were female. Ninety-one (59.9%) participants were cardiac electrophysiologists while 13 (8.6%) were general cardiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR while 62 (48.1%) had treated / referred a patient for treatment. Median number of patients treated was 4 (range 1-100). Common primary indications for STAR were recurrent VT/VF in SDH (45%), recurrent VT/VF without SHD (7.8%) or PVC (3.9%). Based on their knowledge, 49% and 59% of survey participants responded they would consider performing / referring a patient for STAR, respectively. Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%), non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%) and possible higher efficacy than other available treatment options (23%). Survey respondents named one or more previous catheter ablations (CA) or contraindication for CA (79%), diagnosis of SHD (78%), recurrent monomorphic VT with >3 episodes within the preceding 3 months (68%), optimal antiarrhythmic medication (61%) or electrical storm (59%) as prerequisites for the use of STAR. Most respondents foresee a future clinical role for STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively). Although, only a minority expected a first-line indication for it in with or without SHD (7% and 5%, respectively) and STAR was viewed rather as a bail-out option (48% and 35%, respectively).

Conclusions

STAR is a new option for the treatment of recurrent VT that appears to gain acceptance within the EP community. Randomized-controlled trials and an EHRA consensus document are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.Central figureFuture role of STAR
Fracture risk analysis of a stylet-driven lead for left bundle branch area pacing using a human beating heart model
Authors: Liu H , Li W , Alleman W , Victorine K , Shaw R
Published: May 2024

Background

Left bundle branch area pacing (LBBAP) has emerged as a promising approach to cardiac physiologic pacing. However, the mechanical stress and fracture risk has not been studied for stylet-driven leads implanted in the left bundle branch area (LBBA).

Purpose

The main purpose of this study was to evaluate the change in curvature during a cardiac cycle when a stylet-driven lead with a rigid distal end was implanted in LBBA and to identify any increased risk of conductor fracture for the LBBAP lead compared to those implanted at the His bundle (HB), traditional right atrium (RA) and right ventricle (RV) locations.

Methods

A high-resolution, four-dimensional human beating heart model was utilized for simulating the stress on the lead. The bending stiffness of lead body segments was measured with 3-pts bending test and the values were assigned to the finite element model. The curvature change of lead body during one cardiac cycle was measured. The safety factor of lead conductors was calculated using the curvature measurements, the conductor’s endurance limit, and the ultimate stress of the material (MP35N). A higher safety factor indicates better lead durability and lower risk of fracture. A parametric study was also performed to investigate how additional implant factors impact the safety factor of LBBAP leads: lead insertion angle, implant depth, degree of slack, and implant location (Figure 1).

Results

A total of 8 implant scenarios for LBBAP were defined and tested using the combination of the implant factors described above. Two RV implanted locations were tested: RV apex and RV apical septum. One HBP and one RA implant location were tested. The region with maximum change in curvature for LBBAP lead was at 0-10 mm proximal to the ring electrode (Figure 2A). The maximum change in curvature on the lead body for LBBAP, HBP, RV, and RA implants were: 0.022±0.005 (n=8), 0.033 (n=1), 0.036±0.002 (n=2), and 0.024 mm-1 (n=1), respectively (Figure 2B). The safety factor for the lead conductors for LBBAP, HBP, RV, and RA implants were 5.57±1.35 (n=8), 3.48 (n=1), 4.62±0.04 (n=2), and 4.65 (n=1), respectively (Figure 2C). The highest safety factor among all implant locations was 7.63, corresponding to a LBBAP implant scenario with mid-septum location, a 45 degree lead insertion angle towards apex, 7.5 mm lead depth in the septum, and low lead slack. HBP had the lowest safety factor among all implant locations.

Conclusion

The stylet-driven lead with a rigid distal end implanted at the left bundle branch area does not introduce any further risk of fracture compared to the HBP or traditional RA/RV implant locations in this computational modeling study.Fig 1: LBBAP implants testedFig 2: Lead curvature and safety factor
Which paced QRS duration can be achieved in selective and non-selective His bundle pacing?
Authors: Foeldvary M , Grigoryan A , Tribunyan S , Bachour C , Feldmann T , Israel C
Published: May 2024

Background

The paced QRS duration (pQRS) is associated with the risk of developing a pacing-induced cardiomyopathy. His bundle pacing (HBP), either selective (sHBP) or non-selective (nsHBP) can achieve a rather narrow pQRSd in patients with a narrow intrinsic QRS (iQRS) or right bundle branch block (RBBB). We prospectively analyzed the pQRS in sHBP and nsHBP and correlated it with the iQRS.

