bluuebunny/crossref_metadata_2025 huggingface dataset:
Clonal haematopoiesis of indeterminate potential predicts recurrence of atrial arrhythmias after surgical ablation for atrial fibrillation
Authors: Zeng Z , Liu H , Wang P , Chen R , Zheng Z
Published: October 2024

Background

Clonal haematopoiesis of indeterminate potential (CHIP), characterized by the presence of somatic blood cell clone expanding without other haematological abnormalities, was recently shown to be significantly associated with the development and progression of atrial fibrillation (AF). However, the clinical relevance of CHIP in patients underwent surgical atrial ablation remained unexplored.

Aims

This study investigated the potential role of CHIP in the recurrence of atrial arrhythmias after surgical ablation in patients with AF.

Methods

Deep-target sequencing of 74 CHIP (a mean depth of coverage = 4051x) was performed in 132 patients with AF (mean age, 60 years; 75.8% male; mean left atrial diameter, 47mm) who underwent surgical ablation without previous atrial ablation between December 2014 and September 2021. Variant allele fraction (VAF) ≥ 2.0% of any targeted genes indicated the presence of CHIP mutations. The primary outcome is the recurrence of any atrial arrhythmias for >30s after a blanking period of 3 months within a year. The clinical significance of CHIP was determined by multivariable Cox proportional hazards regression.

Results

A total of 17.4% (23 of 132) patients with AF carried CHIP mutations (DNMT3A, 8.3% and TET2, 3.8%). CHIP prevalence varied among AF types, with paroxysmal, persistent, and long-lasting AF counting for 12.5%, 16.5%, and 36.4%, respectively. During one-year follow-up after blanking period, recurrent atrial arrhythmia was documented in 15 (65.2%) and 37 (33.4%) patients in the CHIP and non-CHIP groups, respectively (p = 0.005 for log-rank test). The association of CHIP with atrial arrhythmias recurrence remained significant after fully adjustment (hazard ratio, [95% confidence interval], 1.92 [1.02-3.63]).

Conclusions

CHIP mutations with a VAF ≥ 2.0% were identified in 17.4% AF patients undertaken surgical ablation and was associated with poor prognosis. CHIP assessment may be useful in the personalized management of patients who planned to perform surgical ablation for AF.
Long-term efficacy of concomitant surgical ablation for atrial fibrillation with cardiac surgery
Authors: Sammut M , Lim C J , Cheong S C , Singh M , Lee J , Storey R F , Braidley P , Briffa N , Cartwright N , Chetty G , Forlani S , Greco R , Sadeque S , Hunter S
Published: October 2024

Background

Concomitant surgical ablation (SA) is recommended at the time of cardiac surgery in patients with atrial fibrillation (AF) but it is only performed in the minority due to perceived barriers such as increased risk, longer procedure duration and additional technical skills required [1,2]. Furthermore, long-term outcome reporting is limited to only a few high-volume centres.

Purpose

We sought to report on our centre’s 11-year experience with cardiac surgery and concomitant SA.

Methods

This was a retrospective observational study on 625 patients with AF who underwent SA in addition to other cardiac surgery at our centre between April 2011 and March 2022. Patients undergoing standalone SA were excluded. Complications were recorded up to 30 days post-procedure. Freedom from atrial tachyarrhythmias (ATA) was determined by electrocardiography, Holter monitoring and pacemaker interrogation at various time points, if available, with or without additional therapies for AF.

Results

Mean age was 69 +/- 9.9 years and the median duration of AF was 1.2 years (interquartile range 0.4-3.8), persistent in 79% of patients. The median left atrial volume index (LAVI) was 55 ml/m2 (interquartile range 43-71). Concomitant surgery included coronary artery bypass grafting (26%), mitral (68%), aortic (27%), tricuspid (21%) and/or other (5%). Biatrial Cox-Maze IV was performed in 51% of patients and the left atrial appendage was occluded in 74%. Major complications included 30-day mortality (3%), stroke (3%) and pacemaker implantation (4%). Freedom from ATAs was 80% (312/391), 64% (154/240), 53% (76/144) and 44% (33/75) at 1, 3, 5 and 7 years, respectively (Figure 1). Cox regression demonstrated diabetes mellitus, AF duration, persistent AF and LAVI as predictors of 7-year ATA recurrence.

Conclusion

Concomitant SA for AF has good early and acceptable longer-term rhythm outcomes with no significantly increased complication rate, which should encourage greater uptake of the procedure.
Optimal anticoagulant strategy for periprocedural management of atrial fibrillation ablation: a systematic review and network meta-analysis
Authors: Kino T , Kagimoto M , Ishigami T , Ishikawa T , Hibi K
Published: October 2024

Background

This network meta-analysis was performed to rank the safety and efficacy of periprocedural anticoagulant strategies in patients undergoing atrial fibrillation ablation.

Methods

MEDLINE, EMBASE, CENTRAL, and Web of Science were searched to identify randomized controlled trials comparing anticoagulant regimens in patients undergoing atrial fibrillation ablation up to July 1, 2021. The primary efficacy and safety outcomes were thromboembolic and major bleeding events, respectively, and the net clinical benefit was investigated as the primary-outcome composite.

Results

Seventeen studies were included (n = 6950). The mean age ranged from 59 to 70 years; 74% of patients were men and 55% had paroxysmal atrial fibrillation. Compared with the uninterrupted vitamin-K antagonist strategy, the odds ratios for the composite of primary safety and efficacy outcomes were 0.61 (95%CI: 0.31–1.17) with uninterrupted direct oral anticoagulants, 0.63 (95%CI: 0.26–1.54) with interrupted direct oral anticoagulants, and 8.02 (95%CI: 2.35–27.45) with interrupted vitamin-K antagonists. Uninterrupted dabigatran significantly reduced the risk of the composite of primary safety and efficacy outcomes (odds ratio, 0.21; 95%CI, 0.08–0.55).

