bluuebunny/crossref_metadata_2025 huggingface dataset:
Two-year safety and effectiveness of hybrid ablation versus catheter ablation in patients with non-paroxysmal AF: mid-term results of the CEASE-AF trial
Authors: Wijffels M , Suwalski P , Weimar T , Kosior D , Bulava A , Mokracek A , Monnig G , Sahu J , Hunter S , Van Putte B , Rub N , Nemec P , Ostrizek T , Doll N
Published: May 2024

Background

Hybrid Ablation for atrial fibrillation (AF) combines epicardial and endocardial ablation through a Heart Team approach to target durable, transmural isolation of the pulmonary veins (PV) and left atrial posterior wall (LAPW). While the primary efficacy endpoint at 12 months was met with a significant benefit increase for hybrid ablation, we now report the midterm durability of those results.

Purpose

To evaluate 24-months safety and effectiveness of Hybrid Ablation with left atrial appendage exclusion (LAAE) versus Catheter Ablation in patients with persistent AF/enlarged left atrium and longstanding persistent AF (LSPAF).

Methods

CEASE-AF is a prospective, multi-center, 2:1 randomized controlled trial. Eligible patients were 18-75 years of age, had symptomatic, drug-refractory persistent AF and enlarged left atrium (>4 cm) or LSPAF, and were undergoing a first ablation. Hybrid Ablation consisted of two stages: thoracoscopic epicardial radiofrequency (RF) ablation for PV and LAPW isolation and epicardial LAAE followed by endocardial ablation 91-180 days later. Catheter Ablation consisted of minimum PV isolation by endocardial RF ablation, and repeat ablation was allowed between 91-180 days. In both arms, additional lesions were permitted according to institutional practices. Effectiveness was freedom from AF/atrial flutter (AFL)/atrial tachycardia (AT) off anti-arrhythmic drugs (AAD) (except AADs not exceeding doses which previously failed) and was assessed through 48-h Holter monitoring reviewed by an independent core laboratory blinded to the study. Safety was major adverse events throughout the study, adjudicated by an independent Clinical Events Committee.

Results

There were 102 Hybrid Ablation and 52 Catheter Ablation patients; 26% were female, mean age was 60.7±7.9 years, mean LAD was 4.7±0.4 cm, and 19% had LSPAF with no differences between arms. The 12- and 24-month results are shown for comparison (Table). Through 24-months, effectiveness was 66.3% (63/95) in the Hybrid Arm and 33.3% (17/51) in the Catheter Arm (absolute difference 33.0% [95% CI 14.3%, 48.3%; p<0.001]). Major adverse event rates through 24-months were statistically similar at 10.8% (11/102) in the Hybrid Arm and 9.6% (5/52) in the Catheter Arm (p=1.0). Through 24-months, repeat ablations were performed in 7.4% (7/95) of the Hybrid Arm versus 37.3% (19/51) of the Catheter Arm (p<0.001), and cardioversions were performed in 14.7% (14/95) of the Hybrid Arm versus 29.4% (15/51) of the Catheter Arm (p=0.034) Conclusions: CEASE-AF demonstrated that superior effectiveness of Hybrid Ablation including LAAE versus Catheter Ablation was durable through 24-month follow-up, with 33% absolute improvement in freedom from AF/AFL/AT. Safety rates continued to be similar between arms. Three-year follow-up is ongoing.
Decoding definitions of major bleeding in retrospective observational studies on direct oral anticoagulants for atrial fibrillation: a targeted literature review
Authors: Wang R , Sacks N , Chou J W , Simpson A , Williams C , Smolnik R , Chen C , Ye X , Unverdorben M , Nielsen P B
Published: May 2024

Background

Major bleeding is an adverse event associated with using direct oral anticoagulants (DOACs) for treatment of atrial fibrillation (AF). Incidence rates of major bleeding vary notably between randomised controlled trials (RCTs) and real-world evidence (RWE) studies. This may be attributable to inconsistent major bleeding definitions across RWE studies. RCTs commonly use the International Society on Thrombosis and Haemostasis (ISTH) major bleeding definition, including fatal bleeding, critical area/organ bleeding, bleeding requiring a blood transfusion of 2 or more units, and/or reductions in haemoglobin. These parameters may be absent in RWE studies, leading to utilisation of proxy definitions. Thus, the components used to define major bleeding in RWE studies remain unclear.

Purpose

To examine major bleeding definitions via a targeted literature review of retrospective observational studies on patients with AF receiving DOACs in routine clinical practice.

Methods

Studies of patients with AF receiving DOACs that were published between 2012 and 2022 were identified using keywords and MeSH terms in PubMed. Retrospective observational studies were screened for inclusion by title and abstract, and subsequently by full text. Articles were assessed for the types of databases and DOAC therapies studied. Components of major bleeding definitions were recorded and compared across database types.

Results

Of 328 articles screened, 18 retrospective observational studies were included in this analysis. The most common data sources were claims data (n = 10), followed by electronic medical records (n = 4), and registry data (n = 4). Across studies, major bleeding incidence rates varied from 0.59 to 11.4 events per 100 person-years. Of the 6 components of major bleeding definitions identified, requiring hospitalisation (n = 12) was the most frequent (Figure), though is not essential per the ISTH definition. No articles used fatal bleeding as a component to define major bleeding. Approximately half of all articles used the component involvement of critical organ or site (n = 7). Requiring blood transfusion was used in 6 articles and only 4 used reduction in haemoglobin or haematocrit levels (none of these involved claims data).

