bluuebunny/crossref_metadata_2025 huggingface dataset:
Update on supra-annular sizing of transcatheter aortic valve prostheses in raphe-type bicuspid aortic valve disease according to the LIRA method
Authors: Iannopollo Gianmarco , Romano Vittorio , Esposito Antonio , Guazzoni Giulia , Ancona Marco , Ferri Luca , Russo Filippo , Bellini Barbara , Buzzatti Nicola , Curio Jonathan , Prendergast Bernard , Montorfano Matteo
Published: May 2022

Recent evidence has shown that transcatheter heart valve (THV) anchoring in bicuspid aortic valve (BAV) patients occurs at the level of the raphe, known as the LIRA (Level of Implantation at the RAphe) plane. Our previous work in a cohort of 20 patients has shown that the delineation of the perimeter and device sizing at this level is associated with optimal procedural outcome. The goals of this study were to confirm the feasibility of this method, evaluate 30-day outcomes of LIRA sizing in a larger cohort of patients, assess interobserver variation and reproducibility of this sizing methodology, and analyse the interaction of LIRA-sized prostheses with the surrounding anatomy. The LIRA sizing method was applied to consecutive patients presenting to our centre with raphe-type BAV disease between November 2018 and October 2021. Supra-annular self-expanding THVs were sized based on baseline CT scan perimeters at the LIRA plane and the virtual basal ring. In cases where there was discrepancy between the two measurements, the plane with the smallest perimeter was considered the reference for prosthesis sizing. Post-procedural device success, defined according to Valve Academic Research Consortium-2 (VARC-2) criteria, was evaluated in the overall cohort. A total of 50 patients (mean age 80 ± 6 years, 70% male) with raphe-type BAV disease underwent transcatheter aortic valve replacement (TAVR) using different THV prostheses. The LIRA plane method appeared to be highly successful (100% VARC-2 device success) with no procedural mortality, no valve migration, no moderate-severe paravalvular leak, and low transprosthetic gradients (residual mean gradient 8.2 ± 3.4 mmHg). There were no strokes, no in-hospital or 30-day mortality, and an incidence of in-hospital pacemaker implantation of 10%. Furthermore, measurement of the LIRA plane perimeter was highly reproducible between observers (r = 0.980; P < 0.001) and predictive of the post-procedural prosthetic valve perimeter on CT scanning (r = 0.981; P < 0.001). We confirm the feasibility of supra-annular sizing using the LIRA method in a large cohort of patients with high procedural success and good clinical outcomes at 30 days. Application of the LIRA method optimizes THV prosthesis sizing in patients with raphe-type BAV disease.
ANMCO position paper ‘Appropriateness of prescribing direct oral anticoagulants in stroke and systemic thromboembolism prevention in adult patients with non-valvular atrial fibrillation’
Authors: Mocini David , Di Fusco Stefania Angela , De Luca Leonardo , Caldarola Pasquale , Cipriani Manlio , Corda Marco , Di Lenarda Andrea , De Nardo Alfredo , Francese Giuseppina Maura , Napoletano Cosimo , Navazio Alessandro , Riccio Carmine , Roncon Loris , Tizzani Emanuele , Nardi Federico , Urbinati Stefano , Valente Serafina , Gulizia Michele Massimo , Gabrielli Domenico , Oliva Fabrizio , Colivicchi Furio
Published: May 2022

The appropriateness of prescribing direct oral anticoagulants [dabigatran, rivaroxaban, apixaban, and edoxaban (DOACs)] is regulated on the criteria established in Phase III trials. These criteria are reported in the summary of the product characteristics of the four DOACs. In clinical practice, prescriptions are not always in compliance with established indications. In particular, the use of lower doses than those recommended in drug data sheets is not uncommon. Literature data show that the inappropriate prescription of reduced doses causes drug underexposure and up to a three-fold increase in the risk of stroke/ischaemic transient attack, systemic thromboembolism, and hospitalization. Possible causes of the deviation between the dose that should be prescribed and that prescribed in the real world include erroneous prescription, an overstated haemorrhagic risk perception, and the presence of frail and complex patients in clinical practice who were not included in pivotal trials, which makes it difficult to apply study results to the real world. For these reasons, we summarize DOAC indications and contraindications. We also suggest the appropriate use of DOACs in common clinical scenarios, in accordance with what international guidelines and national and international health regulatory bodies recommend.
ANMCO statement on the use of sodium-glucose cotransporter 2 inhibitors in patients with heart failure: a practical guide for a streamlined implementation
Authors: Di Fusco Stefania Angela , Gronda Edoardo , Mocini Edoardo , Lucà Fabiana , Bisceglia Irma , De Luca Leonardo , Caldarola Pasquale , Cipriani Manlio , Corda Marco , De Nardo Alfredo , Francese Giuseppina Maura , Napoletano Cosimo , Navazio Alessandro , Riccio Carmine , Roncon Loris , Tizzani Emanuele , Nardi Federico , Urbinati Stefano , Valente Serafina , Gulizia Michele Massimo , Gabrielli Domenico , Oliva Fabrizio , Imperoli Giuseppe , Colivicchi Furio
Published: May 2022