Patients and Methods

All consecutive patients who received an implantation with sHBP or nsHBP were enrolled and received a 12-lead ECG before and after implantation (digital recording, 25 mm/s). Measurements of the pQRS after implantation were performed in unipolar VVI 100 bpm mode to exclude fusion beats. QRS duration was measured in 6fold magnification of the digital ECG (600%) 1) for the iQRS, 2) from the beginning to the end of the QRS in sHBP, 3) from the end of the pacing artifact to the end of the QRS in nsHBP, and 4) from the end of the pseudo-delta wave to the end of the QRS in nsHBP (see Fig.).

Results

In 388 patients (78±11 years, 38% female, 18% RBBB, 9% left bundle branch block) with an iQRS of 110±28 ms before implantation, sHBP was achieved in 206 patients (53%), nsHBP in 182 (47%). In sHBP, the pQRS was 88±18 ms, in nsHBP 123±18 ms including the pseudo-delta wave, 83±14 ms excluding the pseudo delta-wave. In sHBP, the pQRS was on average 15 ms shorter than the iQRS. In nsHBP, the pQRS was 9 ms longer than the iQRS when the pseudo-delta wave was included, and 31 ms shorter if it was excluded, the latter mostly due to correction of a RBBB by nsHBP.

Conclusions

In sHBP and nsHBP, very narrow pQRS durations of 80-90 ms can be achieved. The pQRS is frequently shorter than the iQRS, mostly by correction of a RBBB.QRS measurements in sHBP and nsHBP
Temporal evolution of His bundle pacing thresholds: a sub-study of the PACE-CONDUCT trial
Authors: Buia V , Stangl D , Walascheck J , Rittger H , Vitali-Serdoz L , Bastian D
Published: May 2024

Background

His bundle pacing (HBP) has become a valuable alternative for cardiac resynchronization therapy, offering physiological pacing. This substudy of the PACE-CONDUCT trial aimed to explore the influence selective and non-selective HBP on threshold height. We assessed these parameters in patients with both normal conduction and bundle branch block conduction.

Methods

Our study included 61 consecutive patients with a median age of 73 years, who underwent a successful HBP implantation for indications such as sick sinus syndrome, AV Block 2 type 2, binodal disease, and ablate and pace therapy prior to AV-node ablation. Among these patients, 18 exhibited QRS durations exceeding 150 ms, indicating a complete and broad bundle branch block which made them candidates for cardiac resynchronization therapy (CRT). All patients received HBP implantation with the assistance of a 3D electroanatomical system. This system allowed for low-fluoroscopic, atraumatic evaluation of the His bundle (HB) area, presenting the His voltage as a color-coded map for precise electrode placement.

Results

The feasibility of bundle branch correction is generally accepted in selective HBP distal to the site of block, albeit associated with higher threshold values and potentially lower battery duration. Our analysis encompassed 61 patients who underwent HBP implantation, with 23 patients (37,7%) exhibiting selective HBP and 38 (62,3%) non-selective HBP. Remarkably, 10 out of the 23 patients with selective HBP demonstrated a complete bundle branch block correction after HBP implantation even with a basal QRS durations exceeding 150 ms. We evaluated HBP thresholds at implantation, one day post-implantation, and one month post-implantation, correlating these data with selective and non-selective HBP. Threshold values were converted to volts per millisecond (volts × milliseconds) for analysis. Statistical analysis conducted with IBM SPSS 29.0 revealed a significant difference at the day of implantation, indicating higher threshold capture in selective HBP compared to non-selective HBP (one-sided p-value: < 0.01, two sided p value 0.01). However, this difference could not be sustained at the one-day and one-month threshold follow-ups, suggesting normalization of the selective HBP threshold.

Conclusion

In our study, the initially higher threshold in selective HBP normalized within 24 hours compared to non-selective HBP. Additionally, our study demonstrated the feasibility of selective His pacing in patients with complete bundle branch block and broad QRS durations. These findings provide insights into HBP optimization and encourage further investigations with larger patient cohorts to validate our observations and enhance patient care in the realm of cardiac pacing.Threshold trend
Implantable Loop Recorders in patients with Brugada Syndrome: the BruLoop Study
Authors: Bergonti M , Sacher F S , Arbelo E A , Crott L , Sabbag A S , Casella M C , Saenen J S , Sfondrini I S , De Asmundis C D A , Brugada J B , Tondo C T , Schwarz P S , Haissaguerre M G , Auricchio A A , Conte G C
Published: May 2024

Aims

Available data on continuous rhythm monitoring by implantable loop recorders (ILRs) in patients with Brugada syndrome (BrS) are scarce. Aim of this multicentre study was to evaluate the diagnostic yield and clinical implication of a continuous rhythm monitoring strategy by ILRs in a large cohort of BrS patients, and to assess the precise arrhythmic cause of syncopal episodes.