Conclusions

This targeted literature review of retrospective database studies of routine clinical practice decodes proxy use of ISTH major bleeding definitions. Claims data were the most common data source but lacked components describing fatal bleeding and haemoglobin levels. Further research is vital to assess the variation in reported major bleeding rates in RWE studies using proxy definitions in place of the ISTH definition.Figure
Is thyroid function testing necessary in all cases of new onset atrial fibrillation diagnosed in the emergency department? - a real-life study
Authors: Hytting J , Celik S , Bodestrom Eriksson L , Mallios P , Digerfeldt C , Waldemar A , Wijkman M , Hubbert L
Published: May 2024

Background

Atrial fibrillation/flutter (AF) is the most frequent cardiac arrhythmia worldwide. It increases the risk for comorbidities and prompt management is thus important. One established risk factor for AF development is hyperthyroidism, and concomitant disease significantly impacts morbidity in these patients. Therefore, thyroid function testing is recommended in new-onset AF (NOAF) by the European Society of Cardiology. There are few studies examining the prevalence of previously undiagnosed hyperthyroidism in cases of NOAF, especially if diagnosed in the emergency department (ED). Furthermore, previous studies often relied upon thyroid stimulating hormone (TSH) levels to identify cases of hyperthyroidism, this approach is susceptible for diagnostic errors since TSH profiles can overlap in conditions like hyperthyroidism, non-thyroid illness, and central hypothyroidism (of which only the former is associated with AF). Because of this, it's essential to incorporate additional biomarkers for a more precise differentiation.

Purpose

We aim to evaluate the prevalence of previously undiagnosed hyperthyroidism in a real-life NOAF population admitted to and diagnosed in the ED with a 2.5-years follow-up. Furthermore, we aim to interpret thyroid dysfunctions in relation to TSH as well as free thyroid hormone levels and other relevant biomarkers.

Methods

This retrospective registry-based cohort study included all patients attending the ED at a medium-sized hospital in Sweden during 2018 and 2020. Inclusion criteria: main diagnosis of AF (ICD I48) and ≥18 years old. Exclusion criteria: multiple visits, previous AF, abnormal thyroid function within the previous 2 years, and current thyroid hormone substitution.

Results

Patients from a total of 1020 ED visits were screened for eligibility. After exclusion, 325 patients with NOAF were included in the analysis. Of those, 106 (33%) and 232 (71%) had undergone thyroid function testing in the ED and by the end of the 2.5-years follow-up, respectively. We found no cases of hyperthyroidism in the ED and only two cases (1% prevalence) during the 2.5-years follow-up.

Conclusions

In this real-life cohort we found modest thyroid testing rates in the ED, however, a majority of patients underwent testing during follow-up. Despite this, we found no cases of hyperthyroidism in the ED and only two cases during follow-up, this is considerably lower than previously reported and may raise a question whether all patients should undergo thyroid testing, or if thyroid testing should be directed towards those with a suspected thyroid disease.
Increased risk of supraventricular tachycardia with polycystic ovarian syndrome
Authors: Raj K , Jyotheeswara Pillai K , Mahajan P R A N A V , Sarcon A N N A H I
Published: May 2024

Background

Many arrhythmias are known to be triggered by hormonal imbalances. Polycystic ovarian syndrome (PCOS) is a common hormonal imbalance seen in reproductive aged women. There is sparse literature linking PCOS to increased risk of atrial fibrillation (1). We hypothesise that PCOS could also be associated with Supraventricular tachycardia (SVT)

Purpose

To determine if PCOS is a risk factor for SVT and Atrial fibrillation/flutter (AF/AFL).

Methods

Utilising the National Inpatient Sample (NIS) of the years 2015-2020, We performed a multivariable logistic regression analysis to determine if PCOS was independently associated with SVT and AF/AFL. The NIS is the largest publicly available database of United States containing data on upto 7 million hospital visits per year.

Results

From the years 2015 to 2020, PCOS was present in 367,375 adult patients and SVT was observed in 965, 799 patients. After adjusting for relevant risk factors, PCOS was associated with increased odds of SVT (OR 1.23, 95% CI 1.12-1.36, P<0.001) (Table 1). However, PCOS was not associated with increased odds of atrial fibrillation and atrial flutter (OR 0.72, 95% CI 0.66-0.77, P<0.001)

Conclusion

SVTs have been clinically observed to be more frequent in the luteal phase of the menstrual cycle due to low estrogen. The high androgen/estrogen ratio seen in PCOS may result in a similar increased risk of SVT in PCOS patients. PCOS is known to increase P wave maximum duration and dispersion, indicating abnormal atrial conduction (2). The negative association between AF/AFL is likely because PCOS is seen more commonly in younger patients, and AF/AFL is a disease of older adults. We recommend further studies in PCOS women to confirm our findings and characterise the mechanisms of SVT.
SLAM-guided catheter ablation of AVNRT: single-center experience
Authors: Gul E
Published: May 2024

Aims

Three-dimensional mapping systems have been utilized to reduce fluoroscopy and minimize complications in patients with AVNRT. Recently, voltage-gradient mapping has been introduced to visualize low-voltage bridges. However, there are some limitations of voltage assessment due to catheter contract. Therefore, new Slow pathway Late Activation Mapping (SLAM) has been recently used to reveal slow conduction zone in AVNRT patients.

Method and materials

Seven adult patients with diagnosis of typical AVNRT were included. Electro anatomical mapping systems was used in all patients. Voltage and late activation mapping were performed with high-definition multipolar catheter. His cloud was also tagged in all patients. Voltage of 0.20-0.50 mV was used to delineate voltage-bridges. Latest activation in the SP area along with voltage-guided bridges were targeted with either radiofrequency ablation (RFA) or focal cryoablation (Figure 1 and 2).

