bluuebunny/crossref_metadata_2025 huggingface dataset:
Peak frequency can be effectively used to characterize atrial remodelling in atrial fibrillation
Authors: Al-Aidarous S , Vidal Horrach C , Roney C , Butcher C , Hunter R , Honarbakhsh S
Published: May 2024

Introduction

Characterizing atrial fibrillation (AF) substrate can guide ablation strategies, particularly as current efficacy leaves room for substantial improvement. Low voltage zones (LVZs) correlate with atrial fibrosis and scar and can independently predict AF recurrence. Ablation of these zones improves freedom from arrhythmia, but the chaotic nature of atrial excitation frequently results in overestimation of LVZs limiting accurate substrate identification.

Purpose

While omnipolar voltage (OV) mapping has emerged to address this issue by closely correlating with sinus rhythm (SR) voltage maps, our study builds upon this by investigating a novel parameter, peak frequency (PF), to further refine AF substrate characterization.

Methods

Patients undergoing catheter ablation for persistent AF were enrolled. OV maps and PF maps were created during AF while bipolar voltage (BV) maps were created in SR with atrial pacing at pacing intervals (PIs) of 600ms and 250ms. Areas were classified as fixed scar (consistent LVZs across all maps), functional remodelling (LVZs in AF OV and SR BV 250ms maps) and non-LVZs (normal voltage across all maps). PF was assessed in these areas and defined as the highest frequency detected in the electrogram.

Results

Among 20 patients, the average voltage in AF OV maps differed significantly from SR BV 600ms (0.49±0.76mV in AF OV vs. 1.12±0.97mV SR BV 600ms, p<0.001) but not SR BV 250ms maps (0.49±0.76mV in AF OV vs. 0.52±0.84mV SR BV 250ms, p=0.10). Comparing co-registered points, there was a significant difference between AF OV and SR BV 600ms maps (0.21±0.09mV, p<0.001) but not between AF OV and SR BV 250ms maps (0.06±0.04mV, p=0.10). These findings were also consistent with regards to the proportion of LA area occupied by LVZs (42.4±8.2% AF OV, 24.3±7.4% SR BV 600ms and 39.4±6.7% SR BV 250ms; p=0.001). AF OV maps thereby correlated better with SR BV 250ms maps hence representing both fixed scar and functional remodelling. PF values ≥244Hz were predictive of non-LVZs (OR 3.91, 95% CI 3.77-4.07,) with an AUC of 0.71. A PF of ≤214Hz was predictive of fixed scar (OR 17.67, 95% CI 16.82-18.56, p<0.001) with an AUC of 0.90. A PF between 215-236Hz was predictive of functional remodelling (OR 2.83, 95% CI 2.71-2.95, p<0.001) with an AUC of 0.60. The majority of LVZs identified exclusively in AF OV maps exhibited PFs akin to those in non-LVZs highlighting the ability of PF to pinpoint potential overestimations in LVZs.

Conclusions

PF mapping can effectively discern between areas of fixed scar, functional remodelling, and potential overestimation of LVZs. PF may enhance substrate characterization in AF utilising data solely from electrograms.Trial Design and Zone AssignmentPeak Frequency and Voltage Zones
Long-term outcomes in hybrid versus standalone thoracoscopic ablation in patients with atrial fibrillation: a systematic review and reconstructed individual patient data meta-analysis
Authors: Aerts L , Kawczynski M J , Luermans J G L M , Maessen J G , Bidar E , Heuts S , Maesen B
Published: May 2024

Background

Both hybrid and standalone thoracoscopic atrial fibrillation (AF) ablation techniques have demonstrated favorable outcomes in the management of (long-standing) persistent AF patients, as compared to catheter ablation. However, it is currently unknown whether there is a difference in long-term freedom from AF when comparing these two procedures.

Purpose

To compare long-term freedom from atrial tachyarrhythmias (ATA) in patients undergoing hybrid and standalone thoracoscopic AF ablation.

Methods

A systematic search encompassing PubMed, EMBASE, and the Cochrane Library databases from January 1, 2012, to September 6, 2023, was performed using the following search terms: 'thoracoscopic ablation,' 'hybrid ablation,' 'atrial fibrillation,' and various alternative spellings. Articles were included for pooled analysis of freedom from ATA after meeting the criteria of reporting on consecutive patients and presenting Kaplan-Meier (KM) curves. Individual time-to-event data were reconstructed from the KM curves and included in a multivariable Cox and frailty Cox model with adjustments for age, sex, type of AF, AF duration, and study (frailty term in the frailty Cox model).

Results

In total, 18 studies were included in the meta-analysis for long-term freedom from ATA, comprising 2215 patients. Patients undergoing hybrid thoracoscopic ablation were older (62.0 vs. 58.8 years old, p=0.046), had less frequently paroxysmal AF-history (9.6% vs. 32.1%, p<0.01), and had a longer duration of AF-history (7.0 vs. 5.3 years, p=0.04), as compared to patients undergoing standalone thoracoscopic ablation. There were no significant differences between the two ablation procedures regarding short-term outcomes including early mortality (0.6% vs. 1.0%, p=0.07) and early stroke (1.9% vs 0.9%, p=0.11). Adjusted analysis revealed that hybrid thoracoscopic ablation was significantly associated with greater freedom from ATA (Hazard Ratio [HR]=0.59, 95%CI: 0.43-0.83, p<0.001) compared to standalone thoracoscopic ablation (see Figure 1A). Additionally, older age (HR=1.07, 95%CI: 1.03-1.12, p=0.002) and a higher percentage of male patients (HR=1.02, 95% CI: 1.01-1.03, p<0.001) were significantly associated with ATA recurrence. Adjusted freedom from ATA at 1 year, 3 years, and 5 years was 71.6%, 55.1%, and 46.8% for thoracoscopic ablation, and 82.0%, 69.9%, and 63.6% for hybrid ablation (see Figure 1B).