Methods and Results

A total of 370 patients with BrS and ILRs (mean age 43.5±15.9, 33.8% females) from 18 international centers were included. Overall, 274 (74.1%) were implanted due to symptoms (69.3% syncope, 30.7% palpitations). Over a median follow-up of 3 years, an arrhythmic event was recorded in 30.7% of symptomatic patients (18.6% atrial arrhythmias (AAs); 10.2% bradyarrhythmias (BAs) and 7.3% ventricular arrhythmias (VAs)). In patients with recurrent syncope, the etiology was arrhythmic in 22.4% (59.3% BAs, 25.0% VAs and 15.6% AAs). The ILR led to drug therapy initiation in 11.4%, ablation procedure in 10.9%, implantation of PM in 2.5% and ICD in 8%. At multivariate analysis, the presence of symptoms (HR 2.5, p=0.001) and age >50 years (HR 1.7, p=0.016) were independent predictors of arrhythmic events, while inducibility of VF at EP study (HR 9.0, p<0.001) was predictor of ventricular arrhythmias.

Conclusion

ILR detects arrhythmic events in nearly 30% of symptomatic BrS patients, leading to an appropriate therapy in 70% of them. The most commonly detected arrhythmias are AAs and BAs, while VAs are detected only in 7% of cases. Symptom status can be used to guide ILR implantation.General ResultsArrhythmias
investigating long-term outcomes and predictors of primary outcomes in patients treated for cardiac implantable electronic device infections
Authors: Bulat Z , Arslan S , Gecit M H , Gokce M E , Bilgin M E , Balcioglu S A , Ebeoglu A O , Uzunhasan I , Yildiz M
Published: May 2024

Background

The estimated current infection rate after cardiac implantable electronic devices (CIED) implantation ranges between 1% and 2%, with variations in the literature from 0.13% to 12.6% (2). The rise in CIED implantation rates over the years has led to an escalation in the frequency of device-related infections. This trend is compounded by the elongation of patient comorbidities and life expectancy (3).

Purpose

The study aimed to investigate the primary outcome rates (including death, myocardial infarction (MI), cerebrovascular accidents (CVA), and reinfection) and identify predictors of primary outcomes in patients receiving treatment for CIED infection.

Methods

A retrospective analysis was conducted at a single-center. The study encompassed 2322 patients who sought treatment at the arrhythmia clinic of our Institute between March 2011 and July 2020 and underwent CIED implantation. After excluding 20 patients with active infections and 3 patients postoperative cardiac arrest, 36 patients were diagnosed with CIED infection (1.55% incidence). Diagnosis was based on the Novel 2019 International CIED Infection Criteria. Patients were categorized into groups based on the occurrence of all-cause death, MI, CVA, and reinfection during the follow-up period.

Results

The median follow-up period post admission with CIED infection was 42.5 (7-141) months. Table 1 presents patient characteristics, procedure details, and management-related parameters in the groups stratified by the primary endpoint. Notably, 58.3% of the patients had previously undergone a replacement procedure. Among patients with CIED infection, reinfection was observed in 20.0% of those who had a de novo procedure and 38.1% of those who underwent a secondary procedure (p: 0.25). Cox regression analysis revealed that pre-procedure C-reactive protein (CRP) levels and CHA2DS2-VASc score were independent predictors of the primary outcome (OR: 1.03 (1.00-1.06); P: 0.035, OR: 1.34(1.03-1.88); P: 0.030, respectively) (Table 2).

Conclusion

Long-term outcomes in patients with CIED infection appear to be correlated with pre-procedure CRP levels, indicating the severity of infection, and the CHA2DS2-VASc score, providing valuable insights into patient comorbidities. These factors seem to outweigh the impact of the specific procedure and antibiotic regimens administered. Management should not only focus on the history of CIED infection during follow-up but also prioritize the management of existing comorbidities to improve outcomes. Given the study's limitations such as the small sample size and retrospective nature, further investigations are warranted to confirm these findings.Table 1Table 2
Very early fractures of the stylet-driven Biotronik Solia lead used for left bundle branch area pacing
Authors: Haeberlin A , Hofer D , Noti F , Reichlin T , Breitenstein A
Published: May 2024

Introduction

Left bundle branch area pacing (LBBAP) has become increasingly popular due to the relatively simple implantation procedure allowing for conduction system pacing (CSP). Initially, lumen-less leads have been used primarily for CSP. However, several authors have published encouraging results using conventional stylet-driven pacemaker (PM) leads as well and our centers have largely adopted this approach.

