bluuebunny/crossref_metadata_2025 huggingface dataset:
Pulsed-field ablation for redo procedures after failed radiofrequency or cryo ablation for atrial fibrillation
Authors: Tanner H , Kueffer T , Madaffari A , Muehl A , Maurhofer J , Seiler J , Thalmann G , Servatius H , Kozhuharov N , Noti F , Haeberlin A , Baldinger S H , Roten L , Reichlin T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed-field ablation (PFA) has recently been introduced for pulmonary vein isolation (PVI). It might also be of potential value for redo procedures after failed radiofrequency or cryo ablation for atrial fibrillation (AF).

Purpose

To describe our initial experience using a multipolar PFA catheter for redo procedures after failed AF ablation.

Methods

Consecutive patients undergoing a redo procedure for recurrent atrial arrhythmias at our institution using a multipolar PFA catheter from Mai 2021 until October 2022 were included. A 3D electro-anatomical bipolar voltage map was generated to identify pulmonary vein (PV) reconnection, quantify the level of isolation (antral vs. ostial isolation), and characterize the extent of extra-PV low-voltage tissue. In case of PV reconnection, re-isolation was performed using PFA, with at least four applications in both basket and flower configuration. In case of only ostial PV isolation, additional PFA applications in flower configuration were delivered to widen the isolation to a more antral level. If all veins were already isolated on an antral level and/or if low-voltage areas were found on the posterior wall, a posterior wall ablation was added with the same PFA device at the discretion of the operator.

Results

We identified 170 patients (mean age: 64 ±11years, 45 (27%) women), undergoing a redo procedure using PFA. The median number of previous ablations was 1 (range 1-6), the most recent ablation was performed using radiofrequency in 122 (72%), cryo in 42 (25%), and surgery in 5 (3%) patients. In 104 (61%) patients, at least one reconnected PV was found. In total, 244 of 680 PV (36%) showed reconnection. In addition to PV reisolation, additional antral applications were delivered in 205 of 436 still isolated veins (47%). Posterior wall ablation was added in 112 (66%) patients (43% in paroxysmal AF, 78% in persistent AF, Figure). Median procedure duration was 101 minutes (IQR 80-137).

There was no cardiac tamponade, no stroke, and no esophageal fistula observed in this cohort.

Conclusion

For patients with recurrence after catheter ablation of atrial fibrillation, re-ablation using PFA is feasible and safe. Most common ablation targets were the pulmonary veins and the posterior wall. Whether the complementary effect of a different technology improves outcome needs further investigation.
When does phrenic nerve injury recover after cryoballoon ablation? Data from Japanese multicenter registry
Authors: Shigeta T , Miyazaki S , Isonaga Y , Arai H , Miwa N , Inaba O , Hachiya H , Yamauchi Y , Goya M , Sasano T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Although phrenic nerve injury (PNI) is most frequently encountered complication in cryoballoon ablation, it recovered in most cases. However, the duration of persisting PNI has not been fully investigated yet.

Purpose

This study sought to confirm the clinical course of PNI after the procedure in cases in which reduction of diaphragmatic compound motor action potential (CMAP)was confirmed during cryoballoon ablation of right-sided pulmonary veins (PVs).

Methods

We retrospectively analyzed a total of 237 patients who experienced right PNI confirmed by the CMAP amplitude reduction during cryoballoon ablation in 4 Japanese centers. Cryoballooon ablation of right-sided PVs were performed under CMAP monitoring in all cases, and once CMAP amplitude reduction was observed, freezing was immediately interrupted with a double stop technique. The recovery of PNI was confirmed by chest X-ray, and transient PNI was defined as one recovering before the discharge.

Results

Among 237 patients, PNI occurred during cryoballoon ablation of right superior PV and right inferior PV in 166 and 71 patients, respectively. The mean freezing time to PNI was 126.9±45.6 seconds and the mean balloon temperature when PNI occurred was -50.2±7.5°C. After PNI was confirmed, additional cryoballoon ablation of the same PV or the other ipsilateral PV was performed under CMAP monitoring in 29 and 97 patients, respectively. Transient PNI accounted for 53.2% of patients with PNI (126 out of 237 patients). Among the remaining 111 patients, the PNI recovery was confirmed within 3 months, 6 months or 12 months after the procedure in 42(37.8%), 55 (49.5%), 74 (66.7%) patients, respectively. When we excluded 32 patients who did not undergo sufficient follow-up of chest X-ray, only 5 patients (2.4%) still suffered from PNI at 12 months after the ablation, and the PNI recovery was confirmed after more than 12 months in 3 out of them. When we compared patients who suffered from PNI at 6 months after the procedure with those who did not, there was no significant difference in nadir balloon temperature (-50.4±6.9°C; for PNI recovery [-] vs -50.0±7.8°C; for PNI recovery [+], p=0.75). When freezing time was less than 60 seconds, PNI recovered within 6 months after ablation in all cases, although 23.2% of the patients in whom freezing time was 60 seconds or more still suffered from PNI at 6 months after the procedure (p=0.045).

Conclusion

The right-sided PNI confirmed by the CMAP amplitude reduction during cryoballoon ablation recovers within a couple of days in half of cases, and it rarely persists more than 12 months after the procedure. When freezing was interrupted less than 60 seconds, it is highly expected that PNI recovers within 6 months.
Should we shift warfarin to non-vitamin K antagonist oral anticoagulants for patients with atrial fibrillation staying well on warfarin for years?
Authors: Chao T , Lip G Y H , Chen S A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended over warfarin for stroke prevention for patients with atrial fibrillation (AF) in 2020 ESC guidelines. However, whether warfarin should be shifted to NOACs for patients who stayed very well with warfarin for years remains unknown.