Conclusion

Hybrid thoracoscopic AF-ablation is associated with a higher level of freedom from ATA when compared to standalone thoracoscopic ablation.Figure 1
Direct oral anticoagulants versus vitamin K antagonists as stroke prevention in atrial fibrillation after cardiac surgery: a systematic review and meta-analysis
Authors: Terpstra M M , De Vries T A C , Oortwijn E , De Lind Van Wijngaarden R A F , De Groot J R
Published: May 2024

Background

Cardiothoracic surgery guidelines advocate the use of vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) in the first days to months after major cardiac surgery. No recommendations on choice of anticoagulant in the first months after cardiac surgery have been issued since 2008, before the use of direct oral anticoagulants (DOACs). The basis for this is a lack of data on the safety and efficacy of DOACs after cardiac surgery.

Purpose

To systematically assess and meta-analyze the existing evidence on the effect of DOACs compared with VKAs on efficacy and safety after cardic surgery. We hypothesized that DOACs are non-inferior to VKAs in the setting of AF after cardiac surgery.

Methods

We searched Ovid MEDLINE, Ovid EMBASE, the Cochrane Central Register of Controlled trials and Clinicaltrials.gov from inception till 20 June 2023 and screened references in relevant reviews as grey literature search. Observational studies and randomized controlled trials comparing DOACs with VKAs for stroke prevention in patients with (postoperative) atrial fibrillation after cardiac surgery were included, focusing on procedures through thoracoscopy or thoracotomy. Outcomes of interest included thromboembolic events, all-cause stroke, major bleeding and mortality up to 6 months after cardiac surgery and admission duration. A random effects model was used to determine pooled treatment effects. The level of evidence was rated following the GRADE recommendations.

Results

We identified 4,146 records of which ten were included, together reporting on > 30,000 patients. There were no significant differences in thromboembolic events (OR 0.98; 95% CI 0.61-1.58; I^2 0%; GRADE: very low), all-cause stroke (OR 1.14; 95% CI 0.51-2.54; I^2 0%; GRADE: very low), major bleeding (OR 0.91; 95% CI 0.51-1.62; I^2 53%; GRADE: very low), all-cause mortality (OR 1.00; 95% CI 0.73-1.37; I^2 0%; GRADE: low), admission duration (MD -0.33; 95% CI -1.16 – 0.49; I^2 0%; GRADE: very low) between DOACs and VKAs in the first 6 months after cardiac surgery.

Conclusion

Efficacy and safety of DOACs as stroke prevention in AF following cardiac surgery were similar to that of VKAs in ten studies comprising more than 30,000 patients. Based on the existing literature, there is insufficient evidence to recommend one class of oral anticoagulants over another in the first months after cardiac surgery.Forest plot of primary outcomes
Standalone transcatheter left atrial appendage closure or combined with cryoballoon pulmonary vein isolation
Authors: Schiavone M , Gasperetti A , Moltrasio M , Riva S , Maltagliati A , Majocchi B , Tundo F , Tondo C , Fassini G
Published: May 2024

Background

Head-to-head comparisons between stand-alone left atrial appendage closure (LAAC) and a same-procedure LACC + cryoballoon (CB) pulmonary vein isolation (PVI) (combined procedure) are currently lacking.

Purpose

To compare acute and long-term outcomes between stand-alone LAAC vs a LAAC+CB-PVI combined procedure.

Methods

All patients undergoing LAAC at our institution, having at least 2 years follow-up, were analyzed to assess the impact of additional CB-PVI. The primary efficacy and safety endpoints of our study were the acute procedural success rate and the peri-procedural complications rate. As secondary endpoints, major bleeding, and ischemic events, as well as sinus rhythm rate at 2 years follow-up were assessed.

Results

Among 126 LAAC patients meeting inclusion criteria (males=64.2%), n=55 (43.7%) underwent a combined procedure. LAAC-only patients were older (72.5±7.2 vs 68.9±8.6, p<0.05) and less frequently having paroxysmal AF (23.9% vs 47.3%, p<0.05). Baseline CHA2DS2-VASc was similar among groups (3.3±1.3 vs 2.9±1.1, p=0.07) while LAAC-only patients had higher HAS-BLED at enrollment (3.4±1.1 vs 3.0±1.0, p=0.04). Additional CB-PVI was not a risk factor for incomplete LAA occlusion (OR 0.24–3.78, p=0.96), presence of residual lateral flow (OR 0.26–4.05; p=0.96), intraprocedural need for occluder device resizing compared to pre-procedural assessment (OR 0.27–3.05; p=0.884), and peri-procedural complications (OR 0.25–6.74, p=0.749). At 3-month post-procedural trans-esophageal echocardiography, a combined procedure was not associated with higher risk of incomplete occlusion (OR 0.33–1.59, p = 0.432), nor larger peri-device leakages (coefficient k: -0.65–+0.20, p=0.291). Overall and by-group ischemic (red) and bleeding (blue) relative risk reduction from CHA2DS2-VASc and HAS-BLED predicted yearly rates during follow-up was reported in Figure1. Over a median follow-up of 40 [26–56] months, a combined procedure was not a risk factor for major bleeding (OR 0.31–5.48, p=0.715) or ischemic (OR 0.11–3.56, p=0.599) events. As expected, additional CB-PVI was strongly associated with a reduction of AF recurrences (OR 0.16–0.86, p<0.05), after excluding permanent AF patients from the analysis.