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, dapagliflozin, and empagliflozin, first developed as glucose-lowering agents for the treatment of Type 2 diabetes, have been demonstrated to improve prognosis in patients with heart failure and reduced ejection fraction (HFrEF) regardless of the presence of diabetes. Since these drugs have only recently been included among the four pillars of HFrEF treatment, cardiologists are still unfamiliar with their use in this setting. This article provides an up-to-date practical guide for the initiation and monitoring of patients treated with SGLT2 inhibitors.
Association of ZFHX3 genetic polymorphisms and extra-pulmonary vein triggers in patients with atrial fibrillation who underwent catheter ablation
Authors: Hwang I , Kwon O-S , Hong M , Yang S-Y , Park J-W , Yu H T , Kim T-H , Uhm J-S , Joung B , Lee M-H , Pak H-N
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health and Welfare, National Research Foundation of Korea (NRF)

Abstract

Background

The ZFHX3 gene (16q22) is the second most highly associated gene with atrial fibrillation (AF) and is related to inflammation and fibrosis.

Purpose

We hypothesized that ZFHX3 is associated with extra-pulmonary vein (PV) triggers, left atrial (LA) structural remodeling, and poor rhythm outcomes of AF catheter ablation (AFCA).

Methods

We included 1782 patients who underwent a de novo AFCA (73.5% male, 59.4±10.8 years old, 65.9% paroxysmal AF) and genome-wide association study and divided them into discovery (n=891) and replication cohorts (n=891). All included patients underwent isoproterenol provocation tests and LA voltage mapping. We analyzed the ZFHX3, extra-PV trigger-related factors, and rhythm outcomes.

Results

Among 14 single-nucleotide polymorphisms (SNPs) of ZFHX3, rs13336412, rs61208973, rs2106259, rs12927436, and rs1858801 were associated with extra-PV triggers. In the overall patient group, extra-PV triggers were independently associated with the ZFHX3 polygenic risk score (PRS) (OR 1.65 [1.22-2.22], p=0.001, model 1) and a low LA voltage (OR 0.74 [0.56-0.97], p=0.029, model 2). During 49.9±40.3 months of follow-up, clinical recurrence of AF was significantly higher in patients with extra-PV triggers (Log-rank p<0.001, HR 1.89 [1.49-2.39], p<0.001, model 1), large LA dimensions (Log-rank p<0.001, HR 1.03 [1.01-1.05], p=0.002, model 2), and low LA voltages (Log-rank p<0.001, HR 0.73 [0.61-0.86], p<0.001, model 2) but not the ZFHX3 PRS (Log-rank p=0.819).

Conclusions

The extra-PV triggers had significant associations with both ZFHX3 genetic polymorphisms and acquired LA remodeling. Although extra-PV triggers were an independent predictor of AF recurrence after AFCA, the studied AF risk SNPs intronic in ZFHX3 were not associated with AF recurrence.
Accuracy of noninvasive electrocardiographic imaging using isopotential versus isochronal map for identifying the site of origin of ventricular arrhythmias
Authors: Parreira A , Carmo P , Marinheiro R , Chambel D , Marinescu C , Ferreira A , Marques L , Nunes S , Chmelevsky M , Amador P , Coelho R , Cavaco D , Goncalves P , Marques H , Adragao P
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Background and aim

Previous studies reporting the results of noninvasive electrocardiographic imaging (ECGI) used both isopotential map and isochronal map to assess the site of origin (SOO) of premature ventricular contractions (PVCs). The aim of this study was to evaluate the accuracy of both methods globally, and according to the location of the arrhythmia: from the right ventricular outflow tract (RVOT) or other locations (non-RVOT).

Methods

We studied with ECGI 35 consecutive patients with frequent (>10.000/24 h) PVCs. Patients were excluded if the ablation was not performed (7 patients) or was unsuccessful (7 patients). The study group consisted of 21 patients, 11 male, median age of 56 (44-71) years. The ECGI was performed with the epi-endocardial system Amycard. Two noninvasive maps were obtained: isopotential map based on the analysis of the shape and amplitude of the unipolar electrogram (FND method) and an isochronal map obtained using the activation direction method (ADM) (Figure). The invasive activation map was obtained with the Carto or the Ensite system and radiofrequency was applied at the earliest activation site with QS morphology on the unipolar electrogram and a pace match of at least 11/12. The SOO of the PVCs was considered the site where the PVCs were abolished. We assessed the accuracy of the ECGI to identify the SOO of the PVCs using both methods. A perfect match was defined as a predicted location by the ECGI within the same anatomic segment of the actual SOO of the PVCs, whereas a near match as a predicted location within the same segment or a contiguous one. Values are presented as median (Q1-Q3)

Results

PVCs originated in the RVOT in 11 (52%) patients. The percentage of near matches was not significantly different between FND and ADM methods (95% vs 86%, p=0.50), however the percentage of perfect matches was significantly higher with the FND than with the ADM technique (95% vs 67 %, p=0.031). We found no significant differences in accuracy according to the location of the PVCs, in the RVOT or outside (Table).