Methods

From 2007 to 2010, a total of 167,176 newly-diagnosed AF patients aged ≥20 years were identified from the Taiwan National Health Insurance Research Database. Among these patients, 83,604 were alive to June 1st, 2015 and 54,803 of them who did not experience ischemic stroke or intra-cranial hemorrhage (ICH) have constituted the study population. Among the study population, 8,007 patients who continuously received warfarin and survived for at least 90 days after June 1st, 2015 were defined as the "original warfarin cohort". These patients were then categorized into 2 groups according to the stroke prevention strategies they received after June 1st, 2015; that is, staying on warfarin (n = 6,635) and shifting to NOACs (n = 1,372).

Results

Compared to patients staying on warfarin, the risk of ischemic stroke was lower for patients who were shifted NOACs (aHR 0.886; p=0.002). Also, the risk of major bleeding was lower for shifting to NOACs (aHR 0.849; p<0.001)(Figure). Compared to staying on warfarin, NOACs use was associated with a lower composite risk of ischemic stroke or ICH (aHR 0.842; p<0.001) and ischemic stroke or major bleeding (aHR 0.880; p<0.001).

Conclusions

Even for patients staying well on warfarin for years, shifting to NOACs was still associated with better clinical outcomes.
Incidence and autopsy rates of sudden cardiac death in Northern Finland
Authors: Mantyniemi L , Pakanen L , Holmstrom L , Hamalainen J , Ruuska L , Vahatalo J , Haukilahti A , Perkiomaki J , Huikuri H , Junttila J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius foundation. Finnish foundation for cardiovascular research.

Background/Introduction

Sudden cardiac death (SCD) is one of the most common modes of death in Western societies. The exact incidence and etiological background of SCD is somewhat unknown due to the low number of autopsies performed in sudden death victims. In prior autopsy studies approximately 40% of sudden death victims have other than cardiac cause for the event and in most countries autopsy rates are between 5-25%.

Purpose

Determine the incidence of SCD and autopsy rates for sudden death in Northern Finland.

Methods

We performed a death certificate review of all out of hospital or hospice deaths in 2016 in Northern Finland. Death was determined to be sudden if it occurred within one hour of occurrence of symptoms or if the victim was found dead. Information on autopsy, cause of death, and demographical data were collected.

Results

From a total of 6620 deaths 1412 occurred out of hospital/hospice. Death was classified as sudden in 1067 (16.1%) victims. Mean age was 70.1 yrs (±16.5 yrs) and 66.9% were male. Autopsy rate for all sudden deaths was 73.7%. Among victims under 70yrs autopsy rate was 90.8% and in under 50 yrs 96.2%. In all 785 autopsied sudden deaths 421 (53.6%) were SCD i.e. cardiac cause for death. In a population of 740 000 out of hospital/hospice sudden death incidence in 2016 was 144/100 000 and SCD incidence on 2016 was 77/100 000. Autopsied sudden cardiac death (N=421) was caused by ischemic heart disease (310, 73.6%), hypertensive heart disease (48, 11.4%), cardiomyopathy (50, 11.9%) or other cardiac causes (13, 3.1%).

Conclusions

Autopsy rates of sudden death in Northern Finland are high. The utilization of autopsies in sudden death provide the premises for accurate SCD incidence calculations. The results confirm the assumption that a large part of sudden deaths are non-cardiac and common cardiac diseases are the most frequent cause of SCD in unselected general population.
Management of cardiac arrhythmias in paediatric patients with TANGO2-deficiency disorder
Authors: Sarquella Brugada G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

TANGO2-deficiency disorder (TDD) is a rare paediatric condition caused by bi-allelic mutations in the TANGO2 gene. TDD is characterised by susceptibility to metabolic crises with rhabdomyolysis, encephalopathy, lactic acidosis, hypothyroidism and difficult to manage tachyarrhythmias.

Aim

We describe the electrocardiographic (ECG) findings at baseline and during metabolic crises in patients with TDD.

Methods

Retrospective, single-centre, case series study of patients with TDD (<18 years), with ECG and subcutaneous Holter monitoring, both during metabolic crises and compensated phases.

Results

During the period 2013-2021, 12 patients with TDD were found (median age 6.8 years, IQR 2-11.5 years). In the inter-crisis period, bradyarrhythmias were evidenced: 2/12 patients presented sinus bradycardia, 2/12 pauses of 4 and 10 seconds, 1/12 Wenckebach type block; and tachyarrhythmias: 1/12 presented paroxysmal supraventricular tachycardia and 1/12 flutter. 25% had long QT during non-acute phases (median QTc max 476 ms, IQR 456ms-530ms). There were 14 hospitalisations for metabolic crises. 57.1% had QTc interval prolongation, 35.7% ventricular tachycardias (4/14 monomorphic VT, 1/14 torsade de prongs) and 1/14 Brugada type 3 pattern. Three patients died in the context of severe metabolic acidosis and multi-organ involvement (2/12 due to VT and 1/12 due to cardiogenic shock, bradycardia associated with QTc of 635ms and severe ventricular dysfunction).