Conclusion

Combined LAAC + CB-PVI procedure does not appear to be a risk factor for worse LAAC-related outcomes, while reducing AF recurrences in non-permanent AF patients.Figure 1
Management of peri-device leaks after left atrial appendage closure using endovascular coils and/or amplatzer plugs and radiofrequency ablation
Authors: Maan A , Ambesh P A , Mirza J M , Kawamura I K , Stanton E S , Vashistha K V , Musikantow D M , Turagam M T , Koruth J K , Miller M M , Lampert J L , Whang W W , Dukkipati S D , Reddy V R
Published: May 2024

Background

Peri-device leaks (PDLs) after left atrial appendage closure (LAAC) portend a higher residual risk of thromboembolism in patients with Atrial Fibrillation (AF). Therefore, closure of PDLs has evolved as a procedural strategy to mitigate this residual thromboembolic risk.

Objective

To present our procedural experience and outcome data in patients who underwent PDL-closure after prior LAAC.

Methods

We performed a retrospective review of patients with follow-up imaging data (either transesophageal echocardiograms or Cardiac CT scans) performed at ∼1 year after LAAC between the time-period 5/2015 – 10/2022 to assess PDLs.

Results

We included a total of 532 patients with follow-up imaging data. At a mean follow up of 696±359 days post-LAAC, 63 of 532 (11.8%) patients underwent PDL closure. These PDL closure cohort was age 73.1±9.5 years, 41 of 62 (65%) had paroxysmal AF, and the CHA2DS2-Vasc was 3.7±1.5. In 42 of 62 (67.7%) patients, the initial LAAC device was Watchman, and in 21 (33.8%) patients, it was Watchman-FLX. Of the PDL closure cohort, 8 of 62 (12.9%) had a post-LAAC thromboembolic event (transient ischemic attack [TIA], stroke or systemic embolism). The PDL size was 3.8±2.0 mm. PDL closure was performed using endovascular coils alone in 23 (37.1%), plugs (Amplatzer devices, Abbott) alone in 18 (29%), and combinations of both in 13 (19.4%) patients. In 8 (14.5%) patients, radiofrequency ablation was used in concert with both coils and plugs (Figure). There was only 1 complication (pericardial effusion drained percutaneously) during the PDL closure procedure. During follow-up post-PDL closure, no patient sustained a stroke and only 1 patient had a TIA (Table).

Conclusions

Our data indicate that PDL closure after LAAC is feasible and safe, with a low risk of procedural complications. Such a strategy can be used in a subset of high-risk patients with PDL after LAAC who are at an elevated residual risk of thromboembolism.Table summarizing procedural strategies
Acute haemodynamic changes during left atrial appendage closure
Authors: Herman D , Herman D H , Hozman M H , Valoskova V N , Karch J K , Vesela V J , Vondalova V V , Osmancik O P
Published: May 2024

Purpose

Left atrial appendage closure (LAAC) presents an alternative treatment for stroke prevention in atrial fibrillation (AF) in patients with contraindication for long-term anticoagulation. However, even in patients in AF, left atrial appendage plays an important role in reservoir function of left atrium. The purpose of this study was to assess acute hemodynamic effects during LAAC.

Methods

Consecutive patients indicated for LAAC from January 2022 to October 2023 were enrolled. The invasive hemodynamic measurements were done at the beginning of the procedure after transseptal puncture, and at the end from the procedure after device deployment. Following parameters were measured: systolic, and diastolic blood pressure, and pressure in left atrium (LA), all measurements were done at rest and after 3 minute isometric exercise (handgrip).

Results

Thirty-two patients were included (age 76,2+7,1 yrs, 22 (69%) males, 23 (72%) permanent AF, left ventricular ejection fraction 52+11,8%). No patients experienced moderate/severe mitral insufficiency, the saline intake during procedure was 738 ml. Isometric exercise significantly increased the LA pressure: the LA pressures (rest/exercise) were 13.7+6.7 mmHg/16.7+8.8 mmHg (p=0.003) at the beginning of the procedure, and 17.0+7.3mmHg/20.0+7.3 mmHg (p=0.005) after device deployment. The LA pressure obtained after device deployment (both rest/exercise) were significantly higher compared to values obtained at the beginning of the procedure. (p=0.003).

Conclusions

LAAC is associated acute increase of both rest and exercise LA pressure. Whether its acute negative effect remains over time needs further investigation.
Impact of industry funding on atrial fibrillation clinical trials: insights and implications
Authors: Lan R , Paranjpe I P , Saeed M S , Perez M V P
Published: May 2024

Background/Introduction

Commercial industry is an important source of funding for atrial fibrillation clinical trials, the implications of which have not been analyzed.

Purpose

The purpose of this study is to describe the characteristics of contemporary AF clinical trials and to evaluate their association with funding source.

Methods

We systematically assessed all completed atrial fibrillation trials registered in ClinicalTrials.gov between conception to September 1, 2022, and extracted publicly available information including funding source, trial size, race, ethnicity, sex, intervention, location, and publication status. Trial characteristics were compared using the Wilcoxon rank sum test and Fisher’s exact test for continuous and categorical variables, respectively.