Results

Limited fluoroscopy was used in 4 patients. Acute success was achieved in all patients. Patients had no structural heart disease. Detailed clinical and procedural data was depicted in Table. Cryoablation was used in 2 patients due to very small Koch triangle. Each cryolesion applied for 240 secs and overall, 3-4 lesions were delivered. Ablation at late activation areas successfully eliminated slow pathway. In most of cases, one ablation lesion was adequate to see junctional beats and elimination of dual AV nodal physiology.

Conclusion

SLAM is effective in guiding catheter ablation of AVNRT, with a complete acute success rate and no recurrences at short-term follow-up.
Transbaffle or retrograde aortic approach for atrial arrhythmias ablation in patients with D-TGA treated with atrial switch surgery
Authors: Francisco Pascual J , Santos Ortega A , Perez Rodon J , Adelino R , Seder E , Pijuan A , Dos Subira L , Miranda B , Jordan P , Gordon B , Benito B , Ferreira Gonzalez I , Rivas Gandara N
Published: May 2024

Introduction

Patients with D- transposition of the great arteries (TGA) treated with Senning or Mustard surgeries have high incidence of supraventricular tachycardias (SVTs). Accessing to the pulmonary venous atrium (PVAt) is frequently required to perform the ablation, however it can be challenging.

Aim

To investigate the differences between a retrograde aortic approach (Re-Aa) and transbaffle approach (TBa) for PVAt ablation in this set of patients.

Methods

Prospective observational study in a third level hospital since April 2018 until October 2022, with a medium-term follow-up. All consecutive patients (pt) with history of SVT and atrial switch surgery that underwent electrophysiologic study (EP) and electroanatomic mapping using a high-density Grid mapping catheter and a contact-force ablation catheter were included.

Results

A total of 25 EPs were performed in 20 pt (13 (52%) Female, median age 37 y.o [IQR 34-41], median follow-up time 13 month [IQR 10-37]). In 14 pt the PVAt was mapped and ablated via Re-Aa, and in 11 with TBa. Table 1 shows basal patients characteristics, note that no significant differences between groups were found. In 19 pt (76%) a CTI-dependent flutter was documented (10 (71%) in Re-Aa group and 9 (82%) in TBa, p=0.6). Furthermore, in 7 pt other tachycardia circuits were found. Accurate mapping of all the CTI walls were achieved with both strategies, however, the posterior PVAt wall and the pulmonary veins were suboptimal mapped with Re-Aa due to a lack of catheter contact. Acute ablation success was 83% in Re-Aa and 100% in TBa (p=0.5). Despite a higher recurrence rate in the Re-Aa in the first months (20% vs 0%), no significant differences in recurrences were found between groups within 1 year of follow-up (HR 1.3 [95%CI: 0,2-7], p=0.8) (FIGURE). Complication rate was 20% in Re-Aa and 0% in TBa. All complications were directly related to the arterial vascular access (1 femoral pseudoaneurysm, 1 iliac dissection, 1 mediastinal hematoma), and were successfully treated.

Conclusion

In D-TGA treated with atrial switch surgery, PVAt mapping and ablation is feasible with both strategies with a high acute success rate and without significant differences in recurrences at mid-term follow up. However, TBa is associated with a lower complications rate and also with a better catheter contact and accurate mapping in the PVAt posterior wall.
Optimizing outcomes in catheter ablation for typical atrial flutter: a comparative study of intracardiac echocardiography versus fluoroscopy guidance
Authors: Turcsan M , Janosi K , Debreceni D , Toth D , Bocz B , Simor T , Foldesi C S , Kupo P
Published: May 2024

Background

Catheter ablation is a standard intervention for typical atrial flutters, specifically targeting the cavotricuspidal isthmus (CTI). Intracardiac echocardiography (ICE) plays a pivotal role in providing real-time visualization of anatomical structures during the electrophysiology procedure, thereby enhancing safety and potentially reducing reliance on fluoroscopy, leading to improved procedural outcomes. We aimed to conduct a comparative analysis of procedural and follow-up outcomes between ICE-guided and fluoroscopy-only guided catheter ablations for CTI in patients undergoing treatment for typical atrial flutter.

Methods

A retrospective analysis was conducted at our university center, encompassing 376 consecutive patients in a single-center study. Of these, 158 underwent procedures guided solely by fluoroscopy, while 218 received ICE-guided CTI ablation.

Results

ICE-guidance demonstrated a statistically significant reduction in fluoroscopy time (72 [36; 170] s vs. 888 [578; 1184] s; p<0.01), total procedure time (70 [52; 90] min vs. 90 [60; 105] min; p<0.01), total ablation time (692 [435; 998] s vs. 920 [629; 1373] s; p<0.01), and the duration from the first to last ablation (20.5 [12; 37] min vs. 41.0 [26.8; 59.3] min; p<0.01). Both groups achieved a 100% acute success rate without major complications. The ICE-guided group exhibited a significantly superior long-term success rate (ICE-guided group: 95.74%, fluoroscopy-only group: 89.26%; p=0.048) compared to the fluoroscopy-only group at an average follow-up length of 34 months.

Conclusion

The utilization of ICE-guidance for CTI ablation significantly reduces fluoroscopy exposure, procedure time, and ablation time, ultimately contributing to enhanced long-term success rates when compared to the conventional fluoroscopy-only approach.
A novel predictive model for differentiating cardiac and non-cardiac syncope in syncope-admitted patients
Authors: Wu S , Chen K
Published: May 2024

Background

Syncope due to cardiac causes presents a higher risk for mortality or other adverse events compared to those with non-cardiac causes. Thus, a critical focus in syncope management must be the early identification of these patients.