Conclusions

In paediatric patients with TDD, the most frequent ECG abnormality was QTc interval prolongation with or without metabolic crises. There is a high risk of tachyarrhythmias, mainly VT, being the main cause of death in children with TDD. Subcutaneous Holter monitoring is recommended. During metabolic crises, there should be close ECG monitoring.
Left bundle branch area pacing compared to right ventricular outflow tract pacing: mid-term results and learning curve
Authors: Cabrera Ramos M , Melero Polo J , Vadillo Martin P , Mayo Carlos G V A , Ruiz Arroyo J R , Ramos Maqueda J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The aim was to evaluate efficacy and feasibility of left bundle branch area pacing (LBBAP) with right ventricle outflow tract pacing(RVOP), as well as describing the learning curve.

Methods

Prospective single-center observational study, including 200 patients that required pacemaker implantation. Two groups: LBBAP and RVOP with 100 patients each. Our aim was to compare safety and efficacy as well as the procedure and fluoroscopy times and to describe the LBBAP-learning curve.

Results

Success and acute complication rate were similar in both groups(p=0.56,p=0.65). Time for ventricular lead placement was higher in LBBAP group(18 [13-28] vs 11[7-17]min, p<0.001). Fluoroscopy time was lower in LBBAP, (2.8[1.3-3.7] vs 3.1[2-5.9]min, p=0.02). Paced-QRS was narrower in LBBAP group (122.9±13.7ms vs 145.7±17.6ms, p=0.002). There were no differences related to pacing parameters. In LBBAP group, procedure time was lower in the last quartile (Q4) compared to the first quartile (12 [10.5-15] vs 32[28.5-38.5]min, p<0.001) as well as fluoroscopy time (2[1-4.6] vs 5.1[3.4-12]min, p<0.01). Procedure time was similar between LBBAP-Q4 and RVOP (12[10.5-15] vs 11[7-17]min, p=0.33).

Conclusions

LBBAP is as safe as RVOP and it achieved a narrower paced-QRS than RVOP. It requires a longer procedure time and a shorter fluoroscopy time, with a rapid learning curve.
Marked first-degree AV block may lead to complete AV block development
Authors: Zupan Meznar A , Mrak M , Stublar J , Zizek D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

First-degree atrioventricular (AV) block (PR interval >200 ms) is considered a benign condition with rare progression to a higher degree AV block. The site of block is determined with electrophysiological (EP) study and measurement of His-ventricular (HV) interval, with normal values below 55 ms. Prolonged HV interval > 70 ms is predictive of higher-grade AV block development.

Marked first-degree AV block with a PR > 300 ms may lead to symptoms such as fatigue, poor exercise tolerance and palpitations. When symptoms are correlated to the conduction delay, permanent pacemaker (PPM) implantation to restore AV synchrony should be considered.

In the Framingham heart study, patients with first-degree AV block had a threefold higher risk of PPM implantation. However, there is no data on the HV intervals and the rate of progression of conduction disorder in patients with marked first-degree AV block.

Purpose

To assess the predictive value of HV interval measurement in patients with marked first-degree AV block for progression to a higher-degree conduction disorder.

Methods

We prospectively evaluated consecutive patients with symptomatic marked first-degree AV block that underwent a PPM implantation. His electrograms were recorded during the implantation, and HV intervals were measured from the first deflection of the His signal to the earliest onset of ventricular activation on a 12-lead surface ECG. Patients were followed for 6 months with three out-patient visits, during which the PPM was temporarily inhibited to check for intrinsic AV conduction.

Results

Seventeen patients were evaluated between January 2020 and September 2022. Ten patients (59%) were male, and 7 (41%) were female, with an average age of 61 ± 19 years. All patients had markedly prolonged PR interval (383 ± 47 ms) and narrow QRS complex (100 ± 16 ms). Three patients (17%) had intermittent type 1 second-degree AV block, right bundle branch block was recorded in two (12%) and left anterior fascicular block in four (24%) patients. Except for one patient with a corrected atrial septal defect, there were no echocardiographic signs of structural heart disease with a left ventricular ejection fraction of 61 ± 5%. The HV intervals were on the upper limit of normal values at 54 ± 6ms and no patient had an HV interval above 70 ms. Two patients (12%) developed complete AV block during follow-up: one female, and one male, 28 and 83 years old, respectively, with a PR interval 392 and 363 ms, QRS 104 and 94 ms, and HV 57 and 48 ms. None of the two had any additional conduction blocks at the time of PPM implant.

Conclusion

In our cohort of patients with symptomatic first-degree AV block (PR>300 ms), two patients (12%) developed complete AV block despite normal HV intervals at the time of implant. Closer monitoring, beyond only EP measurements, of patients with markedly prolonged PR intervals is warranted for the potential progression of conduction disorder.
Left bundle branch area pacing versus biventricular pacing for cardiac resynchronisation therapy
Authors: Gomes D , Moscoso Costa F , Rodrigues G , Matos D , Carmo J , Bem G , Santos I , Galvao Santos P , Carvalho P , De Sousa M , Carmo P , Belo Morgado F , Cavaco D , Adragao P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Conventional right ventricular pacing induces dyssynchrony and 20% of patients may need upgrade for resynchronisation therapy (CRT). Currently, left bundle branch area pacing (LBBAP) is growing as an alternative for conventional pacing, preserving left ventricular function.

Purpose

We aimed to describe procedural characteristics of a group of consecutive patients submitted to LBBAP, and to compare the final QRS duration to a group of consecutive idiopathic LBB patients submitted to conventional CRT.