Results

Of the 253 clinical trials assessed, 171 (68%) reported industry funding. Industry funding was associated with a greater median total enrollment (172 vs. 80; P < 0.001), publication rate (56.7% vs. 42.7%; P = 0.04), participation in device trials (48.0% vs. 24.4%; P < 0.001), and multicontinental recruitment location (25.2% vs. 2.4%; P < 0.001) when compared to non-industry funded clinical trials. However, industry funding was not associated with a significant difference in median impact factor (7.7 vs. 7.7; P = 0.723) or median number of citations (60.0 vs. 29.0; P = 0.09). The overall proportion of industry funded trials did not change over time (P = 1.00) since inception of the ClinicalTrials.gov database. Participant demographics remained relatively uniform over time across both industry-funded and non-industry-funded trials.

Conclusion(s).

Industry funded clinical trials in atrial fibrillation are often larger, more frequently published, multicontinental, and device-focused. Industry funding was found to be associated with significant differences in study enrollment, publication metrics, and study interventions. Insights from this study inform trial design, regulation, and policy considerations in the evolving landscape of AF research.TableFigure
Rapid access nurse-led atrial fibrillation clinics reduce hospital readmissions
Authors: Yelinevich I , Mampitiya N , Tanner M , Tate C , Hall C , Child N
Published: May 2024

Background

Atrial Fibrillation (AF) is the most common cardiac arrhythmia and in the UK accounts for about 1.5% of healthcare expenditure mainly through recurrent hospital admissions (1). The European Society of Cardiology 2020 AF guidelines (2) provides a clear framework of all the different components required to provide good patient-centred integrated AF management of which very little is done well within an emergency inpatient setting.

Purpose

We have developed a nurse led Rapid Access AF (RAAF) clinic aiming to prevent repeat admissions and improve patients overall AF care.

Methods

All patients discharged from our institution's emergency department (ED) or acute medical ward with a primary diagnosis of atrial fibrillation are suitable for the Rapid Access AF clinic. At the clinic the patients are given patient education, advise about risk factor modification, access to an "AF hotline" and a simple initial management plan should symptoms worsen with advise about when to attend the emergency department. Patients are then reviewed at a weekly multidisciplinary meeting with the local AF doctors where longer term strategies are made. The clinics have been operating now for 2 years and we have audited the 3 months from January to March 2022 with further follow up at 6 months.

Results

41 out of 64 patients presenting to the emergency department with AF were admitted. However, whether in the ED or subsequent medical ward, treatment as a whole was very simple AF management, similar to that of outpatient care ( e.g. in ED Beta Blockers 34%, Digoxin 16%, oral Flecainide 5%, IV Amiodarone 12.5%, direct current cardioversion 1.5%, no clear AF treatment 16%, anticoagulation in patients with CHADSVASC 2+ 92%). 36 out of 64 patients were discharged to RAAF clinic and were seen on average 22 days post discharge. Readmission rates were 11% vs 32% at 30 days in patients discharged to RAAF compared to standard care and 14% vs 60% at 6 months.

Conclusion

Patients admitted to hospital with a primary diagnosis of AF are at high risk of early readmission. A rapid access AF clinic is effective at significantly reducing hospital readmission rates whilst also providing more holistic integrated AF management.
Evaluation of the cavotricuspid isthmus contractile kinetics within an interventional CMR environment
Authors: Pusterle De Cidrac A , Solana Munoz J , Luca A , Teres C , Le Bloa M , Ascione C , Domenichini G , Pascale P , Antiochos P , Masi A , Paetsch I , Jahnke C , Schwitter J , Pruvot E
Published: May 2024

Background

Cavotricuspid isthmus (CTI)-dependent flutter is a common arrhythmia with recurrences following ablation up to 50%. Previous static morphological analysis have shown that CTI anatomical variability has an impact on ablation time and procedural success. However, whether the contractile kinetics of the CTI affect procedural success remains unknown to date.

Purpose

Assessment of the contractile kinetics of the CTI in a cardiac magnetic resonance (CMR) environment for patients (pts) referred for typical flutter ablation.

Method

32 consecutive pts with typical right atrial (RA) flutter from our Heart Center were included in this study. RA wall contours during a single cardiac cycle were delineated on CMR 2D-images using the Tomtec software. CTIs were divided in 5 segments for detailed motion analysis as shown in the figure 1A. CTI length and displacement were measured both in caudo-cranial and postero-anterior directions. Quantification of the CTI kinetics was performed in Python by computing the 2D-Euclidean distance (between two extreme temporal positions of CTI points).

Results

The mean CTI length of the study population (mean age 66±10 years, 29 males) was 32±13 mm during RA systole and 49±15 mm during RA diastole, resulting in a mean CTI change of 17±7 mm over one cardiac cycle (maximum – minimum length). Figure 1A shows representative MRI views of the CTI during RA systole and diastole. Figure 1B shows examples of hypo- and hyperkinetics CTI from 2 representative pts. Figure 2C shows a gradual increase in segment displacement postero-anteriorly (8.1±7.3 vs 17.2±8.1 mm, p<0.05) and caudo-cranially (1.6±0.8 vs 4.5±2.4 mm) from the Eustachian valve toward the Tricuspid valve. Figure 2D indicates that the 2D-Euclidean displacement of the 5 segments varied between 8±7.7 mm and 18±8.5 mm depending on their location. Interestingly, the overall CTI displacement was 4.5 times greater forward than upward.

Conclusion

To our knowledge, this is the first study investigating the kinetics properties of the CTI in sinus rhythm of patients with typical RA flutter. The CTI showed displacements both in postero-anterior and caudo-cranial directions, with a gradual increase from the Eustachian to the Tricuspid valves. CTI displacement appeared highly variable across patients. Whether the kinetics of the CTI correlate with ablation success will be investigated shortly.
Atrioventricular nodal reentrant tachycardia ablation (avnrt), a female disease. insights from the german ablation registry
Authors: Eitel C , Ince H , Brachmann J , Kuck K H , Willems S , Gerds-Li J H , Tebbenjohanns J , Iden L , Hochadel M , Senges J , Tilz R
Published: May 2024

Background

The German Ablation registry is a multi-centre prospective registry for electrophysiologic ablation procedures.