Conclusions

We found a good agreement between ECGI and invasive maps, however the FND technique showed a better accuracy regardless the site of the PVCs.
Changes of the non-invasive myocardial work in patient undergoing transcatheter aortic valve replacement: the influence of left bundle branch block
Authors: Lakatos BK , Ruppert M , Ladanyi Z , Fabian A , Ujvari A , Tokodi M , Molnar L , Zima E , Apor A , Nagy A , Kovacs A , Merkely B
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Patients with left bundle branch block (LBBB) are known to have substantially increased afterload sensitivity. It gains particular importance in subjects with aortic stenosis: patients with pre-existing LBBB may benefit more from interventions such as transcatheter aortic valve replacement (TAVR) by an effective and rapid reduction of the left ventricular (LV) pressures.

Accordingly, our aim was to investigate the changes of LV myocardial work indices in patients undergoing TAVR by the presence of preoperative LBBB. Non-invasive myocardial work indices are novel echocardiographic parameters which adjust LV deformation to the instantaneous LV pressure, overcoming the the load-sensitivity of the traditional LV functional measures.

Thirty patients undergoing TAVR were enrolled (37% female; age: 78±6 years; aortic valve area [AVA]: 0.7±0.3 cm2). Fourteen patients (47%; LBBB group) showed LBBB pattern on ECG, by demonstrating native LBBB (n=6; 20%) or having ventricular pacing dependency (n=8; 27%), while 16 patients had narrow QRS (53%; non-LBBB group). Prior to the procedure, subjects underwent a detailed echocardiographic investigation. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the aortic systolic pressure. Using these measures, LV global constructive work index (CMWI) and global work efficiency (GWE). were quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

As expected, AVA significantly improved after the procedure in the pooled study group (1.8±0.4 cm2; p<0.001). GLS also significantly increased (-13.2±4.2 vs. -15.2±3.9 %; p<0.01), while CMWI only showed a tendential decrease (2422±788 vs. 2166±640 mmHg%; p=NS) at the follow-up. GLS (-10.6±3.7 vs. -15.5±3.4%; p<0.001), CMWI (1877±679 vs. 2898±529 mmHg%; p<0.001), and also GWE (82±9 vs. 91±4%; p<0.01) was significantly lower in the LBBB-group compared to the non-LBBB patients. At the follow-up, GLS was still significantly lower in the LBBB patients (-13.2±4.6 vs. -16.9±2.1%; p<0.01), however, CMWI was comparable between the two groups (1956±776 vs. 2350±439 mmHg%, p=NS).

Pressure overload of the LV may affect patients with LBBB substantially more than subjects without it. TAVR causes an immediate and significant decrease in the LV afterload, which results in a more pronounced improvement in the LBBB group compared to those with no LBBB.
Novel CineECG to identify disease onset and progression in pathogenic plakophilin-2 mutation carriers
Authors: Boonstra MJ , Kloosterman M , Asselbergs FW , Van Dam PM , Loh P
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation

Introduction

Arrhythmogenic cardiomyopathy (ACM) is a heterogeneous progressive disease. Identification of patients at risk for malignant ventricular arrhythmias is challenging, making extensive cardiac follow-up necessary. CineECG provides insight in the average cardiac pathway of cardiac electrical activity. In previous studies, CineECG proved useful to detect disease progression.

Objective

Evaluate the applicability of CineECG to monitor disease progression in plakophilin-2 (PKP2) pathogenic mutation carriers.

Methods

To compute the CineECG, a 3D heart/torso model and 12 lead ECG is used. From 68 PKP2 pathogenic mutation carriers, all raw ECGs were extracted from the patient database. In pathogenic mutation carriers with definite ACM, the ECG ±2 years before (ECG1), at (ECG2) and ±2 years after (ECG3) diagnosis were selected. In pathogenic mutation carriers without definite ACM, the most recent ECG (ECG2) and the ECG ±2 years before (ECG1) were selected. CineECGs were computed for the QRS complex and the distance between CineECG location at end QRS was determined per subject for subsequent CineECGs.

Results

In 53 pathogenic mutation carriers ≥2 ECGs were available. 33 pathogenic mutation carriers were diagnosed with definite ACM of whom 4 had an ECG before, at and after diagnosis. Average distance between CineECG location at end QRS was 7.8±6.8 mm. In pathogenic mutation carriers with definite ACM, CineECG before and at diagnosis (figure, example 1&2) were different whereas CineECG at and after diagnosis did not always change. In pathogenic mutation carriers without definite ACM, in 14/19 changes in CineECG were observed (figure, example 3), whereas in the others (figure, example 4) not.

Conclusion

Our preliminary results show that CineECG provides additional insight in the changes of cardiac activation in ACM patients and may enable detection of disease progression. Further analysis will also include cardiac repolarization.
Combined pulmonary vein isolation and cavotricuspid isthmus ablation shows no benefit in recurrence of atrial fibrillation
Authors: Jacinto S , Silva Cunha P , Portugal G , Valente B , Coutinho Cruz M , Lousinha A , Bras P , Delgado AS , Bras M , Paulo M , Guerra C , Teixeira AR , Lacerda Teixeira B , Martins Oliveira M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for atrial fibrillation (AF). Strategies have been proposed to improve the success rate of CA, such as prophylactic cavotricuspid isthmus (CTI) ablation. Despite some studies providing no, or limited, incremental benefit of CTI ablation in patients with AF, it is still frequently performed worldwide.

Purpose

The aim of this study is to examine whether CTI ablation, combined with PVI, is associated with improvement in recurrence of AF, compared with PVI alone in AF patients with or without atrial flutter (AFL).