Methods

In our two tertiary referral centers, we assessed all patients, who underwent a LBBAP lead implantation using any lead. We observed several early lead fractures, exhibiting a unique failure mechanism, which we illustrate in this case-series.

Results

Between January 2022 and November 2023 343/393 patients (87.3%) were implanted with a Solia pacemaker lead, 46/393 (11.7%) received a SelectSecure 3830 lead, and 4/393 (1.0%) another stylet-driven lead. Three patients (0.8%) who initially were implanted with a Solia lead experienced very early intracardiac lead fractures within 1, 11 and 13 months after implantation despite good initial electrical performance values (Table shows initial values and values during the time of failure (bold)).

The first case was a 54 year-old woman with permanent 3d degree AV block receiving an LBBAP lead after lead extraction. Four weeks later, she presented with presyncope and exit block at maximum output in uni- and bipolar configuration.

The second case was a 72 year-old man with intermittent 3rd degree AV block in the context of an ischemic heart disease. He received a dual-chamber LBBAP PM. 13 months after the implantation, a bipolar impedance > 2’500Ω and exit block were noted.

The third case was 65 year-old man suffering from sick sinus syndrome. He initially underwent a dual-chamber PM implantation in 2011 and due to ventricular sensing issues a transvenous lead extraction and implantation of a LBBAP lead in October 2022. During device follow-up after 11 months, a fractured LBBAP lead with bipolar impedance >2’500Ω and exit block during threshold testing was noticed.

In all cases, X-rays and macroscopic analysis consistently showed a disintegration of the lead immediately distal to the ring electrode (Figure; site of fracture marked with an arrow). Most likely, this was caused by the repetitive shear stress at the hinge point of the lead where it is entering the septum.

Conclusion

No dedicated stylet-driven CSP lead is available to date. The implantation site and technique for LBBAP may exert higher mechanical stress on the distal part of the lead, making it more prone to fracture than in a conventional position. Currently, the use of conventional stylet-driven leads is still off-label and the performance of such leads should be monitored closely.TableFigure
Transvenous lead extraction: the jugular pull-through technique
Authors: Akhtar Z , Kontogiannis C , Leung L W M , Sohal M , Gallagher M M
Published: May 2024

Background

Transvenous lead extraction (TLE) is vital to the management of cardiac implantable electronic devices (CIEDs). Evolving tools and techniques have contributed to an improvement in procedural safety and efficacy. The jugular access is advantageous in TLE, providing a linear, direct path to the heart for extraction sheaths. However, transfer of a lead with a deployed locking stylet from the subclavian to the jugular carries risk of cardiovascular injury. A novel jugular pull-through technique has been described for safe transfer of the lead and locking stylet from the native site to the jugular access, to facilitate TLE using a powered sheath.

Purpose

We report our early experience of the novel jugular pull-through technique which transfers a locking stylet and lead unit, from the subclavian to the jugular access for completion of TLE.

Method

The jugular pull-through technique entailed transfer of the deployed locking stylet with the lead via a long-sheath from the subclavian access to the jugular. In brief: a long wire positioned in the Superior Vena Cava via the jugular is snared and pulled from the subclavian site, permitting a long 8.5-french sheath to be railroaded through the jugular to surface at the subclavian access. The deployed locking stylet was fed through this long sheath to emerge at the jugular access; the sheath, locking stylet and lead were then pulled as a single entity to transfer the locking stylet and lead from the subclavian to the jugular. The rotational dissecting sheath was then advanced over the lead via the jugular in linear fashion to complete the lead extraction. Data for consecutive jugular pull-through procedures performed between 1/7/2022 – 31/12/2022 in our high-volume TLE institute were collected and evaluated for safety and efficacy.

Results

Three male patients aged 69.8±12.5 years with a left ventricle ejection fraction of 46.7±14.4%, underwent TLE for infection (67%). Of the 7 targeted leads, 4 (57%) were extracted using the jugular pull-through technique, all from the right ventricle (50% ICD) with 128±131.8 months dwell time. Of these 3 cases, 1 suffered diabetes, 1 hypertension, 1 ischaemic cardiomyopathy and 1 hypertrophic obstructive cardiomyopathy. All procedures were performed in the cardiac catheterisation suite under general anaesthesia using a locking stylet, compression coil, Evolution RL (13-french), a Needle’s Eye Snare, a loop snare and a long 8.5-french sheath with its 0.032 guidewire. The jugular pull-through technique facilitated 100% complete procedural success and 100% clinical success in the absence of any complications or procedural mortality; there was no 30-day mortality.