Conclusion

Uninterrupted direct oral anticoagulants are preferred alternatives to uninterrupted vitamin-K antagonists. Interrupted direct oral anticoagulants may be feasible as alternatives. Our results support the use of uninterrupted direct oral anticoagulants as the optimal periprocedural anticoagulant strategy for patients undergoing atrial fibrillation ablation.
Use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation across five stages of chronic kidney diseases
Authors: Chao T , Kuo L , Chan Y H , Lip G Y H
Published: October 2024

Background

Although non-vitamin K antagonist oral anticoagulants (NOACs) were more and more commonly prescribed in the daily practice, data about the use of NOACs in atrial fibrillation (AF) patients with stage 4 and 5 chronic kidney diseases (CKD) are limited. In the present study, we compared the clinical outcomes of AF patients receiving NOACs and those receiving warfarin or non-OACs in different stages of CKD.

Methods

A total of 39217 AF patients aged >20 years whose data about creatinine clearance (CCr) were available were identified from the electronic health record database of a multi-center healthcare system in Taiwan. Patients were categorized into stage 1 to stage 5 CKDs, and the composite risks of ischemic stroke/systemic embolism, major bleeding and mortality were compared between non-OACs, warfarin and NOACs.

Results

Around 12.7% and 9.4% of study patients had a stage 4 and stage 5 CKD, respectively. Compared to non-OACs, the use of OACs (either warfarin or NOACs) were consistently associated with a lower risk of composite events from stage 1 to stage 4 CKD, but not for stage 5 CKD (warfarin: aHR 0.912, 95%CI 0.742-1.121; NOACs: aHR 0.993, 95%CI 0.653-1.537)(Figure 1). Compared to warfarin, NOACs were associated with a lower risk of adverse events for patients with stage 2 (aHR 0.630), stage 3 (aHR 0.712) and stage 4 CKD (aHR 0.749). However, the risk did not differ between warfarin and NOACs for stage 1 and stage 5 CKD (Figure 2).

Conclusions

Although data of the clinical trials for AF patients with stage 4 CKD were relatively lacking, NOACs should still be considered for this AF population. More data are necessary to guide optimal stroke prevention strategy for patients with stage 5 CKD.
Impact of resumption of Oral AntiCoagulation therapy (OAC) after GastroIntestinal Bleeding (GIB) on clinical outcomes in patients with Non-Valvular Atrial Fibrillation (NVAF)
Authors: Sun W , Yan B
Published: October 2024

Purpose

Optimal resumption of oral anticoagulation therapy (OAC) after gastrointestinal bleeding (GIB)has not been well established. This study aimed to compare clinical outcomes between patients who resumed or discontinued OAC after index GIB.

Methods

We retrospectively enrolled consecutive patients with non-valvular atrial fibrillation (NVAF) and prior GIB from January 2018 to July 2022 in 16 public hospitals in Hong Kong. Resumption of OAC was substantiated by new prescription after index GIB on electronic medical records. Patients were divided into 5 groups: (i) OAC naïve (as reference group); (ii) resume direct oral anticoagulant (DOAC); (iii) resume Vitamin K antagonist (VKA); (iv) discontinue DOAC; (v) discontinue VKA. Endpoints included recurrent GIB, ischemic stroke and all-cause death. Risks of target events were estimated for all groups and compared with individuals without OAC, using adjusted sub-distribution hazard ratios (aSHR) derived from Fine and Gray regression models, accounting for death as competing risk for recurrent GIB and stroke, and COX proportional regression for all-cause mortality, adjusting for components of CHA2DS2VASC, HASBLED scores, causes of index GIB (i.e., GI ulcer, diverticular disease, angiodysplasia or undermined) and endoscopy intervention. Among patients who resumed OAC, outcomes were compared between different DOAC agents (i.e, apixaban, dabigatran, edoxaban, rivaroxaban), using VKA as reference.

Results

Of 2,350 patients identified (mean age 80.5±10.4, female 54.5%), 44.0% (n=1,034) were OAC naïve, 4.4% (n=103) discontinued VKA, 11.7% (n=275) discontinued DOAC, 11.2% (n=263) resumed VKA, and 28.7% (n=675) resumed DOAC. During a median follow-up duration of 1.2(IQR:0.2-2.5) years, discontinuation of DOAC (aSHR=0.5(0.29-0.9) was associated with lower risk of recurrent GIB, whereas resumption of VKA (aSHR=1.8(1.0-3.1)) was associated with the highest risk of recurrent GIB (Figure 1a). Among DOACs, apixaban (aSHR=0.5(0.3-0.9)) was associated with the lowest risk of recurrent GIB (Figure 1b). Risk of ischemic stroke across groups were similar. Patients who discontinued DOAC (aHR=1.4(1.2-1.6)) were at higher risk of all-cause mortality, whereas resumption of VKA (aHR=0.4(0.3-0.6)) and DOAC (aHR=0.4(0.4-0.5)) were both associated with decreased mortality (Figure 1c).