Methods

We conducted a retrospective analysis of CA for AF performed at a tertiary center between September 2004 and December 2020. The procedures were divided in two groups: "PVI alone" and "PVI plus CTI ablation". Demographic, clinical, and procedure related data was retrieved. Atrial fibrillation recurrence rate at one year was analyzed for both groups and compared using logistic regression.

Results

A total of 453 procedures were analyzed: PVI alone (n=378; 83.4%) and PVI with CTI ablation (n=75; 16.6%). In the PVI alone group, 12.9% of the patients had concomitant typical AFL and in the PVI plus CTI ablation, 45.8% had typical AFL. Mean age was 57.3±12.1 years, with 63.6% male patients. At one year, AF recurrence rate was higher in the combined PVI with CTI ablation group (30.4%; n=21), compared with the PVI alone group (28.4%; n=97), with no statistical difference between the two groups (Odds Ratio [OD] 1.10; 95% confidence interval [CI] 0.62-1.94; p=0.73). In the subgroup analysis, there was no difference in recurrence between patients with AF without AFL (OR: 1.9; 95% CI: 0.39-9.36; p=0.43), and in patients with AF with concomitant AFL (OR: 10.0; 95% CI: 0.9-110.3; p=0.06).

Conclusion

In AF patients, irrespective of the presence of typical AFL, additional CTI ablation, compared with PVI alone, was not associated with improvement in recurrence of AF.
Zero-fluoroscopy catheter ablation in pregnant women: outcomes and prognosis
Authors: Abdrakhmanov A , Ainabekova B , Nuralinov O , Bakytzhanuly A , Smagulova A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmias are common in pregnant. Catheter ablation is effective treatment in cases of drug refractory arrhythmias. However, data are scarce on outcomes and prognosis of catheter ablation in this population of patient.

Purpose

To define the cohort of pregnant undergoing for catheter ablation for arrhythmias, characterize obstetric and neonatal outcomes and prognosis.

Methods

This single-center, prospective study included all catheter ablation procedures for arrhythmias performed in pregnant from January 2015 until December 2019. Primary outcome was recurrence of arrhythmia. Baseline clinical characteristics, complication rates, obstetric and neonatal outcomes were also evaluated.

Results

In total, we included 48 patients (aged 27.04±4.32 years, mean gestation age 21.8±4.22 weeks), indicated for catheter ablation due to drug refractory arrhythmias. The most common arrhythmia was atrioventricular nodal reentrant tachycardia (n=20; 41.7%). Ablation of accessory pathways performed in 16 cases (33.3%): in left free wall (n=8), in right free wall (n=7), posteroseptal (n=1). In 3 cases was observed combination of accessory pathways with slow conduction ways. Ablation of the right ventricular outflow tract was performed in 9 cases (18.7%) of ventricular tachycardia. In all cases catheter ablation was performed successfully without fluoroscopy. One patient developed an ileofemoral thrombosis. No other complication after ablation was noted. Pregnancy course was benign in all cases without termination. Premature birth was in 2 cases at 35 and 36 weeks of gestation. Full-term pregnancy was in the majority. Preeclampsia developed in 2 pregnant women. In 75% of pregnancy was vaginal delivery, in 25% - Cesarean section. Fetal birth weight was 3226.34±623,1 grams, 5 minute Apgar was 8,92±1,8. There were 48 live births without maternal and fetal mortality. During 1 year follow-up there was no arrhythmia recurrence.

Conclusions

Non-fluoroscopic catheter ablation of arrhythmias in pregnant women is effective treatment options, with a high success rate, low rates of complication, favorable outcomes and prognosis.
Effect of a proactive esophageal cooling device on procedure length - a multicenter comparison of persistent and paroxysmal atrial fibrillation
Authors: Joseph C , Francisco G , Ruppert A , Willms D , Metzl M , Fisher W , Nazari J , Ro A , Zagrodzky J , Zagrodzky W , Sherman J , Bailey S , Athill C
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

During left atrial ablation for the treatment of atrial fibrillation (AF), effective esophageal protection is essential for reducing or preventing thermal injury. Traditional methods include luminal esophageal temperature (LET) monitoring that lead to frequent pauses in the procedure when temperature alarms alert operators to dangerous temperature levels. While there have been recent studies that demonstrate an association between active esophageal cooling and a reduction in procedure duration regardless of AF type, these retrospective studies have been conducted at single or joint centers which may lead to confounding from other time-saving variables that have changed over time.

Purpose

Consequently, we sought to perform a large-scale multicenter comparison to better elucidate the association between procedure length and the use of active cooling in patients with persistent and paroxysmal atrial fibrillation.

Methods

In this study, we collected data from three large hospital centers, one hospital-maintained registry, one physician-maintained registry, and one through EHR data review and aggregated in groups separated by AF type as well as whether the patients received active cooling or LET monitoring. We then compared median procedure durations in each group.