Conclusion

The jugular-pull-through technique allows safe transfer of a fully deployed locking stylet and lead from the subclavian to the jugular access, to facilitate jugular TLE.The jugular pull-through technique
Relationship between ECG parameters and electrophysiological study in post-TAVI de novo left bundle branch block
Authors: Massoullie G , Bordachar P , Ploux S , Souteyrand G , Mondoly P , Amabile N , Jean F , Combaret N , Motreff P , Clerfond G , Eschalier R
Published: May 2024

Background

The measurement of the HV interval in post-TAVI has a determining place in the most recent recommendations. However, its value, in addition to the post-TAVI ECG, remains debated. To describe the correlation in post-TAVI ECG and HV in case of de novo left bundle branch block and his correlation to PR interval prolongation.

Methods

Prospective, open-label study with 12 months follow-up. From June 2015 to November 2018, TAVR recipients were included at 10 centers in the French Multicenter LBBB-TAVR study. 183 TAVR recipients (64% self-expanding valve) had a new-onset LBBB after TAVR persisting for more than 24 hours. HV interval was assessed by intracardiac EPS and compared to ECG parameter on the day of EPS.

Results

1631 ECGs were recovered and double-read. On the day of EPS the mean PR was 224±51 ms, the mean QRS duration was 148±18 ms. The PR increases after TAVI by a maximum of 60±43 ms to reach a mean maximum PR of 252±55 ms. It increases progressively in the post-procedure period from 25±37ms, until the 4th day (44±32ms, p<0.001). The mean HV interval delay was 62±14 ms, the AH was 140±63 ms. The HV interval was weakly correlated with the duration of the PR interval (0.19), the AH interval had a correlation of 0.72. In logistic regression, PR ≥ 240 ms and QRS ≥ 150 ms were independent predictor of HV prolongation (HR 7.6 [3.0 - 12.2], p=0.001 and 5.9 [1.6 - 10.3], p=0.007). The rate of conduction disturbance at 1 year in case of prolonged HV, QRS ≥ 150 ms and PR ≥ 240 ms was 57% vs. 27% if HV < 70 ms (p<0.001).

Conclusions

In post-TAVI de novo left bundle branch block, PR interval prolongation is a dynamic, transient process driven by an alteration of atrioventricular node. The HV interval prolongation is poorly correlated to post-TAVI PR prolongation and LBBB duration.Correlation between ECG and EP studyConduction disorders after TAVR
Ventricular septal defect characteristics influence presence and properties of septal anatomical isthmuses in patients with repaired tetralogy of Fallot
Authors: Wallet J , Kimura Y , Blom N A , Hazekamp M G , Jongbloed M R M , Zeppenfeld K
Published: May 2024

Background

In repaired tetralogy of Fallot (rTOF), the septal anatomical isthmuses (AI), 3, between the ventricular septal defect (VSD) and pulmonary annulus, and 4, between the VSD and tricuspid annulus, are important ventricular tachycardia (VT) substrates when slow conducting. Patients with rTOF can have different VSD characteristics which may influence presence and properties of septal AIs.

Methods

This study included all consecutive patients with rTOF who underwent electroanatomical mapping (EAM) between 2005 and March 2023 for ventricular arrhythmias, risk stratification, or before pulmonary valve replacement and had a surgical report of initial repair available.

Results

In 130 of 154 (84%) patients a surgical report was available (35% female, median age at EAM 38 years [IQR 20-49]), with provided VSD details in 90 (69%). The majority of patients had an outlet perimembranous VSD (n=77, 86%), 7 (8%) a doubly-committed juxta-arterial (DC-JA) VSD, and 4 (4%) a muscular outlet VSD. All patients with a DC-JA VSD had a blocked/absent AI 3. Among patients with a DC-JA VSD with a muscular posteroinferior rim, 50% had AI 4, which was not observed in patients with a fibrous posteroinferior rim. In patients with a muscular VSD, AI 4 was present in 25%. In contrast, in patients with an outlet perimembranous VSD, an AI 4 or a blocked/absent AI 3 were rare findings (1% and 4%, respectively).