Conclusion

In this real-world dataset, resumption of VKA in NVAF patients after GIB was associated with high risk of recurrent GIB and lowest risk with apixaban. OAC resumption either VKA or DOAC was associated with reduced mortality.
Comparing the real-world and clinical trial bleeding rates associated with oral anticoagulation treatment for atrial fibrillation
Authors: Gue Y X , Bloomfield D , Freedholm D , Lip G
Published: October 2024

Background

The prevention of stroke in patients with atrial fibrillation (AF) involves the use of oral anticoagulation, commonly in the form of direct oral anticoagulants (DOAC). However, it comes with an increased risk of bleeding and therefore, counselling patients on their individual risk is important. Although majority of patients initiated on DOAC have been represented within the clinical trials, there are some cohorts which are under-represented in whom clinicians are unable to practice evidence-based medicine.

Methods

Utilising the pooled clinical trial (CT) data sourced from Medidata Enterprise Data Store, 5 recent open-label industry sponsored AF trials were compared with Real-World data (RWD) was sourced from the HealthVerity Marketplace with the occurrence of bleeding events as the primary outcome of interest.

Results

A total of 64,421 patients were included in the analysis, with 3207 patients from the clinical DOAC trials and 61,214 patients from the RWD cohort. Overall, the patients from RWD cohort had more co-morbidities, were older (72.2 ± 11.9 vs 65.3 ±10.7 years old, p<0.001), had higher mean CHA2DS2VASc (3.98 ± 1.9 vs 2.87 ± 1.73, p<0.001) and HAD-BLED scores (2.13 ± 1.02 vs 1/04 ± 0.93, p<0.001) when compared to the trial data.

When comparing the incidence of first major bleed at 12 months post treatment initiation, rates in the RWD cohort was significantly higher (10.69 vs 18.97 per 100 person-years). The impact of comorbidities such as age, CHA2DS2VASc and HAD-BLED scores were similar in both cohorts, however, there was an under-representation of older, females and more co-morbid patients within the clinical trial cohort.

Conclusion

DOAC treated patients have higher bleeding incidence rate in the RWD cohort as compared to clinical trials. This can be explained by the older patient age group with more complex medical histories and higher HAS-BLED scores. The under-representation of higher risk patients and lower proportion of females within clinical trials should be addressed to better translate clinical trial data into real world clinical practice.
Cardiac amyloidosis and left atrial appendage closure: a multicenter retrospective study
Authors: El-Am E , Abbasi M , Rahme S , Al Abcha T , Cheng R , Ustunkaya T , Ellis C , Cariou E , Ullah I , Ambardekar A , Vasbinder A , Hayek S , Garcia-Pavia P , Ruberg F , Grogan M
Published: October 2024

Background

Thromboembolic stroke risk remains a clinical challenge in cardiac amyloidosis (CA) patients with atrial fibrillation because of the increased prevalence of left atrial appendage thrombi irrespective of CHA2DS2-VASc score and a higher prevalence of factors that increase the risk of bleeding with anticoagulation. Left atrial appendage closure (LAAC) is an effective option in patients with atrial fibrillation and high bleeding risk; however, data describing a LAAC strategy for stroke prevention in patients with CA is limited. Among non-CA patients, procedural success and serious complication rates are around 98% and 3% respectively.

Purpose

In this multicenter retrospective study, we aimed to investigate whether left atrial appendage closure (LAAC) could reduce the risk of bleeding complications and ischemic cerebrovascular events in patients with CA.

Methods

In an international multi-center retrospective study, patients with CA that underwent LAAC were included. The diagnosis of CA was established on the basis of histologic confirmation or advanced multimodality cardiac imaging as per current consensus statements.

Results

A total of 28 patients (93% male; 87% ATTR-CA; 13% AL-CA; mean age 80 years) met inclusion criteria. At baseline, mean CHA2DS2-VASc and HAS-BLED scores were 4 and 3 respectively, mean left ventricular ejection fraction was 50%, and mean indexed left atrial volume was 58 mL/m2. 21% of patients had a prior history of ischemic stroke, 14% prior history of hemorrhagic stroke, 7% prior transient ischemic attack, and 54% had a prior history of major or minor bleeding. Procedural success was achieved in 26 patients (93%) with procedural complications occurring in 2 patients (vascular access site bleeding and cardiac tamponade). Regarding in-hospital and follow-up complications, 0% ischemic stroke, 0% hemorrhagic stroke, and major or minor bleeding in 4% of patients. During follow up, device thrombosis occurred in only 1 patient.

Conclusion

LAAC is a feasible and effective alternative to anticoagulation in patients with CA and excessive bleeding risk, with procedural success and complication rates similar to reported studies of non-CA patients.
Atrial Fibrillation in young patients: Insights from the National Inpatient Sample
Authors: Kotta P , Patel T , Chelu M , Nambi V , Khan A
Published: October 2024

Background

The burden of atrial fibrillation (AF) in young patients is not well characterized. We aimed to study trends in AF burden and management over time in patients aged 18-45 years.

Methods

We conducted a retrospective analysis of all primary AF hospitalizations in patients 18-45 years of age using the United States National Inpatient Sample (NIS) data from 01/01/2008 to 12/31/2019. We collected data on clinical and socioeconomic features including demographics, comorbidities, ZIP Code income, resource utilization, and various clinical outcomes. Quartile classification of the median household income of the zip code of the patient’s residence was used to classify socioeconomic status.

Results

The rate of AF hospitalizations decreased over time from 18.7 per 100,000 in 2008 to 13.0 per 100,000 in 2019 (p<0.001) (Figure 1). AF hospitalizations were higher amongst males compared to females (24.0 vs. 7.5 per 100,000), and higher in black patients compared to other ethnicities (20.4 for black vs. 15.6 for white vs. 8.5 Hispanic per 100,000) (Figure 2). The utilization of electrical cardioversion increased from 17.6% in 2008 to 21.9% in 2019 (p<0.001), and the utilization of catheter ablation decreased from 7.1% in 2008 to 4.3% in 2019 (p<0.001) (Figure 1). Men were more likely to undergo electrical cardioversion than women (20.1% vs. 14.8%, p <0.001). White patients were more likely to undergo electrical cardioversion (20.8% vs. 14.3%) and catheter ablation (6.1% vs. 3.3%, p <0.001) compared to black patients. Patients in the highest socioeconomic status quartile were more likely to undergo electrical cardioversion (21.9% vs. 16.4%, p<0.001) and catheter ablation (8.0% vs. 3.7%, p<0.001) compared to patients in the lowest socioeconomic status quartile.