Methods

Single-centre cohort including consecutive patients submitted to LBBAP or CRT since November 2021. Feasibility, procedure and fluoroscopy times, final QRS duration during pacing immediately after implantation, and periprocedural complications were assessed. Successful implantation of LBBA pacing was defined as a left ventricular activation time (LVAT) < 90ms plus right bundle branch block pattern in V1.

Results

A total of 91 patients (mean age 75±11 years, 70.3% male, and 43 [47.3%] with LBBAP) were included. Total procedure (63min [50-76] vs. 91min [71-131], p<0.001) and fluoroscopy times (4.1min [2.4-6.4] vs. 13.4min [8.3-23.1], p<0.001) were significantly lower in the LBBAP vs. CRT group, respectively. In the LBBA pacing group, median LVAT was 86ms (IQR 81-94) and no cases of electrode dislocation or perforation at discharge were reported. Final QRS duration was 112ms (IQR 105-125) vs 127ms (IQR 115-143) in the LBBAP vs CRT groups respectively (p<0.001).

Conclusion

When compared to a group of idiopathic LBB block patients submitted to CRT, LBBAP was faster, required less fluoroscopy time and was associated with final narrower QRS. Further studies are necessary to understand its role in patients with LV dysfunction and indication for resynchronisation therapy.
Defibrillation testing during S-ICD implantation: How relevant? Results from a multicenter study
Authors: Ben Kilani M , Jacon P , Badenco N , Marquie C , Ollitrault P , Behar N , Khattar P , Carabelli A , Venier S , Defaye P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Defibrillation testing (DFT) is still recommended in patients with subcutaneous implantable cardioverter-defibrillator (S-ICD) to ensure proper detection of ventricular fibrillation and confirm effective defibrillation. Given the significant risk of complications, recent studies, are reconsidering the interest of the DFT in S-ICD. The purpose of this study was to assess the clinical "real-life" outcomes of DFT over a mid-term follow-up period after third-generation S-ICD implantation.

Methods and Results

368 patients (pts) (47.9 ± 15.5 years old; male 72.8%) implanted with Generation 3 S-ICD system were included in this retrospective multicenter registry-based study. Mean left ventricular ejection fraction (LVEF) was 40.8% (primary prevention 56.1%). For 99.2% pts, S-ICD implantation was performed using the two-incision technique and intermuscular positioning of the generator was performed for all pts. 81% pts underwent ICD testing during implantation. Reasons for not performing DFT were: very low LVEF (3.5%), intracardiac thrombus (2.4%) and VF induction failure. In 2.2% (8 pts) DFT was unsuccessful, causes were: induction of ventricular tachycardias with rates falling below the shock zone for 3 pts while shocks were ineffective for 5 pts. One patient required revision for contralateral lead implantation, while sensing vector reprogramming and shock polarity modification were efficient for the others. The mean impedance was 68.4 (±14.7) Ω and time to shock therapy ranged from 10 to 33 s, with a mean of 16.7 (±4) s. A total of 36 appropriate shocks (10.1%) have been observed after a FU period of 11.02±8.8 months (1.8 shocks per patient, several shocks for 12pts, failure of the first shock for 5 patients). 17 patients (4.6%) underwent S-ICD system extraction. The reasons were pocket site complication (7 pts), pacing indication for cardiac resynchronization therapy or bradycardia (3 pts), and S-ICD lead dysfunction (4 pts). Extraction after heart transplant was needed in 3 pts. Among the 4 pts explanted for system dysfunction, only one patient had a DFT during implantation. After a mean follow-up of 19±12.1 months, the mortality rate was 3.8% (no S-ICD-related deaths were reported). There was no significant difference between the 2 groups of pts with and without DFT testing (p=0.629).

Conclusion

The DFT remains for the moment highly recommended during S-ICD implantations. Results from randomized studies are still needed to confirm the relevance of DFT during S-ICD implantation.
The prevalence and importance of frailty in cardiac resynchronization therapy patients
Authors: Kuthi L , Behon A , Merkel E , Schwertner W R , Masszi R , Veres B , Kovacs A , Osztheimer I , Zima E , Molnar L , Geller L , Kosztin A , Merkely B
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Nemzeti Kardiovaszkuláris Laboratórium RRF-2.3.1-21-2022-00003.

Background

Frailty, characterized by loss of homeostatic reserves and increased vulnerability to physiological decompensation, results from an aggregation of insults across multiple organ systems. Frailty can be quantified by counting the number of ‘health deficits’ across a range of domains.

Aims

We assessed the frequency of, and outcomes related to frailty in patients with heart failure and reduced ejection fraction who previously underwent cardiac resynchronization therapy (CRT) implantation.

Methods

We used a cumulative deficits approach to construct a 30-item frailty index (FI) and applied it to identify frail patients enrolled in our CRT registry. The 30 items were derived from medical history, other patient characteristics and laboratory results, covering a range of body systems. In keeping with previous studies, patients with FI ≤0.210 were classified as non-frail and those with higher scores were divided into two categories using score increments of 0.100. Our primary endpoint was all-cause mortality.