Purpose

We herein report on catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) according to underlying gender.

Methods

From January 2007 until January 2010 a total of 2918 patients [64.4% female, 55 (43; 67) years] undergoing catheter ablation of AVNRT were enrolled in this registry and followed for at least one year.

Results

Female patients undergoing ablation for AVNRT were significantly younger than male patients [52 (41; 66) versus 60 (47; 70); p<0.001] and had less structural heart disease than male patients [12,1 % (228/1880) versus 30,8 % (320/1038)]. Female patients more often had ≥ one arrhythmia episode per month [73,7 % versus 68,1 %; p<0.001], nevertheless arrhythmia documentation was less often present in female patients [81,7 % versus 85,4 %; p=0.012]. Success rate was high (98,9 %) and major complications prior to discharge (death, myocardial infarction, stroke) were rare (1/2917) without significant difference between female and male patients. During a follow-up period of 682.9 ± 172,9 days, female patients more often experienced arrhythmia recurrences [19,1 % versus 13,8 %; p<0.001].

Conclusions

Almost two-thirds of patients undergoing ablation for AVNRT included in the German ablation registry were female. Female patients were younger and less often had structural heart disease or other comorbidities than male patients undergoing AVNRT ablation. Success rates and complication rates were similar. During follow-up female patients more often experienced arrhythmia recurrences.
Safety and feasibility of left bundle branch pacing for pediatric and congenital heart disease patients
Authors: Ouali S , Jebbari Z , Boudiche S , Ben Rejab R , Mgaieth F , Ben Halima M
Published: May 2024

Background

Conduction system pacing (CSP) has evolved and validated in adults. Due to technical challenges, pediatric and congenital heart disease (CHD) patients were excluded from original trials in this field. We report the safety and feasibility results of our initial experience with pediatric and CHD patients undergoing LBBAP (Left bundle branch area pacing).

Purpose

To analyze the indications, intraoperative outcomes, electrocardiographic and clinical data from the initial follow-up of pediatric and CHD patients who underwent LBBAP.

Methods

Indications, intraoperative technical issues, electronic parameters of the implant and early complications of consecutive pediatric and CAD patients submitted to stimulation of the conduction system were evaluated.

Results

This study was performed between February 2022 and November 2023 and recruited 11 consecutive patients with complete AV block (age: 15-43 years; 7 women) who underwent LBBAP. Four patients had congenital heart disease repaired surgically and two patients with congenitally corrected transposition of the great arteries. Upgrading from VVIR to LBBAP underwent in four patients. Right ventricle (RV) leads were extracted in three patients before CSP. DDD pacemakers with Lumneless 3830 pacing leads were implanted in all patients. The pre-implant QRS duration was 146 (104- 200) ms and 120 (110-130) ms after the procedure. The mean left ventricle activation time was 72 (50-90) ms. The R-wave amplitude was 10.00 (6-29) mV, with a stimulation threshold of 0.8 (0.4-1) V x 0.4 ms and impedance of 676 (534-780) ohms. Transition from non-selective to either myocardial or selective capture and fixation beats were respectively demonstrated in five and three patients. The procedure duration was 125 (70-130) min, and the fluoroscopy time was 15.2 (4-23.6) min. LBBAP substantially shortened the QRS duration and improved LV dyssynchrony echocardiographic parameters in four patients with prior epicardial or endocardial pacing. The LBBAP was successful in all patients with no early complications occured. At mean three months follow-up, QRS duration showed no significant changes compared with baseline.

Conclusion

Our initial experience on cardiac stimulation of the His-Purkinje conduction system through the stimulation of the left bundle branch is a safe and feasible technique in pediatric and CHD patients. The widespread use of this pacing technique is very useful and cost-effective to prevent heart failure in this vulnerable population.
Estimation of ventricular ectopic beat origin with electrocardiographic imaging
Authors: Fambuena Santos C , Llorente-Lipe I , Ros S , Sanchez J , Carta A , Torrecilla E G , Atienza F , Climent A M , Guillem M S
Published: May 2024

Background

Precise identification of premature ventricular contractions (PVC) origins poses a significant challenge in electroanatomic mapping. Electrocardiographic Imaging (ECGI) allows instantaneous and global activation time mapping, providing a fast way to locate the origin of ectopic contractions. However, the standard methodology to estimate local activation times (LAT) in invasive electrograms is not directly transferable to ECGI signals.

Objective

In this study, a new methodology to calculate LAT maps with ECGI is presented and compared to the standard method in both, mathematical simulations and patients.

Method

We conducted computer simulations of five distinct PVCs to generate ECGI signals. Two techniques were applied to estimate LATs: the conventional -dV/dt method, which identifies the steepest negative deflection, and our novel Bayesian approach. The error in the location of the origin of the electrical activation and the similarity of the LAT maps were calculated with respect to the reference computer model. Additionally, we tested both algorithms in four patients with PVCs originated in different locations (three in the output tract of the right ventricle and one in the ventricular base, close the coronary sinus).