Conclusions

VSD characteristics influence presence and properties of septal AIs. In patients with DC-JA VSD septal VT substrates seem to be rare. Detailed surgical information is desirable for patient management.
Factors of unfavorable prognosis in patients with non-high risk pulmonary embolism
Authors: Tseluyko V , Askierov R
Published: May 2024

Introduction

Pulmonary embolism (PE) nowadays is the third leading cause of death in the structure of cardiovascular mortality after myocardial infarction and stroke. Most of patients (pts) with PE are with non-high risk. According to the latest guidelines PESI and sPESI scores are used to predict 30-day outcome of non-high-risk pts. Nevertheless, the question of additional factors which are not included in PESI and sPESI scores and which may be associated with prognosis in such pts remains poorly understood.

Purpose

To identify factors associated with in-hospital mortality in non-high-risk PE pts.

Methods

A retrospective analysis of 635 medical cards of pts with diagnosis "PE" hospitalized in our clinical hospital during 2017 – 2023 period. The diagnosis was verified by multispiral computed tomography angiography (CTPA) of pulmonary arteries and/or by autopsy. There were 530 non-high-risk pts (83,4%). Pts were divided into groups: І group - pts who were discharged from hospital with improved status (479 – 90,4%), II group - pts who died in hospital (51 – 9,6%). Clinical, anamnestic, laboratory and instrumental parameters were measured. Statistical analysis was performed.

Results

According to multivariate analysis of variance, independent factors, which were associated with in-hospital mortality in pts with non-high-risk PE, were: the presence of atrial fibrillation, obesity, age, history of venous thromboembolism, lower levels of O2 saturation, systolic blood pressure (SBP) and higher pulmonary artery pressure (PAP). ROC analysis was performed to determine the thresholds of factors that were associated with in-hospital mortality: SBP ≤124 mmHg, HR≥110 bpm, PAP ≥54 mmHg, age>54 yo.

Conclusions

The factors which were associated with in-hospital mortality in pts with non-high-risk PE were: age, SBP, history of VTE, obesity, AF; blood saturation level, pulmonary artery pressure level.
ECG risk markers among premenopausal and postmenopausal SCD victims
Authors: Eskuri M A E , Holmstrom L , Vahatalo J , Kentta T V , Tikkanen J , Pakanen L , Perkiomaki J , Huikuri H V , Junttila M J
Published: May 2024

Background

Majority of the SCD victims aged 50 years or younger are male. On average menopause occurs at the age of 51.4 years and it has a substantial role in cardiovascular risk burden among women. The mechanisms and risk markers of SCD are not as well defined for women as they are for men possible due to difference in population burden, and electrocardiographic risk markers do not seem to make a difference in this matter.

Purpose

The aim of this study was to determine electrocardiographic findings among women at pre- and postmenopausal age in a large SCD population.

Methods

The Fingesture study has systematically collected clinical and autopsy data from SCD victims in Northern Finland between 1998 and 2017. The cohort consists of 5,869 SCD victims of which 1,238 are women (21.1%). Antemortem electrocardiograms (ECG) were recorded in 1,101 subjects (women 25.3%). Women aged ≥ 52 years were considered as postmenopausal and ≤ 51 years old as premenopausal as the direct information of the menopause lacked due to the retrospective nature of this autopsy-based data.

Results

Only 7.9% of the female subjects experienced SCD under age of 52 years (P<0.001). No statistically significant differences in ECG abnormalities were found between pre- and postmenopausal women. However, almost one female SCD victim out of four lacked any ECG abnormalities in premortem ECG (26.3% of premenopausal and 24.2% of postmenopausal women, P=1.000). In general, ECG abnormalities were more prevalent in SCD victims at postmenopausal age. Though, fragmented QRS, particularly in the lateral ECG leads, was observed in 47.4% of women at premenopausal age group and in 42.1% of women at postmenopausal age even though statistical significance was not obtained (p=0.810). ECG-LVH, as per Cornell's criteria, was present in 4.8% of individuals in premenopausal age group whereas in postmenopausal age group, it was observed in 19.0% of subjects (P=0.140). ECG variables are presented in Table 1. When the analysis was repeated between the women <55 years of age and ≥55 years of age, only left ventricular hypertrophy (LVH; Cornell) was statistically significant and more common in women ≥55 years old (19.5% vs. 3.6%, P=0.037).

Conclusion

Premenopausal SCDs are rare. Approximately one female SCD victim out of four did not have any ECG abnormalities prior to SCD. Only ECG-LVH remained statistically significant in analysis between younger and older women, and was clearly more prevalent finding among postmenopausal SCD victims.Table 1
Left atrial function and polygenic risk scores for predicting atrial fibrillation and related stroke/systemic embolism
Authors: Park H , Kim D H , Jang E S , Yu H T , Kim T H , Uhm J S , Sung J H , Pak H N , Lee M H , Yang P S , Joung B Y
Published: May 2024

Objective

To explore whether the addition of left atrial (LA) function, polygenic risk score (PRS), or both to clinical risk scores improves predictions of atrial fibrillation (AF) and related stroke/systemic embolism (SSE).