Purpose

This study sought to explore the predictive role of readily available clinical features for cardiac syncope and develop a diagnostic nomogram to facilitate its adoption in practice.

Methods

877 patients who were hospitalized with syncope and had a confirmed cause were included in this retrospective study at a tertiary heart center. They were randomly divided into the training set and validation set and were categorized into two groups based on their underlying cause: cardiac syncope and non-cardiac syncope. A wide range of clinical features were analyzed and selected using LASSO regression. Subsequently, we utilized multivariable logistic regression analysis to identify independent predictors and construct a nomogram. The receiver operating characteristic (ROC) curves and the area under the curves (AUCs) were used to assess the predictive accuracy of the predictive model. Furthermore, calibration curves were used to measure the alignment between the predicted and actual observed probability, and decision curve analysis (DCA) was used to evaluate the clinical benefit of the nomogram.

Results

Within the entire cohort, 521 patients were diagnosed with cardiac syncope and 356 patients were diagnosed with non-cardiac syncope. Among 36 candidate variables, five independent predictors for cardiac syncope were selected using the LASSO logistic regression analysis, including BMI (OR 1.088; 95%CI 1.022-1.158), LVEF (OR 0.940; 95%CI 0.908-0.973), logarithmic NT-proBNP (OR 1.463; 95%CI 1.240-1.727), chest symptoms preceding syncope (OR 5.251; 95%CI 3.326-8.288), and abnormal electrocardiogram (OR 6.171; 95%CI 3.966-9.600). Subsequently, a nomogram based on the five independent predictors was developed, yielding AUC of 0.873 (95% CI 0.845–0.902) and 0.856 (95%CI 0.809-0.903) in the training set and the validation set, respectively. The calibration curves showcased the nomogram's strong calibration, and DCA curves revealed its potential as a highly effective tool in clinical practice.

Conclusions

This study has successfully developed and internally validated a novel predictive nomogram for distinguishing between cardiac and non-cardiac syncope, which holds a promise to serve as an effective tool to help facilitate early identification of such patients in clinical practice.ROC curves of the training and test setThe nomogram and web-based calculator
Cardioneuroablation guided by extracardiac vagal stimulation for cardioinhibitory vasovagal syncope
Authors: Teixeira R , Almeida M C , Silva G , Fonseca P , Cardoso F , Almeida J , Ribeiro S , Oliveira M , Sanfins V , Goncalves H , Barra S , Pachon J C , Primo J , Lourenco A , Fontes-Carvalho R
Published: May 2024

Introduction

Vasovagal Syncope (VVS) is often linked to abnormal autonomic reflexes, with hypervagotonia identified as a key mechanism, especially in cases with pronounced cardioinhibition. Cardioneuroablation (CNA), which involves radiofrequency ablation of cardiac vagal ganglia, targets parasympathetic hyperactivity, offering a promising treatment for recurrent VVS. This study evaluates the effectiveness and safety of anatomically guided CNA, which may provide an alternative treatment option to pacemaker implantation for younger patients with severe cardioinhibitory VVS.

Methods

Consecutive patients between January 2019 and October 2023 who underwent CNA at two cardiology centers were enrolled. All patients had a history of recurrent syncope, predominantly cardioinhibitory and unresponsive to conventional treatments. Patients showed no signs of conduction system disease, evidenced by normal rate responses in treadmill stress tests and 24-hour Holter monitoring. Electroanatomic mapping of the left atrium and pulmonary veins was performed. Extracardiac vagal stimulation (ECVS) through the right internal jugular vein, with or without atrial pacing, was utilized to assess baseline responses of the sinus and atrioventricular (AV) nodes. The ablation strategy was tailored based on rhythm disturbances triggered by ECVS, using sequential and anatomically guided ablation of ganglionated parasympathetic plexuses. Radiofrequency ablation, conducted with an irrigated catheter, was guided by the ablation index. Acute success was defined as the absence or significant reduction of cardiac parasympathetic response to ECVS, indicated by the elimination of asystole, severe bradycardia, or AV block. The primary endpoint was syncope recurrence during follow-up.

Results

The study included 25 patients (16 males; mean age 36 ± 12 years). All had documented cardioinhibition, identified through ECG monitoring (N=12), implantable loop recorders (N=5), or head-up tilt tests (N=8). The average number of syncopal episodes per patient in the year preceding ablation was 2.7, ranging from 1 to 10. Ablation was acutely successful in all cases. Post-ablation, there were no immediate complications related to the procedure, except for one convulsion deemed unrelated. Over a mean follow-up of 17 ± 14 months, 23 patients remained syncope-free. Two patients experienced syncope recurrence; despite undergoing a repeat ablation, they eventually required pacemaker implantation.

Conclusion

The results of this study suggest that CNA guided by ECVS, may offer a promising treatment for patients with refractory cardioinhibitory VVS. While the procedure showed a high rate of acute success and a notable reduction in syncope recurrence, further research is warranted to fully establish its role as an alternative to pacemaker implantation.
High-resolution repolarization changes preceding short-coupled ectopy in idiopathic ventricular fibrillation, and effects of quinidine
Authors: Stoks J , Deissler P , Ter Bekke R M A , Volders P G A
Published: May 2024

Background

Idiopathic ventricular fibrillation (VF) is linked to early repolarization, increased repolarization heterogeneity, and (short-coupled) premature ventricular complexes (PVCs). Quinidine, an antiarrhythmic drug with class-IA and -III effects, reduces the occurrence of PVCs and VF, but its effects on repolarization have not yet been studied at the whole-heart level in idiopathic-VF patients.