Results

Among 1004 included patients, 75 (7%) were considered Non-frail, while 271 (27%) and 658 (66%) participants were categorized as Frail in groups 1- and 2. Patients in Frail group 2 were older, had a less favorable renal function, and generally had more comorbidities (i.e. atrial fibrillation, hypertension, ischemic cardiovascular disease) than patients categorized in the Non-frail or Frail group 1. During the median follow-up time of 4.4 (2.3-6.9) years, 17 (22%) patients in the Non-frail group, 103 (38%) in Frail group 1, and 479 (73%) in the Frail group 2 reached the primary endpoint. Non-frail patient group showed the most beneficial survival with a 70% (HR 0.31; 95% CI: 0.23-0.41; p<0.001) lower all-cause mortality risk compared to Frail group 2. Adjusting for relevant covariates, NYHA class, creatinine, and TAPSE were identified as independent predictors for all-cause mortality.

Conclusion

Based on our results, CRT candidates are exceedingly vulnerable with a high prevalence of frailty. The calculated frailty index was associated with the primary outcome of death from any cause. FI proved to be prevalent in individual risk stratification and can predict the outcome.
Response to cardiac resynchronization therapy and treatment with ARNi and iSGLT2
Authors: Fonderico C , Faccenda D , Pergola V , Marrese A , Comparone G , Meola M , Salucci A , Cocchiara L , Addeo L , Ammirati G , Rapacciuolo A , Strisciuglio T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Heart failure with reduced ejection fraction (HFrEF) is associated in about one third of patients with abnormal conduction of the cardiac electrical impulse, resulting in asynchronous activation of the ventricles and worsening of cardiac pump function. Cardiac resynchronization therapy via biventricular pacing (CRT) has demonstrated improvement in cardiac mechanical function. The pharmacological treatment of HFrEF with sacubitril/valsartan (ARNi) and glyphozines (iSGLT2) have been shown to significantly reduce mortality.

Purpose

The objective of our study was 1) to evaluate the effect of therapy with ARNi and iSGLT2 on the recovery of left ventricular ejection fraction (LVEF %) in a population affected by HFrEF and with CRT 2) to evaluate whether there are any differences in terms of improvement in LVEF among patients who introduced these drugs into therapy before CRT implantation and those who introduced them after.

Methods

This single-center retrospective study analyzed patients with HFrEF and CRTD. These patients in our center undergo regular follow-up with cardiology visit, ECG and echocardiography every 6 months. We analyzed clinical features, drug therapy, and echocardiographic data including LVEF. Patients were considered responders they had an increase in LVEF ≥ 5% or a decrease in end-systolic volume of 15% at 6 months. The data analysis was performed with the R software.

Results

258 patients were included, 202 males (78%) with a mean age of 69.4 years, and 67.4% of them with ischemic HFrEF. Diabetes mellitus (68%), dyslipidemia (87%) and arterial hypertension (73%) were the most frequent comorbidities. Fifty-two percent of patients (133) were CRT responders and there was no difference in the proportion of responders between patients receiving ARNi and/or iSGLT2 therapy and those without (55% vs 47%; p=ns). The mean increase of LVEF was also similar between the two groups (+7.7% vs +10.3%; p=ns). In the group of patients taking ARNi or iSGLT2, no significant differences were found between patients taking these drugs already before CRT compared to those who started after.

Conclusions

In this population, HFrEF patients with CRT, therapy with ARNi or iSGLT2 does not affect the response to CRT.
Safety and efficacy of Laser lead extraction in octo- and nonagenarians. A Subgroup Analysis from the GALLERY registry
Authors: Pecha S , Chung D , Burger H , Moeller V , Osswald B , Naegele H , Baersch V , Ghaffari N , Knaut M , Reichenspurner H , Willems S , Butter C , Hakmi S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

In an aging population with cardiac implantable electronic devices (CIED), an increasing number of octogenarians and even nonagenarians present for lead extraction procedures. Those patients are considered as having an increased risk for surgical procedures including lead extraction.

Purpose

We here investigated in a large patient cohort safety and efficacy of transvenous lead extraction with powered extraction sheaths in octo- and nonagenerians.

Methods

A subgroup analysis of the German Laser Lead Extraction Registry (GALLERY) registry was performed. 499 patients were aged ≥80 years and included in this analysis. Primary extraction method was Laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. Predictors for complications and mortality were evaluated in multivariate analysis.

Results

Mean patients age was 84.3±3.7 years, 27.1% were female. 1196 leads were treated. The median lead dwell time was 118.0 (78;167) months. Clinical procedural success rate was achieved in 97.6% of the cases. Procedural failure was observed in 2.1%. Overall complication rate was 4.4%, including 1.8% major- and 2.6% minor complications. BMI<20, was the only statistically significant predictor for procedure related complications. Procedure-related mortality was 0.8%, all-cause in-hospital mortality was 5.4%. Predictors for in-hospital mortality were systemic infection, BMI≤20 kg/m2, procedural complications and chronic kidney disease.

Conclusion

Laser lead extraction in octo- and nonagenarians, is safe and effective. BMI BMI≤20 kg/m2 was the only statistically significant predictor for procedural complications. According to our data, advanced age should not be considered as contraindication for laser lead extraction.
Technical characterization of the single-lead electrocardiogram signal from four different smartwatches and its clinical implications
Authors: Knecht S , Waldmann F , Kuhn R , Mannhart D , Kuhne M , Sticherling C , Badertscher P , Wildhaber R
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Department of Cardiology, University Hospital Basel, University of Basel, Switzerland

Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Muttenz, Switzerland

Background

Smartwatches with the capability of single-lead electrocardiograms (ECGs) acquisition have been established as valuable tool for the detection of atrial fibrillation (AF). For the currently available smartwatches, however, the technical specification of the acquired ECG signal is unclear.