Results

The results indicated a substantial improvement in identifying the earliest activation site using our Bayesian algorithm, with a reduced localization error (1.5 ± 2.5 cm to 0.6 ± 1.5 cm). The root mean squared error (RMSE) was also significantly lower when comparing our Bayesian LAT maps to the reference LATs obtained in the simulations (19.0 ± 5.3 vs. 10.8 ± 4.5 ms). Patient data revealed smoother and more physiologically consistent propagations in the Bayesian maps, aligning with the PVC origins identified via electroanatomical navigation systems.

Conclusion

This study demonstrates that ECGI signals, when processed with advanced Bayesian techniques, significantly enhance LAT estimation. The proposed methodology improves the localization accuracy of ectopic beats and has practical implications for optimizing PVC treatment protocols.
Percutaneous stellate ganglion blockade as an add-on therapy for the treatment of arrhythmic storm
Authors: Prolic Kalinsek T , Salihovic M , Podlogar V , Stublar J , Irsic J , Jan M
Published: May 2024

Introduction

Arrhythmic storm (AS) due to repetitive ventricular arrhythmias (VA) is a life-threatening condition that can be resistant to antiarrhythmic therapy. Sympathetic nervous system plays an important role in triggering and maintaining VA. Reducing sympathetic activity by percutaneous stellate ganglion blockade (SBG) may improve outcomes in treating AS.

Purpose

To evaluate the effect of SBG on outcomes of AS.

Methods

In this retrospective study, we analyzed 18 patients treated with SBG for AS from August 2017 to May 2022. All patient experienced VA while on antiarrhythmic drug therapy. SBG was performed under ultrasound guidance to avoid vascular structures. Either 0.75% levobupivacaine or 0.5% ropivacaine were applied to block the stellate ganglion after negative aspiration. The decision to perform unilateral or bilateral SBG was left to the operator.

Results

The majority of patients were male (17/18, 94.4%), mean age was 61.8 ± 13.4 years, mean BMI 28.1 ± 5.39 kg/m2, mean LVEF was 34.4 ± 12.2%, majority had an ischemic cardiomyopathy (12/18, 66.7%). Half of the patients had monomorphic VA (9/18, 50.0%), the other half had polymorphic VA (9/18, 50.0%). Majority of patients were hemodynamically unstable (13/18, 72.2%) and more than a third had a cardiac arrest (7/18, 38.9%). Half of the patients had unilateral SBG (9/18, 50.0%), and the other half bilateral SBG (9/18, 50.0%). SBG was repeated in two patients (2/18, 11.1%). On the repeat procedure, both had bilateral SBG. There were 4 minor complications (4/18, 22.2%) and no major complications. Two patients had intermittent Horner’s syndrome, one had a small hematoma on the puncture site, and one had small hematoma in the mediastinum. All complications resolved on their own and did not require an intervention. In the 72 hours after SBG, 5 patients had a recurrence of VA (5/18, 27.8%). After the discharge, 6 patients also had a recurrence of VA (6/18, 44.4%). SBG significantly reduced mean number of VA episodes in the next 72 hours (12.3 ± 11.1 vs 4.3 ± 10.6; P=0.007) with a mean difference of 8.0 VA episodes (95% CI, 4.5 - 14.0; P=0.007) (Figure 1). One patient died due to recurrent VA leading to ischemic brain damage (1/18, 5.6%). Four patients died due to non-VA related causes (4/18, 22.2%). Two deaths were due to septic shock, the other two due to cardiogenic shock. Details of baseline characteristics and outcomes are in the Figure 2.

Conclusion

SBG significantly reduces episodes of VA after failed antiarrhythmic drug therapy in patients presenting with AS.A before-after graph of VA after SBG.Baseline and outcomes table.
Termination without global capture: electrocardiographic and anatomical characteristics using 3D-electroanatomical mapping system in reentrant ventricular tachycardia
Authors: Katsume Y , Hasegawa K , Ikewaki H , Mohri T , Tashiro M , Nonoguchi N , Hoshida K , Togashi I , Ueda A , Matsuo S , Sato T , Soejima K , Stevenson W G
Published: May 2024

Background

Termination without global capture (TWGC) is the phenomenon which a pacing stimulus applied during ventricular tachycardia (VT) terminates the tachycardia without generating a QRS complex, and is considered as an indicator for the critical component of the circuit. The details of the electrocardiographic and anatomical characteristics of the site using a 3D-electroanatomical mapping system (3D-EAM) remain unknown.

Purpose

This study aimed to retrospectively analyze the cases that showed TWGC during VT mapping and ablation, and to investigate the electrocardiographic characteristics and relationship with the substrate identified by 3D-EAM.

Methods

Of 632 cases of VT associated with structural heart disease from July, 2019 to July, 2023 at a university hospital and a university medical center, cases with TWGC were analyzed.

Results

TWGC was observed in 10 patients (median age 61 years, 9 males, 5 ischemic cardiomyopathy, median LVEF 31%) at least once (12 times) in 11 locations. Local capture was observed in 6. The QRS morphology generated by continued pacing after TWGC matched the clinical VT in only 5 VTs (42%). Five showed decremental conduction of stimulus to QRS interval following the TWGC. In 11 locations, 4 corresponded to scar area (<0.1 mV) in the voltage map, 6 to border zone (0.1-1.5 mV), and 1 had no information on 3D-EAM. Of 12 times of TWGC, 3 were at the entrance, 1 at the central isthmus, and 1 at the exit. Acute elimination of clinical VT was successful in 7 of 10.