Results

There were a total of 753 patients included in this study. Of the 360 patients with paroxysmal AF, 179 received active esophageal cooling while 181 underwent LET monitoring. In the persistent AF group with 393 patients, 157 received active esophageal cooling and 236 underwent LET monitoring. Among patients with paroxysmal AF, the median mean procedure duration was 137 minutes in the LET monitored group, and 90 minutes in the actively cooled group with an overall reduction of 47 minutes (P<.001). In patients with persistent AF, the median procedure duration was 148 minutes in the LET monitored group and 94 minutes in the actively cooled group with an overall reduction of 54 minutes (P<.001). The relative reduction as a percent of total procedure time was 34%, and 36%, for paroxysmal and persistent AF cases, respectively.

Conclusion

In this large multicenter review, there is a significant reduction in procedure length when using active esophageal cooling, regardless of AF type.
Is it possible to predict mortality and recurrence of VT afterablation? PAINESD risk score applicability vs new predictors
Authors: Martins AM , Silverio Antonio P , Couto Pereira S , Brito J , Valente Silva B , Alves Da Silva P , Garcia AB , Simoes De Oliveira C , Nunes Ferreira A , Lima Da Silva G , Carpinteiro L , Cortez-Dias N , Pinto FJ , De Sousa J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) prevents ventricular tachycardia (VT) recurrences in patients (pts) with structural heart disease (SHD), and might have a favorable outcome, but is associated with severe short-term complications. Identification of pts at high risk of periprocedural acute haemodynamic decompensation has important implications at procedural planning.

The PAINESD risk score is a promising tool to predict VT ablation procedure-related mortality.

Aim

To evaluate the accuracy of the PAINESD risk score to predict short-term mortality after structural VT ablation and to compare it with other conventional clinical predictors.

Methods

Prospective, observational, single-centre study of consecutive pts with SHD (ischemic or nonischemic), referred for VT-CA. High-density substrate maps were collected, through endocardial, epicardial or combined endo-epicardial approaches according to clinical data and operator preference. The primary endpoint was 30-day mortality or hemodynamic decompensation. Univariate Cox regression analysis was used to identify relevant clinical predictors and to compare them with the PAINESD risk score. Multivariable Cox proportional hazards regression models were used to estimate predictors of 30-day mortality.

Results

A total of 102 pts with SHD referred for VT ablation were evaluated(mean age: 67±11 years, 94% male, 78.4% in NYHA class I-II; mean LVEF was 34±11%). The baseline PAINESD risk score was 12.39±5.8, 19.6% at low risk, 36.3% at intermediate risk and 27.5% at high risk of adverse events. Overall 30-day mortality was 4.9%. The PAINESD did not predict 30-days mortality or hemodynamic decompensation (p= 0.93). Indeed, a non- significant trend to higher short and long-term mortality was noticed in high-risk score pts – Figure 1. On univariate analysis age>65 years (p=0.019), LVEF <35% (p=0.049), body mass index<28kg/m2 (p=0.019), CKD (p=0.001) and previous VT ablation (p=0.022) were prognostic predictors. On multivariate analysis, only LVEF<35% (HR2.225; CI95% 1.004-4-774,p=0.038) and CKD (HR 3.35; CI95%: 1.31-8.51, p=0.011) were independent predictors of short-term prognosis.

Conclusions

In our population, LVEF<35% and CKD were the strongest predictors of short-term mortality. PAINESD risk score was not accurate in predicting adverse events. New score systems must be derived for prognostic stratification in this population, incorporating the reduction on the actual short-term event rates after VT ablation.
Rapid mode in novel generation visually guided laser balloon system: feasibility, safety, and impact on procedural outcomes
Authors: Martignani C , Ziacchi M , Statuto G , Spadotto A , Angeletti A , Massaro G , Bartoli L , Orlandi M , Diemberger I , Ginex S , Provasi F , Grassini D , Galie N , Biffi M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Laser balloon (LB) systems are increasingly used for pulmonary vein isolation (PVI) in catheter ablation of atrial fibrillation (AF). The novel generation of the visually guided LB system includes a rapid mode (RM) feature, which potentially allows a continuous circumferential lesion for PVI. Nevertheless, data on its practicability and on its impact on procedural outcomes are lacking.

Purpose

To analyse the applicability of RM and its effect on procedural and fluoroscopic time in a cohort of patients who underwent catheter ablation of AF using a LB system.

Methods

Between September 2020 and December 2021, we prospectively included all consecutive patients who underwent PVI with LB at our centre. All the procedures were performed by the same two operators. For each pulmonary vein (PV), we firstly attempted to obtain a complete circumferential lesion at 13 W using the RM. If its application was not possible or incomplete, we performed additional single lesions at 5.5, 8.5 or 13 W to achieve complete visual PVI. Finally, we calculated the percentage of singular and total circumferential lesions made with RM for every procedure and evaluated its influence on procedural outcomes.

Results

75 patients were enrolled. We identified and successfully isolated 289 PVs, with mean procedural and fluoroscopic time of 171±51 and 38±15 min, respectively. Use of RM for more than 70% of the circumferential lesion was possible in 185 veins (64%), while we obtained complete isolation using only RM in 90 veins (31%). Reasons for interruption of RM were unfavourable anatomy, imperfect visualization of the ostium of the PV and presence of blood between the balloon and the anatomic substrate. For each vein, we observed a significantly shorter ablation (13±8 vs 23±12 min, p<0.001) and fluoroscopic time (3±3 vs 5±4 min, p<0.01) if >70% of the circumferential lesion was made through RM. Further, total procedural (157 ±52 vs 192±42 min, p<0.01), ablation (53±17 vs 88±27, p >0.001) and fluoroscopic time (30±15 vs 36.9±14 min, p 0.025) were significantly shorter if more than 70% of total circumferential lesion was achieved through rapid mode. There were five pinhole balloon ruptures during application of RM. No major complication occurred.