Purpose

To study dynamic changes in repolarization preceding short-coupled PVCs using noninvasive electrocardiographic imaging (ECGI) in a patient with idiopathic VF, and the antiarrhythmic effects of quinidine.

Methods

ECGI was performed during sinus rhythm in a 61-year-old male with an ICD (secondary prevention; 2.5 mg nebivolol daily) two days after recurrent idiopathic VF (Fig. A). This was done 1) at baseline, 2 minutes before short-coupled ectopy ("baseline"); 2) at baseline, 10 seconds before the short-coupled PVC ("pre PVC"); and 3) at 2 hours after start of quinidine 200 mg ("on-quinidine").

The ECGI procedure consisted of a 224-electrode body surface potential map and a contrast-enhanced CT scan to obtain torso and heart geometries. After reconstruction of epicardial unipolar electrograms (UEGs), local activation and repolarization times (ATs and RTs) were derived from UEGs by assessing the steepest downslope of the QRS complex and steepest upslope of the T waves, respectively, of 10-second signal-averaged beats. AT and RT duration (first to last AT or RT) were assessed.

Results

At baseline, QRS duration and QT interval measured 107 ms and 343 ms, respectively, on the standard 12-lead ECG. ECGI-derived epicardial AT duration was 72 ms, and RT histogram span 92 ms. The coupling interval of the PVC that triggered VF in the ICD readout was 340 ms (Fig. A). During 44 minutes of ECGI, 157 short-coupled PVCs from the moderator-band region were recorded (Fig. B; no tachycardia or VF). Just prior to a PVC, epicardial early repolarization at the PVC origin decreased by 26 ms (star in Figs. C-E), and the RT histogram broadened to 109 ms (Fig. E).

While on-quinidine, (25 minutes; QRS duration 107 ms, QT interval 419 ms), epicardial repolarization was prolonged (Fig. C/D), also at the site of abnormal impulse formation. Quinidine had increased the epicardial AT duration to 79 ms, and RT histogram span to 133 ms. PVCs were completely suppressed.

The patient remained free of sustained arrhythmias while on-quinidine.

Conclusion(s)

In this case of short-coupled idiopathic VF, epicardial early repolarization shortened momentarily prior to abnormal impulse formation. We found dynamic substrate-trigger characteristics that likely facilitate reentrant excitation. Quinidine prolonged the duration of epicardial activation and repolarization, suppressing the ectopy and VF recurrence.
Propranolol in polymorphic ventricular premature beats
Authors: Scheurlen C , Van Den Bruck J H , Filipovic K , Erlhoefer S , Woermann J , Dittrich S , Schipper J H , Pavel F , Ackmann J , Lueker J , Steven D , Sultan A
Published: May 2024

Background

Therapy of polymorphic premature ventricular contractions (pPVC) is sometimes challenging despite improved catheter ablation options especially in patients suffering from non-ischemic cardiomyopathy. Previous studies have proven the benefit of non-selective ß-blocker such as propranolol in the stetting of electrical storm. Data for the use of propranolol to treat pPVC is sparse.

Aim

We sought to analyze the potential benefit of propranolol in the setting of failed or only partially successful pPVC ablation.

Methods

This retrospective analysis included patients (pts) undergoing catheter ablation (CA) for pPVC or pPVC triggered ventricular tachycardia (VT) at our center between January and October 2023. If ablation was unsuccessful or not all PVCs were completely abolished oral propranolol was started after the procedure. Propranolol replaced selective ß-blocker in case of preexisting medication. The dosage was up titrated to 240mg/d if feasible. No other antiarrhythmic drug was administered simultaneously. Follow-up (FU) was conducted 3 months after ablation. During FU visit at least one 24-48h ecg was obtained to assess PVC burden.

Results

A total of 13 CA in the setting of pPVC with propranolol naive patients were performed (mean age 62.6±10.3 years, 10 pts (77%) male; 6 patients suffering from non-ischemic cardiomyopathy). The mean left ventricular ejection fraction (LVEF) was 46.6±14.6%. Five patients had previous catheter ablation. Site of ablation was: 2 left papillary muscle, 2 outflow tract (RVOT), 7 great cardiac vein/ left ventricluar summit, 1 moderator band and 1 lateral mitral valve annulus. In all cases only transient or moderate pPVC suppression was achieved by CA.

After a mean follow-up (FU) of 113.3±30.2 days a complete 3-month FU was obtained in 11 pts. The preprocedural mean pPVC burden of 14.0±7.7% was significantly reduced using propranolol to 4.2±7.7%; p=0.03 within three month after CA. No major propranolol complications occurred.

Conclusion

Data on the use of propranolol in the setting of pPVC is sparse. This analysis demonstrates for the first time a significant burden reduction of pPVC after starting propranolol in patients with failed or incomplete CA for pPVCs. Of note, although patients suffering from HFmrEf and HFrEF were included no clinical deterioration of preexisting heart failure was observed. Further comparative studies are needed.Propranolol PVC burden
Cryoablation of ventricular tachycardia using ultra-low temperature technology: acute success and insights from the post-interventional CMR
Authors: Dinov B , Dilk P , Paetsch I , Jahnke C , Hindricks G , Sossalla S T , Darma A
Published: May 2024

Background

Radiofrequency catheter ablation (RFCA) has good acute and long-term success rates in idiopathic and ischemic ventricular arrhythmia (VA). Drawbacks of the RFCA are reversibility of the edema and limited penetration of the RF energy into the tissue which explain a worse effectiveness in midmyocardial substrates. In comparison to RFCA, the lesions produced by ultra-low temperature cryoablation (ULTC) which uses near-critical nitrogen cryogen at -1960C can be both deeper and irreversible, depending on the duration of the freeze.