Purpose

The aim of the current study was to characterize quantitatively the raw signal of the single-lead ECG of four currently available smartwatches (Apple watch series 6, Withings ScanWatch, Samsung Galaxy Watch 4, Fitbit Charge 5) and assess their clinical applicability based on their technical features.

Method

A bench test was performed applying a synthetic, well-characterized signal to the electrodes of the watches (Figure: (A) Apple watch series 6, (B) Withings ScanWatch, (C) Samsung Galaxy Watch 4, (D) Fitbit Charge 5). The frequency response to this input signal was acquired and Bode plots were calculated (Figure, second column: Bode diagrams show the frequency response (upper) and the phase angles (lower)). To compare the ECG characteristics of the four watches, the synthetical response to a pre-recorded surface ECG dataset was calculated based on the frequency characteristics determined above (Figure, third column: The synthetical raw signal is shown in grey, the response of the watch in blue).

Results

The frequency responses of all four watches shows a bandpass filter, with an additional 50/60 Hz narrow-band filter (Figure). While the recommended high-pass cut-off at 0.5 Hz was fulfilled by all devices (1), a low-pass cut-off was observed for all devices below 70Hz (instead of 150Hz) resulting in a significantly damped signal. In detail, a damping of -6dB, corresponding to a signal amplitude reduction of 50%, was observed above 70 Hz and below 0.4 Hz for all watches.

A QRS complex amplitude reduction was observed for the Apple, Withings and Samsung watch. A pronounced noise filtering is visible for the Samsung and Fitbit Smartwatch. A difference for the clinically relevant characteristic fiducial points, such as the onset of the P-wave or QRS complex, cannot be observed in these examples. However, when using the tangent method to detect the end of the T-wave to calculate the QTc value, a difference between the measures can be observed for the Withings Watch.

Conclusion

The technical characteristics in terms of filtering characteristics of the single-lead ECG from four commercially available smartwatches differ and must be taken into consideration when attempting to use smartwatches beyond the detection of AF.
In silico biatrial fibrosis ablation improves atrial fibrillation outcome
Authors: Roney C , Alonso J S L , Sim I , Ulgen O , Rodero C , Strocchi M , Kotadia I , Honarbakhsh S , Narayan S , Plank G , Vigmond E , Williams S E , Niederer S
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council Fellowship

Background

In DECAAF II, left atrial (LA) fibrosis ablation plus PVI did not improve AF outcome compared to PVI alone across the study cohort. We hypothesize that biatrial fibrosis ablation could improve AF ablation therapy outcome in a subset of patients with properties identified through a large virtual in silico trial.

Purpose

To investigate the effects of anatomy, fibrosis distribution, and LGE-MRI threshold on ablation outcome using a virtual cohort of 4000 patients.

Methods

We constructed 1000 biatrial models from a statistical shape model and we mapped pectinate muscles, Bachmann’s bundle and fibers from an atlas. For each of the 1000 anatomies we applied a randomly selected fibrosis map from a library of 100 clinical maps. We then created four versions of each case by assigning one of four randomly selected right atrial (RA) fibrosis distributions with Utah grades 1-4 (Fig 1A), giving 4000 virtual patients. Four ablation approaches were applied to each patient model after 5 seconds of AF: PVI, PVI & LA fibrosis, PVI & RA fibrosis, PVI & biatrial fibrosis. LGE-MRI was thresholded for fibrosis ablation at either 1.2 or 1.32 image intensity ratio (IIR). The outcome was classified 5 seconds post ablation.

Results

Biatrial fibrosis ablation is more effective than LA ablation. For patients with high (Utah 4) RA fibrosis, biatrial fibrosis ablation increases AF termination compared to LA fibrosis ablation (Figs 1B & 2A: 62% vs 14%), this compares to cases with low (Utah 1) RA fibrosis (21% vs 14%). For patients with high LA (Utah 4) fibrosis, biatrial ablation is more effective than LA ablation (Fig 2B: 52% vs 19%), this compares to patients with low (Utah 1) LA fibrosis (17% vs 7%). Increasing IIR threshold for ablation decreases termination (LA fibrosis ablation: 15.8% termination at IIR 1.2, 11.0% at IIR 1.32; biatrial: 41.5% at IIR1.2; 20.3% at IIR1.32). Anatomy has a larger effect on biatrial ablation outcome (31.2% of outcomes change between anatomies) than on PVI only ablation outcome (20.0% change).

Conclusion

Biatrial fibrosis ablation is superior to LA fibrosis ablation for cases with high RA fibrosis. Biatrial fibrosis distribution should be considered when targeting AF ablation therapy.
The Omnipolar Mapping Technology - a new mapping tool to overcome bipolar blindness resulting in true high-density maps
Authors: Dittrich S , Scheurlen C , Van Den Bruck J H , Filipovic K , Woermann J , Erlhoefer S , Schipper J H , Lueker J , Steven D , Sultan A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Mapping, using the novel omnipolar technology (OT) obtains omnipolar signals displaying true voltage, real-time wavefront direction and speed, independent of catheter orientation and external reference. Employment of OT potentially overcomes so called "bipolar blindness" (conventional bipolar electroanatomic mapping). Hence, OT potentially improves substrate assessment, comprehension of tachycardia mechanisms and gap detection after previous catheter ablation (CA).

Purpose

Purposes of our study was to analyze previously performed left atrial (LA) and left ventricular (LV) maps for differences using automated OT vs. SD vs. the previously published HD Wave (HDW) algorithm.