Conclusions

RM is a novel feature in the latest generation of LB system. In our cohort, it showed good applicability and safety, while significantly reducing procedural times. Further studies are needed to understand its possible impact on clinical outcomes.
Quantifying the variability of bipolar voltage amplitude with sensing angle in residual conduction isthmuses in atrial scar
Authors: Merino JL , Kim S , Relan J , Castrejon Castrejon S , Sanroman M , Escobar Cervantes C , Martinez Cossiani M , Carton A
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

The angle between the activation wavefront and bipole may conceal the conduction isthmus in conventional bipolar voltage mapping, but the extent of variability of electrogram (EGM) voltage amplitude with directional changes has not been quantified.

Purpose

Using a well-defined model of discrete atrial conduction, we sought to use Omnipolar Technology (OT) to assess variability of voltage amplitude as a function of sensing angle, in sites of residual conduction and scar tissue.

Methods

During redo pulmonary vein isolation (PVI) procedures, baseline voltage maps were acquired during coronary sinus pacing (500 ms) using a rectangular 16-pole catheter (HD Grid). During retrospective analysis with OT research software, all EGM’s ≤1 cm radius from the site of PVI were classified as GAP (vs No-GAP; Panel A) The variability of voltage amplitude (OT-ΔV) with sensing angle (θ) was computed as the difference between the maximum and minimum voltages (OT-Vmax - OT-Vmin), in both GAP and No-GAP subregions (Panels A & B).

Results

23 GAP sites were identified in 12 of 15 consecutive patients studied. 3464 EGM’s (1386 GAP vs 2078 No-GAP) were analyzed. Global mean OT-ΔV was 0.46±0.80 mV. GAP regions showed significantly (P<0.0001) higher OT-ΔV as compared with No-GAP regions (0.80±1.03 mV vs 0.24±0.47 mV respectively; Panel C) The mean Δθ angle for OT-ΔV was similar in both GAP and No-GAP regions (88.6±11.3° vs 88.0±13.6°, P=0.1; Panel D).

Conclusion

The variability of voltage amplitude as a function of bipole orientation can be significant, especially in GAP regions (0.80±1.03 mV). (2) OT-ΔV holds promise for identification of residual conduction within atrial scar tissue.
Early local impedance drop during pulmonary vein isolation using a novel contact force sensing catheter is associated with acute lesion efficacy
Authors: Perge P , Sallo Z , Piros K , Nagy VK , Osztheimer I , Merkely B , Geller L , Szegedi N
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

The predictive role of adequate local impedance drop in lesion formation using a novel contact force sensing ablation catheter for pulmonary vein isolation was recently described. The purpose of our pilot study was to assess the temporal characteristics of local impedance drop and its correlation with acute lesion efficacy.

Methods

Point-by-point radiofrequency pulmonary vein isolation was performed with 50 W energy setup in power-controlled mode. The efficacy of applications was assessed by pacing along the circular ablation line. We considered the lesions successful if loss of capture was achieved. Local impedance, contact force and catheter position data of the applications with 10 msec resolution was analysed. The local impedance of successful and unsuccessful applications was compared at baseline and 2, 4, 6, 8 and 10 sec time points, respectively. We characterized the local impedance for each time point with the mean of the 5 impedance value closest in time.

Results

184 applications were analysed, 167 were successful and 17 were unsuccessful. There was no difference in mean contact force (p=0.142) and contact force range (p=0.606) between successful and unsuccessful applications. The baseline local impedance was significantly lower in the unsuccessful group (p<0.0001), while successful applications had significantly larger local impedance drop at the 2 (p=0.0006), 4 (p<0.0001), 6 (p=0.0066), 8 (p=0.016) and 10 sec (p=0.0106) time points compared with the unsuccessful group. Local impedance did not change significantly over time in case of unsuccessful applications (p=0.192), while it decreased significantly in case of successful applications (p<0.0001).

Conclusion

Early rapid drop of the local impedance may predict effective lesion formation, while slowly changing or unchanged local impedance is associated with unsuccessful applications. In case of a slow local impedance drop during the first 6 seconds of radiofrequency application, it might be reasonable to stop the application and start a new one after catheter repositioning.
Untargeted toxicology in sudden cardiac arrest victims
Authors: Stampe NK , Glinge C , Rasmussen BS , Bhardwaj P , Linnet K , Jabbari R , Hassager C , Kjaergaard J , Tfelt-Hansen J , Winkel BG
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme to J.T.-H under acronym ESCAPE-NET

Background

Sudden cardiac arrest (SCA) is a major public health challenge and is associated with poor outcomes. Many drugs are known to increase risk of arrythmias and ultimately sudden cardiac death. To our knowledge an untargeted toxicological analysis has not previously been performed in an initially resuscitated SCA cohort.

Purpose

We aimed to determine the qualitative and quantitative drug composition present in SCA patients by using forensic toxicological analytical chemistry of all illicit, non-prescription and prescribed drugs, and further investigate whether these drugs are in therapeutic levels or overdosed and to correlate the clinical findings with the toxicology results.