Methods

A total of 36,919 individuals without AF who were assessed for LA emptying fraction and AF-PRS were included from the UK Biobank imgaing enhancement. The primary aims were incident AF and AF-related SSE. AF-related SSE was ascertained when previously undiagnosed AF was identified at the time of an SSE or up to 1-year after an SSE.

Results

Among the 36,919 participants (median 64 years; 52.4% women), 535 incident AF and 27 AF-related SSE developed over a median follow-up of 2.9 years. Both LA emptying fraction and AF-PRS were associated with the risk of incident AF (hazard ratio [HR] per standard deviation [SD] decrease in LA emptying fraction; 2.13; 95% CI, 1.99-2.27 and HR per SD increase in AF-PRS [95% CI]; 1.65 [1.52-1.79]) and AF-related SSE (HR per SD decrease in LA emptying fraction [95% CI]; 3.52 [2.85-4.35] vs. HR per SD increase in AF-PRS [95% CI]; 1.86 [1.30-2.68]). The addition of LA emptying fraction to a clinical risk score was associated with a significant improvement in C-statistics for incident AF (C-index; 0.704 to 0.788, p for difference in C-index <0.001) and AF-related SSE (C-index; 0.666 to 0.868, p<0.001) but not for AF-PRS (p for difference in C-index > 0.05). The addition of LA emptying fraction was associated with a net reclassification of 26.2% and 21.8% for incident AF and AF-related SSE whereas 11.5% and none with the addition of AF-PRS, respectively. There was limited additive predictive utility with the combination of the two markers over LA emptying fraction alone for both incident AF and AF-related SSE (p for difference in C-index > 0.05).

Conclusions

Adding LA function to a clinical risk score was associated with statistically significant and clinically meaningful improvements in risk predictions of AF and AF-related SSE compared with adding AF-PRS. The addition of both LA function and AF-PRS to a clinical risk score had limited additive predictive utility compared with the addition of LA function alone.
Artificial intelligence-estimated electrocardiographic age as a recurrence predictor after atrial fibrillation catheter ablations
Authors: Park H , Kim D H , Park J W , Yu H T , Kim T H , Uhm J S , Joung B Y , Lee M H , Hwang C , Pak H N
Published: May 2024

Aims

The application of artificial intelligence (AI) algorithms to 12-lead electrocardiogram (ECG) provides promising age prediction models. We explored whether the gap between the pre-procedural AI-ECG age and chronological age can predict atrial fibrillation (AF) recurrence after catheter ablation.

Methods

We validated a pre-trained residual network (ResNet)-based model for age prediction on four independent multinational datasets: CODE-15%, PTB-XL, UK Biobank, and SaMi-Trop cohorts. Then, we evaluated AI-estimated ECG (AI-ECG) age for AF recurrence in a single-center AF catheter ablation (AFCA) cohort, which included 4,794 patients with de-novo AFCA and pre-procedural sinus rhythm ECGs. We categorized the AI-ECG age gap into two groups: aged-ECG (>13 year) and normal age (≤13 year) groups based on the maximum log-likelihood for AF recurrence according to the difference between chronological age and AI-ECG age.

Results

The ResNet-based AI-ECG age model successfully reproduced the chronological age on the independent datasets (total ECG number=414,804): CODE-15% (r=0.83), PTB-XL (r=0.74), UK Biobank (r=0.53), and SaMi-Trop (r=0.60). During median 22 (9-47) months after AFCA, patients with aged-ECG had a significantly higher AF recurrence rate (adjusted hazard ratio 1.31, 95% confidence interval [1.17-1.48], p<0.001) than normal age group. In the sub-group analyses, the aged-ECG affected more in patients with paroxysmal AF than in non-paroxysmal AF (P for interactions <0.001) and after cryoballoon pulmonary vein isolation (Cryo-PVI) than radiofrequency PVI (P for interactions <0.001).

Conclusions

Pre-procedural AI- ECG age has a prognostic value for AF recurrence after AF catheter ablation.
Recognition of Brugada type 1 pattern on ECG by Echo State Networks
Authors: Vozzi F , Pedrelli L , Dimitri M G , Piacenti M , Rossi A , Zucchelli G , Solarino G , Nesti M , Notarstefano P , Pieragnoli P , Persiani E , Morales M A , Micheli A
Published: May 2024

Background/Introduction

The development of artificial intelligence (AI) and machine learning (ML) techniques, which can identify data patterns in electrocardiography, has led to the development of automated analysis tools for standard 12-lead ECGs. These tools are able to identify specific features associated with different cardiac diseases, which may be helpful in clinical practice [1]. One field of application is represented by Brugada Syndrome (BrS) diagnosis, which, despite characteristic ECG features, can be challenging to diagnose and correctly distinguish from other diseases.