Methods

Maps of patients undergoing CA for atrial or ventricular arrhythmia were initially acquired using HDW settings in conjunction with the Advisor HD Grid mapping catheter. These maps were then analyzed retrospectively applying the automated OT algorithm vs. SD vs. HDW. to reveal differences in voltage and point density. Additionally, detection of pulmonary vein (PV) gaps and LV scar area was evaluated.

Results

In 45 consecutive patients 135 maps were analyzed. The study population undergoing CA consisted of: 30 (22.2%) patients undergoing repeated CA for recurrence of persistent atrial fibrillation (persAF)/left atrial tachycardia (AT) and 15 (11.1%) patients with ventricular tachycardia (VT) or premature ventricular contractions (PVC). Atrial maps revealed a significantly higher point density using OT (21471) vs. SD (6682) or HDW (12189, p<0.001). Mean voltage was significantly higher using OT (0.75mV) vs. SD (0.61mV) or HDW (0.64mV, p<0.001). OT maps detected significantly more PV gaps vs. SD (4 vs. 2, p=0.001). In LV maps, OT revealed a significantly higher point density (25951) vs. SD (8582) and HDW (17071), p<0.001. Mean voltage was significantly higher for OT (1.49mV) vs. SD (1.19mV) and HDW (1.2mV), p<0.001. Detected scar area was significantly smaller using OT (25.3%) vs. SD (33.9%, p<0.001).

Conclusion

Using OT results in a higher voltage and point density compared to SD and HDW. Therefore displayed scar extend is significantly smaller in atrial and ventricular maps. Also, more PV gaps were detected using OT. The OT algorithm potentially improves scar delineation, facilitates substrate characterization, and may improve procedural outcome.
Impact of increased physical activity in patients after pulmonary vein isolation - BE-ACTION trial
Authors: Seifert M S , Meretz D , Haase-Fielitz A , Georgi C , Bannehr M , Moeller V , Janssen G , Minden H H , Grosse-Meininghaus D , Butter C
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical School Brandenburg and Local Government Concil Brandenburg

Background

Pulmonary vein isolation (PVI) is one of the key therapies for patients with atrial fibrillation (AF), however, there are numerous recurrences after ablation. Improving cardiorespiratory fitness (CF) may result in fewer recurrences of AF. The aim of the present study (Brandenburg Enhance ACTIvity ONset after pulmonary vein isolation - BE-ACTION) was to evaluate the impact of increased physical activity in patients after PVI on the recurrence of AF.

Methods

From January 2018 to April 2021, 200 patients with scheduled PVI were randomized at 4 different centres and fitted with an activity tracker for 24-hour activity monitoring via mobile phone. Patients aged between 50 and 77 years with a BMI between 23 and 35 kg/m2 were included. Patients with orthopaedic limitations were excluded. Patients in the ACTION group (n=99) were contacted regularly by telephone by a physical therapist and intensively motivated if the steps fell below 6,000 steps per day. Patients in the No-ACTION group (n=101) received standard of care. A loop recorder was implanted in 74 patients; those who refused loop recorder implantation underwent 7-day Holter monitoring at 6 and 12 months after PVI. Recurrence was defined as any atrial arrhythmia >30 sec, cardioversion or need of redo ablation after blanking period (3 month) up to 12 month.

Results

The number of steps per day increased in all pts from 7,918 (5,725-10,989) at week 2 after PVI to 9,511 (7,230-12,800) at 6 months and to 9,788 (6,962-12,152) at 12 months (p<0.001; Friedman), figure 1. In the ACTION group, the number of steps per day continued to increase between 6 and 12 months, whereas it decreased in the No-ACTION group. In total, recurrence of arrhythmia was found in 58 patients (29.9%: 31 patients with loop recorder, 14 with Holter monitoring and 13 with ECG). Recurrence occurred in 24 patients (25%) in the ACTION group and 34 patients (35%) in the No-ACTION group (p=0.140), table 1.

Conclusion

The level of daily physical activity was unexpectedly high in this study. The use of an activity tracker led to an increased daily physical activity in patients with AF after PVI. A further increase of activity did not reduce the recurrence of atrial arrhythmia in the ACTION group.
A novel saline-based occlusion tool allows for dye-less cryoballoon-based pulmonary vein isolation and fluoroscopy reduction
Authors: Rottner L , Obergassel J , Borof K , My I , Moser F , Lemoine M , Wenzel J P , Kirchhof P , Ouyang F , Reissmann B , Metzner A , Rillig A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon (CB)- based pulmonary vein isolation (PVI) remains guided by fluoroscopy and dye. The novel saline injection-based occlusion tool allows for pulmonary vein (PV)-occlusion assessment without the need for dye injection.

Aim

To compare KODEX-EPD guided CB-PVI using the novel saline injection-based workflow with conventional cryoablation for acute efficacy, fluoroscopy exposure and dye volume.

Methods

Consecutive atrial fibrillation (AF)- patients undergoing CB-PVI in conjunction with KODEX-EPD (CryoEPD group) were analyzed. A left atrial image was created to visualize pulmonary vein (PV) anatomy prior to ablation. PV-occlusion was assessed with the KODEX-EPD occlusion tool along with saline injection. Patients undergoing conventional CB-PVI (CryoCONV group) in the same time period acted as controls.

Results

One hundred forty patients (91/140 (65%) persistent AF) were studied. Seventy patients underwent CryoEPD procedures (64 ± 13 years, 21 (30%) female) and seventy patients underwent CryoCONV procedures (68 ± 10 years, 27 (39%) female).