Methods

We performed a prospective single-tertiary-center study and included all SCA victims (aged 18-90 years) admitted to our cardiac intensive care unit, between February 2019 to November 2019 (Figure 1). Traumatic and overt overdose related SCA were not included in the study. Drugs used during resuscitation and administered prior to sample collection were identified in each patient and excluded.

Results

We prospectively identified 85 all-cause SCA patients with a median age of 60 years (IQR: 53-71) and male predominance (80%). The majority had a shockable rhythm as first rhythm (95%). The major cause of cardiac arrest was acute and chronic ischemia (56/77, 66%), followed by cardiomyopathy (9/77, 12%), idiopathic ventricular fibrillation (8/77, 10%), bradycardia (2/77, 2.6%), primary arrhythmia (1/77, 1.3%), other (1/77, 1.3%). The remaining 8 patients (9.4%) died prior to diagnosis.

A positive toxicology was identified in 67 patients (79%) with a total of 218 detected drugs. The most frequent drugs were mild analgesics (32/85, 38%), beta-blockers (21/85, 25%) and ACE-inhibitors/ARB (20/85, 24%). A total of 9 (11%) patients had one or more potentially abusable drugs detected, with the most common being opioid agonists in 5 patients (Figure 2). Importantly, all drugs were found at sub-therapeutic or therapeutic concentrations. None had overdose concentrations. Moreover, polypharmacy was common and a median of 2 drugs (IQR: 1-4) were detected (excluding caffeine that was detected in 83 patients).

Conclusion

We found that the majority had drugs detected, and polypharmacy is displayed in a considerable proportion. Potentially abusive drugs were encountered in 11%. However, we did not identify any occult overdose related cardiac arrests among all resuscitated SCA patients. In our setting, toxicological screening in cardiac arrest patients who is not obviously overdosed is excessive.
Detection of endo-epicardial atrial low-voltage areas using unipolar and omnipolar voltage mapping
Authors: Van Schie MS , Knops P , Zhang L , Van Schaagen FRN , Bogers AJJC , Taverne YJHJ , De Groot NMS
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): NWO-Vidi

Medical Delta

Background

Endocardial bipolar voltage mapping has emerged as an invasive tool for defining potential target sites for ablation therapy of atrial tachyarrhythmia. Bipolar low-voltage areas (LVA) are commonly considered surrogate markers for areas of conduction disorders. However, bipolar LVAs can be located exclusively at either the endocardium or epicardium. Furthermore, identification of bipolar LVAs is hampered by considerable directional differences in bipolar voltages. Omnipolar voltage mapping, on the other hand, provides maximal bipolar voltage from a collection of electrograms and is directional independent. Unipolar is preferred to identify intramural or epicardial substrates as unipolar electrograms comprise a larger region of myocardial electrical activity. It, however, remains unknown whether simultaneously recorded endo- and epicardial unipolar and omnipolar voltages are complementary or contradictory on identifying LVAs at the opposite layer.

Purpose

To 1) examine endo-epicardial characteristics in unipolar and omnipolar voltages, 2) explore the relation between various types of voltages in identification of LVAs from an endocardial and epicardial point of view and 3) examine whether characteristics of LVAs can be predictive for LVAs at the opposite layer.

Methods

Intra-operative simultaneous endo-epicardial mapping (interelectrode distances 2mm) of the right atrium was performed in 93 patients (67±9 years, 73 male). Cliques of 4 electrodes (2x2 mm) were used to define maximal omnipolar (Vomni,max) and unipolar (Vuni,max) voltages. LVAs were defined as Vomni,max ≤0.5 mV or Vuni,max ≤1.0 mV.

Results

Epicardial Vuni,max were larger than corresponding endocardial Vuni,max (8.2 [4.9–11.6] mV vs 6.1 [3.2–10.9] mV, P<0.001) and they were strongly correlated (R2=0.85, P<0.001). Epicardial Vomni,max were also larger than endocardial Vomni,max (6.7 [3.2–10.9] mV vs 3.3 [1.1–8.6] mV, P<0.001), although there was no correlation between both layers. The majority of unipolar and omnipolar LVAs occurred at either the endocardium (74.2% and 82.0%) or epicardium (52.7% and 47.6%) alone and the opposite areas frequently contained normal voltages. Epicardial Vuni,max and Vomni,max were most accurate in identifying endo-epicardial-LVAs (respectively 47.3% and 52.4% vs 25.8% and 18.0%).

Conclusions

Unipolar and omnipolar LVAs are frequently located exclusively at either the endocardium or epicardium and could be undetectable when measuring from the opposite layer only. Endo-epicardial LVAs are most accurately identified using combined epicardial unipolar and omnipolar voltages. Therefore, a combination of simultaneously recorded endo-epicardial low unipolar and low omnipolar voltage may be more indicative of dual-layer LVAs and probably arrhythmogenic substrates.
Atrial high-rate episodes in patients with devices without a history of atrial fibrillation
Authors: Doundoulakis I , Gavriilaki M , Tsiachris D , Arsenos P , Antoniou CK , Soulaidopoulos S , Dimou S , Xintarakou A , Xydis P , Kordalis A , Dilaveris P , Gatzoulis KA , Tsioufis K
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial high-rate episodes (AHREs) recorded with cardiac implantable electronic devices (CIEDs) have been associated with the development of clinical atrial fibrillation (AF) and increase in stroke, and death risk.