Conclusions

We found significant differences in inpatient AF burden across different patient populations. We identified differences in inpatient AF management based on sex, ethnicity, and socioeconomic status. Further research is needed to better understand these differences, their impact on clinical outcomes, and strategies to improve healthcare disparities.
Participation of epicardial connection in transverse conduction across the crista terminalis in patients with upper and lower loop reentry atrial tachycardias
Authors: Ishihara T , Takasugi N , Wakasa S , Ichiryu H , Masuda Y , Naruse G , Watanabe T , Yamada Y , Kanamori H , Okura H
Published: October 2024

Background

The crista terminalis (CT) sometimes serves as a partial or complete conduction barrier, which is rate- and site-dependent. The basis, location and extent of the transverse conduction across the CT have been controversial. The pseudo-focal activation pattern indicates passive activation from the anatomically opposite chamber or structure. We previously reported cases of transverse CT conduction exhibiting a pseudo-focal activation pattern, indicating the CT conduction utilizing an epicardial connection (EC) in patients with upper loop reentry (ULR) atrial tachycardia (AT).

Purpose

This study aimed to investigate the prevalence and characteristics of transverse CT conduction using a high-resolution electroanatomical mapping system during CT-dependent AT and to compare between the ULR and lower loop reentry (LLR) ATs.

Methods

A total of 119 consecutive patients with macroreentrant AT were studied. The diagnosis of ULR/LLR AT was made based on endocardial activation mapping and entrainment pacing obtained from various sites around the superior/inferior vena cava. Transverse CT conduction utilizing an EC was defined as follows; (1) a centrifugal activation pattern with the earliest activation (EA) site >5 mm away from the CT, (2) later activation observed between the EA and the CT, and (3) the EA site exhibiting a pseudo-focal activation pattern (multiple breakthroughs or a small r wave on unipolar electrogram).

Results

Eighteen (15.1%) of the 119 patients were diagnosed with CT-dependent AT (15 men; median age, 71.5 years; AT cycle length, 265 ms; left atrial diameter, 42.5 mm; left ventricular ejection fraction, 49%). The 18 patients were divided into 2 groups: 9 patients with ULR and 9 with LLR AT. There were no significant differences in clinical characteristics (sex, history of cardiac surgery and organic heat disease) between ULR and LLR groups. Transverse CT conduction utilizing EC was more frequently observed in the ULR group than in the LLR group [77.8% (7/9) vs 22.2% (2/9), P=0.05]. In all patients with transverse CT conduction utilizing EC, scars extended along the CT. AT cycle length was significantly longer in the ULR group than in the LLR group (295 vs 235 ms, p=0.001). All ATs were successfully eliminated by radiofrequency ablation at the breakthrough sites and/or along the CT in ULR patients or by cavotricuspid isthmus ablation in LLR patients.

Conclusions

Half (9/18) of the patients with CT-dependent AT exhibited transverse CT conduction with a pseudo-focal activation pattern, suggesting the existence of an EC between the sinus venosus and the right auricle. The high prevalence of the pseudo-focal pattern in patients with the ULR compared to those with the LLR may provide insights into mechanisms.Figure1Figure2
Collision mapping enables accurate localization of the slow pathway in atrioventricular nodal reentrant tachycardia
Authors: Seewoester T , Dilk P , Nedios S , Oebel S , Lindemann F , Deserio M , Feher M , Bollmann A , Bode K
Published: October 2024

Introduction

Atrioventricular Node Reentry Tachycardia (AVNRT) is commonly treated with catheter ablation, with high success and low complication rates. However a small risk of complete AV block still remains. Recent studies could show that using collision map is a feasible approach in mapping the slow pathway.

The aim of the current study is to show a reduction of the total ablation points needed to modify/ablate the slow pathway using the collision mapping compared to conventional 3D mapping guided slow pathway modulation/ablation and therefore minimize the risk of a complete heart block.

Methods

Patients diagnosed with AVNRT (n = 24) underwent collision mapping for slow pathway identification, compared to a historical cohort (n=76) using conventional mapping.

For collision mapping a dynamic visualization of atrial propagation during sinus rhythm was condcted. Two propagation fronts were observed to collide at the triangle of Koch, one propagation through the slow and one through the fast pathway. The designated collision zone was considered ideal for catheter ablation (Figure 1). The endpoint after ablation in both groups was non-inducibility of AVNRTs.

Results

After propensity score matching the collision mapping group needed significantly fewer ablation impulses (2 (IQR 1 - 5) vs. 6 (IQR 2,5 - 11,5) p = 0.002) and shorter ablation time (p < 0.001) compared to the conventional group (Table 1). No significant differences were observed in procedure time (p = 0.209), fluoroscopy time (p = 0.296), or dose area product (p = 0.391).