Purpose

We aimed to evaluate the acute effectiveness of a new ULTC technology for VA by examining post-interventional cardiac magnetic resonance images (CMR) with late gadolinium enhancement (LGE), as a part of multi-center Cryocure-VT study.

Methods

Between December 2022 and May 2023, we ablated 6 patients (age 63±16%; 5 male) with sustained VA and structural heart disease. Three patients had previous myocardial infarction; 1 cardiac sarcoidosis, 1 LMNA/C dilated cardiomyopathy and 1 post-myocarditis VA. LGE-CMR was available in all patients before the ULTC. At first, electro-anatomical mapping and VA induction were performed followed by ULTC using transseptal access. Each application consisted of freeze-thaw-freeze cycle with freeze duration at operator’s discretion based on manufacturer-recommended duration-depth curve. At the end, induction protocol was repeated to assess the acute success. Additionally, LGE-CMR was performed after ablation as an attempt to visualize the cryo-lesions.

Results

Median of 6 applications (IQR 4.75-7.5) of cryo-energy were applied per patient. Median procedure time was 180 min (IQR 97-180), and median fluoroscopy time of 20 min (IQR 15-26). Septal VA exits were detected in 3/6 patients; in 1 the exit was at aorto-mitral continuity; in 2 – basal inferior. After ablation, no VAs were inducible in 5/6 (83%) patients. The only patient with failure to ablate all VAs had fewer applications (n=4) and shorter freeze duration of 30 sec., as compared to the rest. Post-procedural CMR revealed new LGE with up to 75% transmurality in 5/6 patients; microvascular obstruction in 4/6 patients. Only LV edema, but no LGE was observed in the patient with shortest freeze time, who also had intra-hospital recurrence. No complications occurred.

Conclusions

Cryoablation of VA using a new ultra-low temperature technology is effective and safe to ablate VT even in patients with mid-septal substrates. New LGE in result of ULTCA can be observed in CMR and the lesions depth depends on the duration of application.
Predictors of decremental conduction after extrastimulus in post-infarction ventricular tachycardia substrate maps
Authors: Acosta Martinez J , Regal Somet M , Frutos Lopez M , Sanchez Brotons J A , Gonzalez De La Portilla-Concha C , Lopez Baizan J , Arana Rueda E , Pedrote A
Published: May 2024

Introduction

Ventricular tachycardia (VT) substrate ablation techniques attempt to identify areas of decremental conduction (DC) within the scar, given their close relationship with VT isthmuses. DC identification requires the systematic use of extrastimuli during substrate mapping. This can be time consuming and induce ventricular arrhythmias during mapping.

Objective

This study aims to identify predictors of decremental response after extastimulus that allow recognizing areas with higher probability of DC conduction in order to focus functional mapping of the substrate on them.

Methods

Sixteen consecutive ischemic patients (93.8% male, 66.3±12.4 years) undergoing VT substrate ablation were included. A detailed substrate map during right ventricular (RV) pacing was obtained in all of them. Systematic analysis of electrograms (EGMs) recorded from the infarct area was performed during RV pacing at 600-500 ms, and during a short-coupled RV extrastimulus. Electrograms during RV pacing exhibiting decremental evoked conduction delay after an extrastimulus (DECD-AE) were compared to those not showing DECD-AE.

Results

Mean low voltage (<1.5 mV) area was 45±18.6 cm2. A total of 1744 EGMs were analyzed. Of them, 453 (26%) showed DECD-AE. Bipolar EGMs showing DECD-AE exhibited a higher number of deflections [4(interquartile range 3-5) vs 2(1-3); p<0.0001], a higher amplitude [0.52(0.27-1) vs 0.3(0.14-0.7) mV; p=0.003] and similar duration [114(102-135) vs 117(100-133 ms); p=0.492] compared to EGMs without DECD-AE. The area under curve was 0.64 for bipolar voltage and 0.8 for number of bipolar deflections. The presence of <3 bipolar deflections excluded DECD-AE with a negative predictive value of 98.5%.

Conclusions

In areas of myocardial scar, bipolar EGMs with <3 deflections are unlikely to present DECD-AE. Focusing functional mapping on signals with ≥3 deflections could simplify procedures and save time.
Epicardial catheter ablation of ventricular tachycardia in patients of acm - from a university hospital report in switzerland
Authors: Guan F U , Brunckhorst C , Duru F , Feifan O Y , Saguner A M
Published: May 2024

Background

Arrhythmogenic left ventricular cardiomyopathy (ALVC) as a subtype of arrhythmogenic cardiomyopathy (ACM) is increasingly being recognized. Cardiac magnetic resonance (CMR) has emerged as the primary imaging modality for the diagnosis of ACM. In patients with right-dominant ACM (ARVC) and recurrent sustained ventricular tachycardia (VT), endocardial +/-epicardial ablation yields good clinical outcomes in the long-term. However, studies on VT ablation in ACM with LV involvement are scarce.

Purpose

We sought to investigate clinical outcomes of VT ablation in ACM patients with LV involvement.

Methods

The study included patients from the Zurich ACM Registry who met 2020 "Padua Criteria" for ACM and underwent VT ablation between January 2018 and July 2023. Epicardial ablation was performed in patients with recurrent sustained VT despite endocardial ablation, those lacking and endocardial substrate or if the ECG of the VT / substrate on CMR was suggestive of an epicardial origin. Catheter ablation was guided by activation/entrainment mapping for mappable VT, and pace mapping/voltage mapping during sinus rhythm for unmappable VT. Consecutive follow-up of all patients was performed according to our protocol.