Purpose

We sought to perform a systematic review with a meta-analysis to evaluate the prevalence of AHREs detected by CIEDs, their association with stroke risk, development of clinical AF, and mortality among patients without a documented history of AF.

Methods

We searched several databases, ClinicalTrials.gov, references of reviews, and meeting abstract books without any language restrictions up to 9 September 2020. We studied patients with CIEDs in whom AHREs were detected. Exclusion criteria were an AF history. Our primary outcome was the risk of ischemic stroke in patients with AHREs.

Results

We deemed eligible eight studies for the meta-analysis enrolling a total of 4322 patients with CIED and without a documented AF history. Evidence of moderate certainty suggests that patients with documented AHREs were 4.45 times (95% CI 2.87–6.91) more likely to develop clinical AF. Evidence of low confidence suggests that AHREs were associated with a 1.90-fold increased stroke risk (95% CI 1.19–3.05).

Conclusion

The present systematic review and meta-analysis demonstrated that among patients without a documented history of AF, the detection of AHREs by CIEDs was associated with significant increased risk of clinical AF and stroke.
Prognostic value of plasma neutrophil gelatinase-associated lipocalin for cardiovascular events in patients with chronic heart failure and atrial fibrillation
Authors: Lashkul D , Syvolap VD
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

We aimed to assess the prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL), a marker of renal tubular damage, in patients with heart failure with or without atrial fibrillation (AF).

Methods

The study involved 113 (83.2% men) patients with mean age 60.0 [54.0-67.0] years with II-IV functional class (recommendations of the New York Heart Association) is due to ischemic heart disease. Serum levels of NGAL were quantified by ELISA. Echocardiography was performed according to the American Society of Echocardiography/European Association of Echocardiography recommendations. Receiver operating characteristic (ROC) curve analysis was used to determine the best NGAL cut-off to predict events. Cox proportional hazards models were used to investigate the prospective association between NGAL and events during follow-up. Outcome was cumulative incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke, HF hospitalization) at 36 months.

Results

Median plasma NGAL in patients with and without AF was 34 (25-46) ng/ml and 26 (18-44) ng/ml, p<0.01, respectively. The ROC curve showed an optimal admission NGAL level cut-off >25.5 ng/mL, with 70% sensitivity and 89% specificity. The area under the ROC curve (AUC) was (0.814; p<0.01). In patients with CHF and atrial fibrillation multivariable analysis shows, that NGAL independently associated with outcomes (HR 2.35, 95% CI 1.2-4.61; p<0.01).

Conclusions

Admission plasma NGAL >25.5 ng/ml appears a sensible tool for in-hospital AF prediction as well as an marker for adverse cardiovascular outcome during long-term follow-up period.
The impact of different fat depots in the body on the progression of atrial fibrillation - data from RACE V
Authors: Weberndoerfer V , Van De Lande ME , Artola Arita VA , Nguyen BA , Elvan A , Hemels MEW , Thieleman RG , De Melis M , Schotten U , Van Gelder IC , Rienstra M , Crijns HJGM , Mihl C , Linz D
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation, Medtronic

Background

Paroxysmal atrial fibrillation (PAF) progression is associated with cardiovascular complications and worse outcome. Obesity is independently associated with AF prevalence and progression. The association between different fat depots in the body with AF is unclear.

Aim

We aim to systematically investigate the association of different fat depots in the body with AF.

Methods

417 patients with PAF and continuous rhythm monitoring (implantable loop recorder or pacemaker) were included in the prospective RACE V study. In addition to extensive phenotyping at baseline including calculating BMI and measuring waist circumference (WC) epicardial and pericardial fat were measured on non-contrast enhanced cardiac CT scans by tracing the pericardium manually on every slice and afterwards fat automatically summed between -50 and -150 HU. Epicardial fat was defined as fat within the pericardium, pericardial fat as fat inside the pericardium and adjacent to the pericardium and thoracic fat as adjacent fat outside the pericardium. AF progression was defined as (1) progression to persistent or permanent AF, or (2) progression of PAF with >3% burden increase within 2.2years of follow-up. Multivariable logistic regression analysis was used to analyse the association of different fat pads with AF progression.

Results

Six percent of patients per year showed AF progression (51/417) after a median follow-up of 2.2 (1.6-2.8) years. Multivariate analysis identified WC (odds ratio [OR] 1.03, 95% confidence intervals [CI] 1.01-1.06, p=.014) to be associated with AF progression. Epicardial fat (OR 1.00, 95%CI .99-1.01, p=.407), pericardial fat (OR 1.00, 95%CI .99-1.01, p=.311), thoracic fat (OR 1.00, 95%CI .99-1.01, p=.372), and BMI (OR 1.03, 95%CI .97-1.10, p=.328) showed no relation with AF progression.

Conclusion

AF progression occurred in 6% per year in patients with PAF. In contrast to epicardial, pericardial and thoracic fat measured in a semiautomatic way, WC was the only fat depot associated with AF progression. Whether a more different assessment of obesity and epicardial fat may demonstrate an association with AF progression warrants further study.