Conclusion

Collision Mapping in AVNRT ablation showed a notable reduction in ablation points, suggesting enhanced procedural efficiency and safety.Figure 1Table1
Safety of electrophysiological study in atrioventricular block risk stratification in new-onset persistent left bundle brunch block following transcathether aortic valve implantation
Authors: Iraola Viana D , Sanchez-Gomez J M , Garcia Blas S , Jimenez Aguilella A , De Las Heras Pellicer L , Gabaldon Perez A , Martinez Brotons A , Bondanza Saavedra L , Dominguez Mafe E , Sanchis Fores J , Ferrero A
Published: October 2024

Background

A significant percentage of patients develops a persistent complete left bundle branch block (LBBB) following TAVI. Electrophysiological (EP) study could be useful to stratify the risk of atrioventricular block (AVB) in these patients, guiding the need of follow-up and the indication of definite pacemaker.

Purpose

The primary objective of the study was describing the incidence of bradyarrhythmic events in the 30-day follow-up of patients with new-onset LBBB: AV block with ECG long-term monitoring system (Nuubo) in patients with negative EP study, and ≥ 5 % of ventricular stimulation in patients with positive EP study and pacemaker implantation.

Methodology

Observational prospective study of consecutive patients without previous permanent pacemaker implantation where transfemoral TAVI was implanted between 2021 and 2023. In case new-onset complete LBBB was present after TAVI, an EP study was performed. EP study was considered positive when His-Ventricule interval was more than 70ms, or after procainamide infusion at 10mg/kg, more than 100ms or more than double the basal HV interval. In case EP was positive, a permanent pacemaker was implanted. In case EP was negative, a 30-day follow-up with ECG long-term monitoring system (Nuubo) was performed.

Results

In this cohort, 266 patients without pacemaker following TAVI were included. Persistent new-onset left bundle branch block was present in 10,15% of patients (n=27). EP study was positive in 29.62% of patients (n=8), following a definite pacemaker implantation. During follow-up, only one patient (12.5%) was dependent of ventricular stimulation. The group with negative EP study (n=19) were monitored with a 30-day ECG long-term monitoring system (Nuubo). No bradyarrhythmic events were registered in this group.

Conclusions

Approximately one tenth of patients develop persistent new-onset LBBB after TAVI. Events were seldom in both study groups. Positive EP study patients were dependent of ventricular stimulation in 12.5% of cases, and there was no bradyarrhythmic event registered in EP negative group. EP study could be a safe tool to stratify AVB risk in new-onset LBBB following TAVI.
Predictor of A4-amplitude using preprocedural electrocardiography in patients with leadless pacemakers
Authors: Kawatani S , Kotake Y , Takami A , Nakamura K , Tomomori T , Okamura A , Kato M , Yamamoto K
Published: October 2024

Background

Based on the historical studies of leadless pacemakers (LP), high atrio-ventricular synchrony (AVS) with mechanical sensing-based VDD pacing is largely influenced by A4-amplitude. A limited study investigated the predictors of A4-amplitude using clinical and echocardiographic parameters.

Objective

This study aimed to investigate the predictors of A4-amplitude preoperatively to select patients who could benefit the most from AVS among patients with VDD LPs.

Methods

Data from patients who received VDD LP implantations from November 2021 to August 2023 at our institution were analyzed. Twelve-lead electrocardiography and transthoracic echocardiography were performed before VDD LP implantations. To assess the electrical indices associated with the A4-signal, the electrocardiographic morphological P-wave parameters were analyzed including the P-wave duration, P-wave amplitude, maximum deflection index (MDI), and P-wave dispersion.

Results

A total of 50 patients who underwent VDD LP implantations (median age, 84 years; 64% male) were included and divided into two groups based on the median value of A4-amplitude, the high-A4 group (A4-amplitude >2.5m/s2, n=26) and low-A4 group (A4-amplitude ≤2.5m/s2, n=24). There was a significant difference between the high-A4 and low-A4 groups in the LVEF (P=0.01), P-wave dispersion (P=0.01), and MDI (P<0.001). A multivariate logistic analysis revealed that a lower MDI was an independent predictor of a high A4-amplitude (odds ratio: 0.78, 95% confidence interval: 0.67 to 0.92; P=0.003).

Conclusion

Preoperative electrocardiographic evaluations of the P-wave morphology may be useful for predicting A4-amplitude. The MDI was the only independent A4-amplitude predictor that seemed promising for selecting VDD LP patients.abstract figure
Discovering an unknown risk. The unnoticed, potientially life-threatening risk to people with an inherited cardaic arrhythmia during the non-cardiac perioperative period.
Authors: Mcglinchey L , Barr O , Cook N
Published: October 2024

Background

Patient safety is a global goal. Known risks to patient safety are a challenge however, that challenge is significantly increased when a risk is unknown but exists. It is estimated that 18 million major surgeries in Europe are non-cardiac surgical procedures. Preventable adverse events remain a challenge within healthcare systems worldwide. Potentially life-threatening conditions such as inherited cardiac arrhythmias (ICA) can be triggered by a number of factors during the perioperative phase. Healthcare professionals’ lack of knowledge, awareness or confidence about risks associated with ICAs during non-cardiac surgical procedures may have an impact on patient safety and quality of care for people with an ICA.

Purpose

To determine the knowledge and experience of ICA by healthcare professionals, their views towards and confidence in caring for a person with an ICA in a surgical environment.

Method

A multiple method study using a twenty-four-item questionnaire was distributed to registered nurses and midwives, surgeons and anaesthetists within surgical areas of seventeen hospitals in the Republic of Ireland and Northern Ireland of which 154 were returned and nine qualitative face to face interviews with registered nurses, midwives, and anaesthetists within surgical areas of one hospital in the Republic of Ireland and one hospital in Northern Ireland.