Results

Twenty-one ACM patients underwent n=24 VT ablation procedures. Of those 20 patients, 6 patients (30%) had LV involvement on CMR. Eight (33%) patients underwent epicardial +/- endocardial ablation. Among patients receiving epicardial ablation, 3 patients (38%) had LV involvement. These three underwent a single ablation procedure, which was epicardial only. Total follow-up was 30 months (range 4-43). Three-month sustained VT/VF recurrence rates were 12% in the ACM group with LV involvement vs 25% in ACM without LV involvement. All patients with sustained VT/VF recurrence underwent repeat ablation via an epicardial approach within 3 months and were free of sustained VT/VF thereafter during a median follow-up of 12 months. One-year recurrence rate did not differ between ACM patients with LV involvement vs. without LV involvement (7.7% vs 8.3%, P＝0.117). Seven out of eight epicardial ablations achieved freedom from VT/VF after one-year follow-up. One ARVC patient with previous endocardial ablation had recurrent VT one month after epicardial ablation, which was free of VT after Flecainide combined with beta-blocker. No significant differences were found in the use of beta-blockers and antiarrhythmic drugs between both groups (ACM with LV involvement vs. without LV involvement) at baseline and during one-year follow-up.

Conclusions

Single or adjuvant epicardial substrate ablation of VT in arrhythmogenic cardiomyopathy is promising in terms of postprocedural VT free survival, especially in patients with left ventricular involvement demonstrated by CMR.Figure 1Figure 2
Clinical practice and outcome of S-ICD replacement: results from the multicenter rhythm detect registry
Authors: Palmisano P I E T R O , Pieragnoli P , Viani S , Nigro G , Francia P , Biffi M , De Filippo P , Pisano E , Bisignani G , Giammaria M , Ottaviano L , Tordini A , Migliore F , Valsecchi S , Bianchi V
Published: May 2024

Background

Subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy is expanding rapidly. However, there are few data on the S-ICD replacement procedure.

Objective

The aim of this analysis was to describe the procedure and outcome of S-ICD replacement in clinical practice.

Methods

From 2013 to 2022, consecutive patients undergoing de-novo implantation of an S-ICD were enrolled at 66 Italian centers of the Rhythm Detect Registry. We analyzed consecutive patients who required S-ICD replacement.

Results

319 S-ICD generators (49 Cameron, 270 Emblem) were replaced for battery depletion. All the procedures were performed in electrophysiology laboratories, by one or two expert operators. In 118 (37%) cases, the replacement was performed as outpatient procedure. The procedure was performed under local anesthesia with or without conscious sedation in 297 patients (93%). The previous S-ICD generator was in an intermuscular pocket in 195 (61%) patients, and in a subcutaneous pocket in the remaining 124 (39%). 39 (31%) generators were shifted from subcutaneous to intermuscular pocket, and their PRAETORIAN score improved from 43±20 to 34±13 (p=0.007). In most cases (308 (97%)), the defibrillation test was not performed after replacement, but the overall PRAETORIAN score was very low (37±28). The S-ICD system was successfully replaced in all patients and no complications were reported; the procedure duration was 39±16 min and was comparable in the case of generator re-implanted in the same pocket or in case of shift to a new pocket.

Conclusions

S-ICD replacement was safe and easy to perform, with no peri-operative complications. In clinical practice the replacement procedure is often an opportunity to optimize the position of the generator
Safety and feasibility concerns of radiotherapy in the presence of subcutaneous implantable cardioverter-defibrillator
Authors: Tajstra M , Dyrbus M , Stapor-Fudzinska M , Rutkowski T , Gasior M , Blamek S
Published: May 2024

Introduction

Radiotherapy (RT) in patients with cardiac implantable electronic devices (CIED) is performed increasingly more frequently. Currently, there is no evidence, whether RT in patients with subcutaneous implantable cardioverter-defibrillator (sICD) is feasible and safe.

Purpose

To perform the first in-vitro analyses using a model of left lung cancer treated with stereotactic body radiotherapy (SBRT) with the presence of an sICD.

Methods

Three functional sICDs explanted from patients following the heart transplant underwent RT. In one device (No º3), the lead had to be cut during explantation at ~ 3 cm from the tip. A computed tomography-based SBRT plan was calculated for a left lung tumor (located 3.5 cm from the sICD). Three fractions of 18 Gy with a nominal energy of 6 MV were delivered, and the maximum dose calculated for the sICD was 3.5 Gy. Each sICD and lead were placed on an anthropomorphic phantom in the nominal location. The intervals between fractions were 7 days. The next step was a direct irradiation of the sICD with an open-field RT with 25 fractions of 2 Gy, then 2 of 20 Gy, 1 of 40 Gy, and a final fraction of 100 Gy. Before and after each fraction, the devices were interrogated, and to verify whether RT affects the devices in the possibly least optimistic clinical scenario, high-voltage therapies were turned on for each fraction and off for the intervals between them.

Results

A major depletion in the battery percentage (from 88% to 16%) between the first and second fraction of RT in device No. 2 was observed, while in two other devices, major reductions in the device battery longevity were observed after the third fraction of RT (from 38% to 14% and from 60% to 15%, respectively). The estimated doses for sICDs in those stages of RT were respectively 1.2 Gy, 3.5 Gy, and 3.5 Gy. Due to a significant drop of the battery longevity in device No 2º, only two remaining sICD underwent the open-field RT.

During the direct irradiation, an unannounced shock was delivered during the interrogation directly after the 14th fraction of 2 Gy, in a device with a macroscopically intact lead. An external interference was demonstrated, which was interpreted as an arrhythmia in the ventricular fibrillation zone. The complete device reset occurred in both devices after having received approximately 195 Gy.