A total of 560 PVs were identified and successfully isolated. Mean procedure time was 66 ± 15 minutes for the CryoEPD group, and 65 ± 19 minutes for the CryoCONV group (p=0.3). Fluoroscopy time (CryoEPD 6 ± 4 minutes; CryoCONV 13 ± 6 minutes, p<0.001) and dose area product (CryoEPD 193 [111; 297] cGycm2; CryoCONV 381 [268; 614] cGycm2, p<0.001) were lower in patients undergoing CryoEPD compared with CryoCONV procedures. No dye was needed in the CryoEPD group while 53 ± 18 ml dye per patient were administered for the CryoCONV group (p<0.001). The overall complication rate was comparable between both groups (p=0.5).

Conclusion

KODEX-EPD guided AF-ablation enables dye-free CB-based PVI with reduced fluoroscopy exposure when compared to conventional CB-ablation, without differences in acute procedural outcomes or procedure duration.
Local impedance drop guided versus lesion size index guided pulmonary vein isolation: acute success and reconnections
Authors: Lyan E , Pantlik R , Maslova V , Frank D , Demming T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Insufficient lesion depth and discontinuity of lesion lines are reasons for reconnections after point-by-point radiofrequency pulmonary vein isolation (PVI). Different technologies have shown to be useful for prediction of effective lesions. Measurement of the magnitude of local tissue impedance drop (LID) and calculation of lesion size index (LSI) based on monitoring of contact force are examples for corresponding technologies.

Purpose

To compare the acute efficacy of LID guided with LSI guided PVI.

Methods

In this retrospective study we compared two groups of patients who underwent point-by-point radiofrequency PVI for treatment of atrial fibrillation. In the LID-guided group (n=35) energy was delivered using IntellaNav MiFi (Boston Scientific, MA, USA) ablation catheter. Ablation was terminated when LID reached a plateau (Figure A). In the LSI-guided group (n=31) lesions were created using Tacticath (Abbott, MA, USA) ablation catheter until the target LSI was reached in each point (LSI=5 for anterior and LSI=4 for posterior segments respectively, Figure B). The inter-lesion distance of <6 mm with power of 40 W for anterior and 30W for posterior segments was used in both groups. A gap-map and touch-up ablation was performed along the index ablation line if the first pass PVI did not occur, or in the case of an acute reconnection after 20 min of waiting time. In the post hoc analysis initial levels and drop of local and system impedance, average contact force and LSI were included in models predicting PV gaps.

Results

All PVs were successfully isolated by encirclement of ipsilateral veins with significantly longer median ablation time 30(IQR:27-35) min in LID-guided group as compared to LSI-guided group:25 (IQR:21-31) min (p=0.035). First-pass PVI was achieved in 97 out of 132(73%) circles (LID-guided:43 out of 70 [61%] circles vs LSI-guided:54 out of 62 [87%] circles, p=0.002). Acute reconnections occurred in 14 out of 132 (11%) circles (LID-guided:9 out of 70 [13%] circles vs LSI-guided: 5 out of 62 [8%] circles, p=0.54, Figure C). Overall, significantly more patients had PV gaps when LID-guided ablation was used as compared to LSI-guided (26 out of 35[74%] vs 13 out of 31[42%] respectively, p=0.016). In the post hoc analysis a LID<9.7Ω was the only predictive parameter for PV gap (sensitivity=96.4%, specificity=67%).

Conclusions

LSI-guided ablation resulted in successful PVI with significantly shorter ablation time and fewer PV gaps as compared to LID-guided. This reflects the nature of contact force guided ablation anticipating the quality of catheter-tissue interface before each application, which is not possible with an impedance-only guided approach.
Peri-procedural anesthesia and patient pain experience in pulmonary vein isolation by means of very high power short duration radiofrequency ablation
Authors: Poggi S , Strisciuglio T , Iuliano A , Spiniello G , Schillaci V , De Simone A , Stabile G , Solimene F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Very high-power short-duration (vHPSD) temperature-controlled radiofrequency ablation (vHPSD) may reduce ablation times and improve patient tolerability, permitting pulmonary vein (PV) isolation under mild conscious sedation.

Purpose

Evaluate the anesthetic drugs use and patients ‘pain experience during vHPSD PV isolation.

Methods

Thirty-three consecutive patients, with paroxysmal atrial fibrillation (AF), treated with QDot Micro catheter and vHPSD (90 w for 4 s) (vHPSD Group), were compared with the last 33 consecutive patients, with paroxysmal AF, treated with a surround flow contact force-sensing catheter guided by the ablation index (450 at anterior and superior sites at 50 W, 330 at posterior and inferior sites at 40 W) (AI Group). Anesthetic drugs (midazolam and fentanyl) use were compared as well as pain experience, measured using a 0-10 scale.

Results

All PVs were isolated. PV isolation ablation time in the vHPSD Group (5.9±1.4 min) was shorter than in the AI Group (25±11 min, p<0.001). Pain experience was significantly lower in vHPSD group (4.5±2 vs 6.6±1.8, p< 0.001). No patients required general anesthesia; fentanyl use was required in 4 vHPSD Group patients vs 25 AI Group patients (p<0.001). A lower dose of midazolam was required in vHPSD Group (2.3±1.2 mg vs 3.6±1.7 mg, p < 0.001).

Conclusions

vHPSD radiofrequency ablation for PVI can be performed under conscious sedation using only benzodiazepine in most of patients without compromising patient pain experience.