Results

Triangulation and convergence of data found a lack of knowledge in relation to inherited cardiac arrhythmias the study focused on, Long QT syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) and Brugada syndrome. Within this, it was reported that 88.4% of participants were not aware of the drugs to avoid lists. Of those who were aware, 11.6%, no surgeon reported being aware of the drugs to avoid lists. It was also reported that participants had no confidence to care for people with an ICA in surgical settings. Years since graduation did not equate to an increase in confidence to care for these conditions. Participants reported reliance on the anaesthetist to be knowledgeable, manage care or take the lead should an adverse event occur. However, only seven of the nineteen anaesthetists who took part were aware of the drugs to avoid lists for ICA.

Conclusions

This study has found a lack of knowledge and confidence relating to inherited cardiac arrhythmias in surgical settings. It also highlighted that anaesthetists are seen as the professional to go to, however they may be unaware of this. Many surgeries take place globally which have the potential to induce an adverse event in people with an ICA that may result in death. This study has found an unknown blind spot which is a serious patient safety issue and a hazardous medical risk factor.
Significance of J wave with inverted ST-T polarity induced by ill-timed atrial premature beats and its association with Torsade de Pointes in patients with acute acquired long QT syndrome
Authors: Ichiryu H , Takasugi N , Wakasa S , Ishihara T , Masuda Y , Naruse G , Watanabe T , Yamada Y , Kanamori H , Okura H
Published: October 2024

Background

When ventricular cardiomyocytes become depolarized during their relative refractory period (RRP), the amplitude of the action potential (AP) becomes lower than that of preceding AP, since some sodium channels are in their refractory state. If the membrane voltage does not reach a level high enough to activate voltage-dependent calcium channels, the AP duration becomes markedly shortened due to loss of AP dome. In patients with long QT syndrome (LQTS), intrinsic differences in AP duration and/or AP restitution kinetics exist between ventricular endocardium and epicardium. Thus, we hypothesized that atrial premature beats (APBs) can capture the RRP and amplify a transmural voltage gradient that manifests as a J wave with inverted ST-T polarity (APB-induced J wave).

Purpose

To investigate the prevalence of APB-induced J wave and examine the contribution to the development of Torsade de Pointes (TdP) in patients with acute acquired LQTS.

Methods

A total of 34 consecutive patients with acute acquired LQTS (14 men; median age, 69 years; median QTc, 645.5 ms) and documented TdP were enrolled. APBs were observed before the onset of TdP in 18 (52.9%) patients. The 34 patients were divided into 2 groups based on the presence or absence of APB-induced J wave with inverted ST-T polarity: APB-J wave group (n=8) and non-APB-J wave group (n=26).

Results

APB-J wave group constituted 23.5% (8/34) of the studied patients. There were no significant differences in clinical characteristics (sex, age and QTc) between the 2 groups. Macroscopic T-wave alternans was more frequently observed before TdP onset in APB-J wave group than non-APB-J wave group (75% vs 15.4%, p=0.003). The ill-timed APBs with J wave directly initiated TdP in all patients in APB-J wave group. APB-J wave group experienced TdP even after initiating conventional therapy more frequently than non-APB-J wave group (3.5 vs 1 event, p=0.04).

Conclusions

APB-induced J wave is observed in approximately one-fourth of acute acquired LQTS patients with TdP and is associated with an increased risk of TdP. Our observations suggest that APBs can amplify the transmural dispersion of repolarization manifested as a J wave.Figure1Figure2
Risk factors for fatal ventricular arrhythmias in heart failure with preserved ejection fraction: a report from the CHART-2 Study
Authors: Ito T , Noda T , Nochioka K , Shiroto T , Yamamoto N , Sato H , Chiba T , Hasebe Y , Nakano M , Takahama H , Takahashi J , Shimokawa H , Yasuda S
Published: October 2024

Background

Fatal ventricular arrhythmia events (FAE), such as sustained ventricular tachycardia (VT) and ventricular fibrillation (VF), along with sudden cardiac death (SCD), represent serious complications in patients with heart failure (HF). While individuals with severely reduced left ventricular ejection fraction (LVEF), particularly below 35%, are deemed at high risk for lethal arrhythmic events and are considered for implantable cardioverter-defibrillator (ICD) therapy, recent studies have highlighted the occurrence of FAE or SCD in heart failure with preserved ejection fraction (HFpEF) as well. However, the specific risk factors for FAE or SCD in patients with HFpEF remain inadequately elucidated.

Purpose

This study aimed to investigate the incidence of FAE or SCD and identify their associated risk factors in patients with HFpEF.

Methods

We retrospectively analyzed the data from our multicenter observational study, the CHART-2 Study, where a total of 10,219 patients were enrolled between 2006 and 2010. Among them, we included patients with HF and LVEF≥50% (n=2,423) with available LVEF data at one year (Figure 1A). They were categorized into two groups based on LVEF status; 198 with decreased LVEF (35-50%; D-group) and 2,225 with preserved LVEF (≥50%; P-group). The primary endpoint was the composite event of FAE or SCD, and all statistical analyses were adjusted for competing risks due to all-cause mortality.

Results

Among the 2,423 patients with HFpEF (mean age: 69±12 years, 35% female), 120 patients (5.0%) experienced the composite event of FAE or SCD during a median follow-up of 9.1 years (interquartile range: 4.5-11.2 years), with a cumulative incidence of 5.1% at 10 years. Gray’s test revealed a significantly higher incidence of the primary endpoint in the D-group compared with the P-group (10.6% vs. 4.5% at 10 years, p<0.001, Figure 2A). Multivariable analysis identified mild decline of LVEF (Hazard Ratio [HR] 2.20, 95% confidence interval [CI] 1.34-1.60; p=0.002) and non-sustained VT (HR 2.33, 95% CI 1.37-3.97; p=0.002) as independent risk factors for composite event. Landmark analysis demonstrated a consistent trend in the composite event of FAE or SCD in both groups (Figure 2B).