Conclusions

The presented findings strongly indicate an association between RT and the malfunction of the sICD occurring in the anthropomorphic phantom model of left lung tumor, as well as the risk of inappropriate shocks during the open-beam direct radiation on the devices.Battery longevities before and after RT
Feasibility and effectiveness of left bundle branch area pacing after TAVR: the single center experience
Authors: Bakytzhanuly A , Turubayev E , Esilbayev Z H , Bagibayev S , Nuralinov O
Published: May 2024

Introduction

Transcatheter aortic valve replacement (TAVR) is a safe alternative to open-heart surgery in patients with symptomatic severe aortic stenosis and high surgical risk due to multiple comorbidities, advanced age, and severe left ventricle dysfunction. Due to anatomical considerations of the atrioventricular node, conduction abnormalities requiring the implantation of a pacemaker are common findings after TAVR. High-grade atrioventricular block and new-onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR.

Purpose

The aim of our study was to assess the feasibility, success rates, and effectiveness of LBBAP in patients requiring pacing after TAVR.

Methods

A total of 302 patients underwent the TAVR procedure in our institution in the period from January 2022 to November 2023. In this cohort, 38 patients required ventricular pacing in the postoperative period. 16 patients who underwent permanent pacing using LBBAP were included in this observational study. Patients undergoing traditional right ventricular pacing biventricular pacing or leadless pacemaker implantation were excluded from the study.

Results

LBBAP was successfully performed in 16 patients (89%). 2 patients underwent conventional CRT implantation (1 cardiac resynchronization therapy pacemaker and 1 cardiac resynchronization therapy defibrillator) in order to severe calcification and presence of fibrotic tissue in the target area. The mean age was 60.5±2.74 years, and 10 patients (62.5%) were women. According to the patient’s medical history, 14 patients (84%) had hypertension; coronary artery disease – 2 (12.5%), 2 (12.5%) patients had atrial fibrillation and atrial flutter, and 7 (43.5%) patients had diabetes mellitus. The mean left ventricle ejection fraction (LVEF) was 46.2±14.7%. Interventricular septal thickness 11.8 ± 1.9 mm. Type of conduction diseases: Infranodal AV block and LBBB were present in 9 (56.5%) patients. 5 (31,25%) patients had persistent complete AV block and 2 (12,25%) had Mobitz II AV block. In 2 patients we observed congestive heart failure combined with LBBB. Pre-TAVR QRS morphology was normal in 15 (93%), and RBBB morphology in 1 (7%). The mean QRS duration at baseline was 105±20 ms. Pre-implant QRS duration 135±52 ms. The single-chamber pacemaker was implanted in 1 patient, dual-chamber pacemaker - 13 patients, and cardiac resynchronization therapy defibrillators in 2 patients. Procedural duration and fluoroscopy times were 105. ± 31.9 min and 18 ± 11 min, respectively.

Conclusion

Complete AV block and new-onset LBBB after TAVR is still an important issue. LBBB correction using conduction system pacing technology is an effective strategy for this type of patient. LBBAP is one of the most exciting developments in pacing therapy over the last few years. Long-term clinical outcomes and safety of physiological pacing data are limited and require further investigations
Efficacy and safety of lumenless leads compared with stylet-driven leads for left bundle branch area pacing
Authors: Melero Polo J , Murciano Marques E , Sales Belles C , Vadillo Martin P , Ramos Maqueda J
Published: May 2024

Introduction

Left Bundle Branch Area Pacing (LBBAP) was initially performed with lumenless leads (LLLs). In the last years, stylet-driven leads (SDLs) have emerged as an alternative. However, we are still lacking data comparing these two different approaches.

Purpose

To compare the efficacy and safety of LLLs Vs SDLs for LBBAP.

Methods

116 patients who underwent LBBAP attempt in our institution were prospectively included (mean age 74 ± 9 years, 40 (34%) female). We recorded and analyzed baseline characteristics, procedural findings, LBB capture criteria, lead parameters, success rates and complications. A 6-month remote follow-up data was programmed in every patient.

Results

We analyzed 75 patients who received LLLs and 41 patients with SDLs. Baseline characteristics were similar in both groups (table 1). There were no significant differences regarding Paced QRS (114 ± 18 ms Vs 117 ± 19 ms, p = 0.36), presence of a LB potential (16 (21%) Vs 9 (22%), p = 0.93), V6 R-wave peak time (V6RWPT) (83 ± 15 ms Vs 82 ± 16 ms, p = 0.71) or V6–V1 inter-peak interval (40 ± 17 ms Vs 37 ± 13 ms, p = 0.37). Time to lead implant was also similar (37 ± 18 minutes Vs 37 minutes ± 13 minutes, p = 0.87). Mean pacing voltage threshold was higher for SDLs after implantation (0.71 ± 0.33 V Vs 0.86 ± 0.30 V, p = 0.02) and also at the 6-month remote follow-up (0.75 ± 0.28 V Vs 0.9 ± 0.34 V, p = 0,04). R-wave amplitude and impedance were also higher in SDLs (table 1).

According to 2023 EHRA clinical consensus statement on conduction system pacing, we achieved confirmed LBBP in 63 patients (54%), likely LBBP in 30 patients (26%) and Left Ventricular Septal Pacing (LVSP) in 21 patients (18 %), with no differences between groups (table 1). After the 6-month follow-up, a higher probability of lead dislodgement was appreciated in the SDLs group (3 (7%) Vs 0 (0%), p = 0,01).

Conclusions

LLLs and SDLs are effective tools to perform LBBAP, achieving similar paced QRS and and success rates. SDLs were associated with slightly higher pacing threshold. After the 6-month follow-up, a higher probability of lead dislodgement was appreciated in the SDLs group.