Conclusions

More than half of the sites with TWGC were located at the border zone in 3D-EAM. TWGC also occurred in the central or exit area, and local capture was observed frequently.Termination without global capture
Left and right ventricular function measured by strain analysis predicts one-year mortality in ventricular tachycardia ablation patients with structural heart disease
Authors: Szakal I , Beke S , Komlosi F , Toth P , Vamosi P , Arnoth B , Bohus G Y , Szegedi N , Sallo Z , Perge P , Osztheimer I , Kovacs A , Merkely B , Geller L , Nagy K V
Published: May 2024

Introduction

Radiofrequency catheter ablation has become increasingly important in the management of scar-related ventricular tachycardia (VT). Wide range of clinical and procedural predictors of VT recurrence and mortality are described by previous studies. However, currently known echocardiographic predictors are mainly limited to conventional echo parameters. Speckle tracking echocardiography (STE) is a novel and promising method to evaluate systolic and diastolic function. STE derived parameters, such as global longitudinal strain (GLS), are proven predictors of mortality and arrhythmic events in heart diseases.

Aims

The aim of the present study was to assess whether STE derived parameters could be considered predictors of VT recurrence and mortality after catheter ablation of ventricular tachycardia in patients with structural heart disease.

Methods

We measured pre-ablation strain and strain rate parameters with speckle tracking. Left ventricular four-chamber longitudinal strain (LV4CLS), early diastolic strain rate (e’-sr), right ventricular free wall longitudinal strain (RVFWLS) and right ventricular four-chamber longitudinal strain (RV4CLS) were assessed in 73 cases. Patients were followed up for one year. Endpoints were VT recurrence, which was defined as either ICD recording of a sustained VT episode requiring therapy or an episode of sustained VT recorded on 12-lead ECG or CIED, and all-cause mortality.

Results

Univariate analysis using the Cox proportional hazard model revealed that only lower LVEF (HR: 0.52 [0.31-0.88], p=0.02) was associated with higher VT recurrence in the first year among the echocardiographic parameters. High LVEDD (HR: 3.9 [1.31-11.65], p=0.02), low TAPSE (HR: 0.52 [0.28-0.98], p=0.04), low LV4CLS (HR: 0.4 [0.19-0.83], p=0.01) and low RV4CLS (HR: 0.31 [0.13-0.72], p<0.01) were the predictors of 1-year mortality.

Conclusion

Strain parameters, especially right ventricular four-chamber longitudinal strain may supplement conventional echocardiographic parameters in the prediction of one-year mortality after catheter ablation in patients with structural heart disease. Further prospective clinical studies are necessary to verify the significance of strain parameters.
Cardiac tumors with life threatening arrhythmia, an eight year single centre experience
Authors: Kamel O , El Husseny M W , Hammouda T , Hosny H H , Ahmed E A , Nasr A N , Abdelfattah M A , Shaaban M S , Elguindy A E , Afify A A , Yacoub M Y
Published: May 2024

Background

Cardiac tumors are rare cardiac disorders which occur either as primary or secondary tumors. They have a wide variety of clinical presentations from accidental discovery till sudden cardiac death. Manifestations are mainly due to mass effect, local invasion, embolization, or constitutional symptoms. (1) Cardiac tumor related arrhythmias are more often incessant, especially in younger children, and the mechanism can be reentry or triggered automaticity. (2)

Arrhythmia management depends on its clinical impact as well as tumor size, site, and nature. Surgical resection is preferred in life threating arrhythmias however, the decision should be tailored.

Purpose

To describe our institution’s tailored approach in treatment of cardiac tumors presenting with life threatening ventricular arrhythmias (VAs), including surgical resection, coiling of feeding vessels or even ICD implantation with long term rhythm monitoring.

Methods

We reviewed patients with primary cardiac tumors presenting to our center from 2015 to 2023 with emphasis on those with life threatening VAs. Patient records were examined for clinical presentation, ECGs, imaging modalities, histopathological analysis of the resected tumors and interrogation data for those with cardiac implantable electronic devices (CIEDS).

Results

Over 8 years, 64 patients were diagnosed to have primary cardiac tumors. Of those, 3.8% (6 patients) presented with life threatening monomorphic VT, half of them were pediatrics. Tissue characterization by CMR and histopathological analysis for the resected tumors revealed: 4 fibromas, one lipoma and one hemangioma. Surface ECGs during VT showed exit at, or close to, the site of the tumor (Table). Total surgical resection was performed in four cases (3 fibromas and one lipoma), one of them (the youngest, 6 months old) died during the postoperative period due to refractory heart failure. Partial resection was done in one patient with fibroma as the tumor involved the majority of RV free wall while the patient with hemangioma underwent coiling of the feeding vessels twice with marked decrease in the tumor size however he had one further episode of VT, so ICD was implanted. Over a mean follow up period of 3 years, four patients had no recurrence of tachycardia as confirmed with implantable loop recorders (ILRs) while the patient with ICD had infrequent episodes.

Conclusion

Total surgical resection, albeit risky, is highly effective in eliminating life threatening VAs caused by cardiac tumors. Other modalities like partial resection or coiling of the feeding vessels could be effective in high-risk patients. Devascularization, in our hemangioma case was not totally protective. Finally, ILRs were highly beneficial in confirming long-term freedom of arrhythmia after resection.Table: VT exit, tumor site and typeECG, CMR, angiogram& surgical view
Cardiac magnetic resonance to predict appropriate therapies in secondary prevention
Authors: Castrillo Golvano L C , Vazquez-Calvo S , Ventosa-Blazquez O , Thomsen A F , Forado I , Garre-Beng P , Borras R , Guasch E , Tolosana J M , Arbelo E , Porta-Sanchez A , Sitges M , Brugada J , Mont L , Roca-Luque I
Published: May 2024

Introduction

Implantable cardioverter-defibrillator (ICD) therapy plays a pivotal role in the management of patient’s survivors of life-threatening ventricular arrhythmias (secondary prevention). Risk of recurrence may be related to presence of myocardial scar and its components (including core mass, border zone (BZ) mass, and BZ channels) assessed with late gadolinium enhancement cardiac magnetic resonance (LGE-CMR).