Conclusion

In patients with HFpEF, even a mild decline in LVEF, which typically does not prompt ICD consideration, was significantly associated with a heightened risk of FAE or SCD. Therefore, a chronological clinical assessment, encompassing changes in LVEF, is essential for patients with HFpEF.
Regional cardiac denervation predicts sustained ventricular arrhythmias in non-ischemic cardiomyopathy patients without LGE on CMR imaging
Authors: Jungen C , Chen S , Wijnmaalen A P , Dibbets-Schneider P , Piers S , Kimura Y , Androulakis A F A , Van Der Geest R , De Geus-Oei L , Scholte A H J A , Lamb H J , Jongbloed M R M , Zeppenfeld K
Published: October 2024

Background

In patients with non-ischemic cardiomyopathy (NICM) and no late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR), risk prediction for the occurrence of sustained ventricular arrhythmias (VA) is challenging. Global and regional sympathetic denervation has been associated with VA in patients with ischemic cardiomyopathy. Its prognostic relevance in NICM is unknown.

Purpose

To assess the risk prediction of sympathetic denervation for the occurrence of VA in NICM patients without LGE.

Methods

Consecutive patients from the ‘Leiden Nonischemic Cardiomyopathy Study’, who underwent programmed electrical stimulation, LGE-CMR and 123I- MIBG imaging between 2011-2018 were included. The presence of LGE and global and regional sympathetic denervation on 123I- MIBG was evaluated and patients were followed for occurrence of VA. Global denervation was assessed using the heart-to-mediastinum ratio. Regional denervation was evaluated by calculating the number of denervated segments (DS), the ratio of DS, the summed defect score and the weighted denervation size.

Results

Of 75 included patients (63 years [52-68], 79% male, LVEF 36% [27-44], 37% inducible for VA) 35 had no LGE. During 4.5±1.6 years follow-up, VA occurred in 8/35 (23%) patients without LGE and in 18/40 (45%) patients with LGE. Among patients without LGE, those with VA had greater regional sympathetic denervation (number of DS 8 [8-10] vs. 2 [1-5], P=0.004; ratio of DS 0.5 [0.5-0.7] vs. 0.2 [0.1-0.4], P=0.007; defect score 36 [31-41] vs. 18 [14-24], P=0.01; weighted denervation size 47 [39-53] vs. 22 [16-30], P=0.01).

In univariable analysis the number of DS (HR 1.25, 95% CI 1.06–1.46, P=0.006) was associated with the occurrence of VA in patients without LGE. Denervation of ≥ 7 segments identified patients without LGE at risk for VA (AUC: 0.83, sensitivity: 88%; specificity: 89%). Among patients with LGE, innervation state was not associated with VA during follow-up.

Conclusions

In NICM patients without LGE the extent of regional denervation may contribute to risk stratification for VA.Graphical Abstract
A risk score for ventricular arrhythmia in mitral valve prolapse
Authors: Syed F , Diamond J , Cesmat A , Chaudry A , Gupta S , Weickert T , Simpson R
Published: October 2024

Background

Prior studies have identified that complex and frequent ventricular ectopy (cfVE) predicts sudden death in patients with mitral valve prolapse (MVP).

Purpose

To develop a risk stratification score which predicts rates of cfVE in patients with MVP based on clinical, ECG and echocardiographic features.

Methods

Data was collected on 637 patients aged 18–90 years with MVP at our institution between 2016-2019. Complex and frequent ventricular ectopy was defined as the presence of > 1% premature ventricular contraction (PVC) burden or non-sustained ventricular tachycardia on Holter monitoring or > 1 PVC on 12-lead ECG. Univariate analysis was performed to identify independent predictors of cfVE. Factors found to be statistically significant on univariate analysis were then evaluated using multivariate logistic regression. Variables analyzed included age greater than 65, moderate or greater mitral regurgitation, female gender, African American race, atrial fibrillation, coronary artery disease, congestive heart failure, inferior or lateral T wave inversion, bileaflet (vs. unileaflet) prolapse, myxomatous mitral valve morphology, mitral annular dysjunction, left ventricular ejection fraction less than 40%, left ventricular hypertrophy, diabetes, and hypertension. Risk points were attributed to multivariate predictors of cfVE using their odds ratios. Predicted probability of cfVE, derived by logistic regression, was used to categorize scores into low, moderate, and high risk. Rates of cfVE were compared between risk groups using Pearson’s Chi-squared test. All-cause mortality was compared between risk score groups with Kaplan-Meier analysis.

Results

Complex and frequent ventricular ectopy was present in 182 (28.6%) patients. Multivariate predictors of cfVE were mitral annular disjunction (MAD, OR 3.2, 95% CI 1.9-5.4), bileaflet (vs. unileaflet) prolapse (OR 2.1, 95% CI 1.4-3.3), congestive heart failure (OR 2.2 95% CI 1.3-3.7) and inferior or lateral T wave inversion (TWI, OR 2.1, 95% CI 1.3-3.2). Risk points of 1.5 for MAD and 1 for bileaflet prolapse, CHF and TWI were totaled to group patients into low (score 0, n=274, 43.0%), moderate (score 1-2, n=276 ,43.3%) and high (score 2.5-4.5, n=87,13.7%) risk groups. Rates of cfVE were 11.7% for low, 35.5% for moderate and 59.8% for high-risk groups (p<0.0001). On Kaplan Meier analysis, risk group significantly correlated with mortality (p<0.0008).