Purpose

Within the Brugada Syndrome and Artificial Intelligence Applications to Diagnosis system study, we are developing an innovative model for diagnosing Type 1 BrS based on electrocardiographic pattern recognition through the Echo State Networks (ESN), a Recurrent Neural Network (RNN) type of architecture.

Methods

From patients enrolled in 5 Centers, 306 12-lead ECGs were obtained. The datasets were composed of spontaneous Type 1 pattern (coved) (group A, 98 patients); patients undergoing ajmaline test, classified as positive (group B, 47 patients) or negative (group C, 35 patients) according to test results; 220 controls with no clinical and familial history of arrhythmias (group D). ESN analyzed, as input, data collected from 1 beat of the ECG V2 lead. The datasets were used for the ESN model training and were assessed through a double cross-validation approach. The ESN performance was compared with the evaluation of 4 independent cardiologists, and sensitivity, specificity and accuracy were determined.

Results

The ESN model correctly classified 280/306 ECGs (91.5%), with a performance of 3.6 points superior to clinicians (269/306, 88.0%). ESN sensitivity (87.0% vs. 86.9%) and specificity (94.5% vs. 89.1%) are described in Table 1; accuracy in each group of the dataset (groups A, B, C, and D), represented in Table 2, were comparable to or greater than those of clinicians.

Conclusion(s)

In this work, an ESN-based system for diagnosing Type 1 BrS pattern on ECG was developed. Our results show that this ML model can detect ECG patterns associated with Type 1 BrS with accuracy, sensitivity and specificity comparable or superior to clinicians. In the future, we will use a larger dataset to increase the model performance further, with the real possibility of becoming a tool for everyday clinical practice.ESN and clinicians' diagnostic accuracyECG accuracy in each dataset group
Deep embedded clustering of physical behaviour in patients with an implanted cardioverter-defibrillator identifies high and low risk profiles
Authors: Kolk M Z H , Frodi D M , Langford J , Andersen T O , Jacobsen P K , Risum N , Tan H L , Svendsen J H , Knops R E , Diederichsen S Z , Tjong F V Y
Published: May 2024

Introduction

Patients at high risk of sudden cardiac death are treated with an implantable cardioverter-defibrillator (ICD). Patterns in physical behaviour may be prognostic for clinical deterioration. Deep embedded clustering (DEC) employs deep neural networks to learn compact and meaningful representations from high-dimensional data, on which an unsupervised clustering then operates.

Purpose

The objectives of this study were to use DEC to identify and describe behavioural profiles in a prospective ICD cohort and assess their risk of clinical outcomes.

Methods

Data from the multicenter, prospective SafeHeart study conducted at our 2 centers, was used. Patients received an implantable cardioverter defibrillator (ICD) between May 2021 and September 2022, who then wore wearable devices during 6 months that capture physical behaviour. Latent representations were extracted from the time-series behavioural data using a variational autoencoder, and used as input to an unsupervised machine learning algorithm (Figure 1). Kaplan-Meier survival curves were used to visualise the annual risk of appropriate ICD-therapy, and the composite of all ICD-therapy and death.

Results

A total of 272 patients (mean age of 63.1 ±10.2 years, 81% male) were eligible, with a total of 37478 days of behavioural data (138 ±47 days per patient). DEC identified five distinct behavioural profiles: Cluster A (n=70) had high activity levels, mainly at light-to-moderate intensity. Cluster B (n=51) showed above-average sleep efficiency. Cluster C (n=63) exhibited a high-intensity activity profile. Cluster D (n=42) had frequent waking episodes and poor sleep. Cluster E (n=46) had very low physical activity levels and an impaired sleep architecture. Significantly differences were observed between clusters A-E in ICD-therapy and mortality (log-rank p-value 0.04) (Figure 2). Clusters B and D exhibited a threefold decrease in the annual risk of appropriate ICD therapy compared to cluster E.

Conclusion

DEC reveals distinct behavioural profiles in a prospective ICD cohort, with their inherent risk on outcomes. Wearable accelerometer devices enable behavioural monitoring that may provide opportunities for improved personalised risk prediction in a notoriously heterogeneous high-risk patient population.Deep embedded clustering of behaviourEvent rates stratified for clusters