Purpose

Our study aims to analyze the role of imaging in predicting the risk of recurrent ventricular arrhythmias and improving the risk stratification for appropriate ICD therapy in patients receiving an ICD for secondary prevention.

Methods

From 2015 to 2020, a total of 111 patients with LGE-CMR before ICD implantation for secondary prevention. Scar tissue including core, BZ and BZ channels were automatically detected by specialized investigational software in patients with LGE-CMR. Patients were followed until a new event was detected.

Results

The mean age was 65.4 ± 11.4 years; 87% were men; 55% had ischemic cardiomyopathy. The mean left ventricular ejection fraction was 37.8 % ± 14.31%. Patients were followed for a median of 3.26 years (IQR 1.4-4.9). Within the first year of follow-up 22% of patients had received an appropriate therapy, 39% within 3 years and 53% within 6 years.

Chronic kidney disease and New York Heart Association (NYHA) class were associated with the primary endpoint [HR 1.94(1.06-3.55), P-value 0.032)] and [HR 1.86 (1.19-2.91), P-value 0.006)], respectively. Regarding CMR characteristics, BZ percentage was also associated with appropriate ICD therapy in the follow up [HR 1.04(1-1.08), P-value 0.048)]. Other CMR parameter, such as BZ mass, BZ core %, BZ core mass and core mass showed a trend to predict ICD therapies during follow-up. ROC curve analysis with Youden’s index defined an optimal BZ percentage cutoff value for recurrence prediction of 9.5% [HR 0.49 (0.28-0.85)].

Conclusion

In patients receiving an ICD for secondary prevention, chronic kidney disease, NYHA class and BZ percentage analyzed by LGE-CMR were predictors of recurrent ventricular arrhythmia. A cutoff of BZ of 9.5% could be used to select patients with high risk of recurrence.
Stereotactic arrhythmia radioablation for refractory ventricular tachycardia. A retrospective analysis and optimisation of the planning phase
Authors: Solana Munoz J , Luca A , Herrera-Siklody C , Van Der Ree M , Postema P , Teres C , Le Bloa M , Domenichini G , Pascale P , Blanck O , Verfhoff J , Schiappacasse L , Pruvot E
Published: May 2024

Introduction

Stereotactic arrhythmia radioablation (STAR) is used as a rescue treatment for refractory ventricular tachycardia (VT). However, the planning phase to accurately delineate the clinical target volume (CTV) still suffers from limitations due to the incompatibility of data formats between 3D electro-anatomical mapping systems (EAM) used for VT ablation and STAR planning software. The concordance between the CTVs as defined by the planning software (CTVSTAR) and the CTV based on EAM data (CTVEAM) remains unknown.

Purpose

Within the STOPSTORM European consortium, we compared the concordance between CTVSTAR and CTVEAM in our series of 13 patients (pts) treated by STAR for refractory VT. We also evaluated need for redo ablation of VT after STAR.

Method

Using the software Slicer3D, two protocols were retrospectively compared: Protocol 1 comprised the manual contouring of the CTVSTAR based on 4D-CT SCAN drawn side-by-side using EAM (Carto3, Biosense Webster) screenshots and diagnostic reports. Protocol 2 comprised semiautomatic segmentation of CTVEAM based on 4D-CT SCAN using imported EAMs annotated with landmarks for VT substrate delimitation. The delineation of CTVEAM included 3 steps: (1) semiautomatic segmentation of ventricular myocardium (VM), the blood-pool of the concerned ventricle and at least 2 additional cardiac cavities; (2) 3D-alignment of EAM with the segmented cavities; and (3), 3D-delineation of CTVSTAR identified as the transmural section of VM segment surrounding the EAM’s VT substrate delimited by STAR tags (Figure 1). Volume overlap (Dice coefficient, 100% meaning complete overlap) and volume absolute difference (VAD, 0% meaning similar volumes) between CTVs were compared. The following cumulative averages were computed over time: redo ablation (RedoA) and CTV.

Results

Figure 1 illustrates the last treated patient (#13) in whom the delineated volumes, CTVSTAR (red) and CTVEAM (blue), displayed good matching (Dice 72% and VAD 4. Figure 2 shows the comparison between CTVSTAR and CTVEAM for the 13 pts (65±7 yo) treated with STAR, resulting in a mean Dice of 47±17% and mean VAD of 40±51%. Figure 3 shows the cumulative RedoA and the cumulative averaged CTVSTAR and CTVEAM over time. Interestingly, the need for redo ablation decreased with increasing CTVs.

Conclusion

Our study demonstrates the efficacy of STAR treatment for refractory VT. Our confidence in STAR led to higher CTVs and lower RedoA over time. The high variability of CTV delineation using two different protocols suggests that STAR planning phase can be optimised by appointing intraprocedural anatomical landmarks to the VT substrate.
Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients
Authors: Mazza A , Bendini M G , Leggio M , Valsecchi S , Boriani G
Published: May 2024

Aim

In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation.

Methods

We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded.

Results

The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as independent predictor of death (Hazard Ratio, 1.33; 95% CI, 1.09–1.63; P=0.005). However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (Hazard Ratio, 2.13; 95% CI, 1.38–3.29; P<0.001), but not with RBBB.

Conclusions

In patients with standard pacemaker indications and normal or moderately depressed LV function the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.Time to event