Conclusion

In patients with MVP this risk stratification tool, using the presence of mitral annular disjunction, bileaflet prolapse, history of congestive heart failure and T-wave inversion, represents a viable method of predicting risk of cfVE, which correlates with all-cause mortality.Univariate and multivariate analysisKaplan-Meier Curve
Targeting ventricular tachycardia originating from the anterolateral papillary muscle with stereotactic body radioablation therapy
Authors: Khaykin Y , Comsa D , Le K , Gao-Kang J , Pirbaglou M , Sadek M , Pantano A , Taremi M
Published: October 2024

Background

Ventricular Tachycardia (VT) is prevalent in the setting of non-ischaemic cardiomyopathy (NICM), a heterogeneous group of conditions characterized by myocardial dysfunction in the absence of coronary artery disease. Challenges of catheter ablation to treat VT in NICM patients are well known, and recurrence rates can be as high as 58%. Stereotactic body radioablation therapy (SBRT) involves precise delivery of radiation to arrhythmogenic substrates, and represents a novel treatment to reduce recurrent implantable cardioverter defibrillator (ICD) therapies in patients with refractory VT. Though SBRT has shown preliminary effectiveness in reducing VT episodes, its effectiveness in NICM patients has not been widely evaluated.

Purpose

To evaluate SBRT effectiveness in NICM patients with scars at the basal anterolateral papillary muscle at a tertiary care center between November-December 2022.

Methods

Eligible patients had their VT substrate mapped using a single-use ECGI vest and a 4D-CT simulation scan. In addition, MRI scans were used to aid anatomical identification of the anterolateral papillary muscle which could not be seen on the non-contrast diagnostic CTs. SBRT was delivered in a single fraction of 25 Gy under image guidance. Effectiveness of the treatment was evaluated as changes in frequencies of total antitachycardia pacing (ATP) and ICD shock episodes from 6 months pre-, and within to 3, 6, and 12 months follow up post SBRT.

Results

Participants were 3 males with NICM, aged 56, 60, and 73 with previous dual chamber ICD implantation, 2 of whom had a history of VT ablation/ VT storm and paroxysmal atrial fibrillation. All participants had basal lateral scar, and were receiving beta blockers, mexiletine, and amiodarone with refractory VT before SBRT treatment. Prior to SBRT, ICD device interrogation showed a total of 119 (77, 7, and 35 in patients 1-3 respectively) ATPs, and 27 (10, 1, and 16 in patients 1-3 respectively) ICD shocks delivered. At 12 month follow-up, none of the participants experienced any episodes of ATP or ICD shock. Ejection fraction remained consistent pre-post SBRT.

Conclusion

SBRT showed remarkable success in reducing ATP and ICD shock episodes, facilitating uncomplicated 1 year follow-up in 3 male patients with NICM and VT from the anterolateral papillary muscle.
The effect of afterload on right ventricular pacing-induced left ventricular dysfunction: a translational study
Authors: Ruppert M , Lakatos B K , Balint T , Nagy D , Ladanyi Z S , Sayour A A , Olah A , Barta B A , Molnar L , Osztheimer I , Straub E , Zima E , Geller L , Radovits T , Merkely B
Published: October 2024

Introduction

Right ventricular (RV) pacing (RVP) impairs left ventricular (LV) function. Nevertheless, the interaction between arterial afterload and RVP-associated LV dysfunction has not been investigated yet.

Purpose

We sought to examine the effect of afterload on RVP-evoked LV hemodynamic changes in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) as well as in a small animal model of sustained LV pressure overload (PO).

Methods

Thirty-five patients with AS and a previously implanted pacemaker underwent detailed echocardiographic examination immediately before TAVI and also on the second postoperative day. The ultrasound measurements were carried out during intrinsic, narrow QRS rhythm and during frequency-matched RVP as well. Global myocardial work index (GMWI) was calculated to assess LV contractility. In parallel, LV pressure-volume analysis was performed in Wistar rats with transverse aortic constriction (TAC) or sham operation (Sham) during intrinsic narrow QRS rhythm (termed as TAC-Vsense and Sham-Vsense) as well as during RVP (termed as TAC-Vpace and Sham-Vpace). RVP was achieved in rats by an octopolar electrophysiology catheter placed in the RV.

Results

RVP decreased LV contractility in AS patients before and after TAVI as well. Nevertheless, the extent of RVP-evoked LV dysfunction was alleviated following pressure unloading (ΔGMWI: -37±7 vs. -25±8%, before TAVI vs. after TAVI, P<0.05). Similarly, although RVP was associated with reduced LV contractility in both the TAC (the slope of the maximum rate of LV pressure rise-end-diastolic volume relation [dPdtmax-EDV]: 92±8 vs. 53±6mmHg/s/µl, TAC-Vsense vs. TAC-Vpace; P<0.05) and Sham groups (dPdtmax-EDV: 74±5 vs. 60±9 mmHg/s/µl, Sham-Vsense vs. Sham-Vpace; P<0.05), the negative inotropic effect of RVP was found to be stronger in the TAC compared to the Sham group (ΔdPdtmax-EDV: -42±4 vs. -19±6%; TAC vs. Sham, P<0.01). Furthermore, reduction of the maximal rate of LV pressure decrease (ΔdPdtmin: -20±3 vs. -5±5%, TAC vs. Sham, P<0.01) and prolongation of the active relaxation time constant (Δτ: 22±3 vs. 6±3%, TAC vs. Sham, P<0.01) also occurred to a greater extent in case of sustained LV PO, indicating augmented diastolic dysfunction.

Conclusion

Our translational results indicate that RVP-induced LV dysfunction might be afterload dependent.