bluuebunny/crossref_metadata_2025 huggingface dataset:
Microelectrode voltage mapping for substrate assessment in catheter ablation of ventricular tachycardia: a dual-center experience
Authors: Compagnucci P , Dello Russo A , Bergonti M , Cipolletta L , Parisi Q , Volpato G , Colonnelli M , Saenen J , Valeri Y , Carboni L , Marchese P , Marini M , Sarkozy A , Natale A , Casella M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The assessment of the ventricular myocardial substrate critically depends on the size of mapping electrodes, their orientation with respect to wavefront propagation, and interelectrode distance.

Objective

we conducted a dual-center study to evaluate the impact of microelectrode mapping in patients undergoing catheter ablation (CA) of ventricular tachycardia (VT).

Methods

We included 21 consecutive patients (median age, 68 [12], 95% male) with structural heart disease undergoing CA for electrical storm (n=14) or recurrent VT (n=7) using the QDOT Micro catheter and a multipolar catheter (PentaRay, n=9). The associations of peak-to-peak maximum standard bipolar (BVc) and minibipolar (PentaRay, BVp) with microbipolar (BVμMax) voltages were respectively tested in sinus rhythm with mixed effect models. Furthermore, we compared the features of standard bipolar (BE) and microbipolar (μBE) electrograms in sinus rhythm at sites of termination with radiofrequency energy.

Results

BVμMax was moderately associated with both BVc (β=0.85, p<0.01) and BVp (β=0.56, p<0.01). BVμMax was 0.98 (95% CI, 0.93-1.04, p<0.01) mV larger than corresponding BVc, and 0.27 (95% CI, 0.16-0.37, p<0.01) mV larger than matching BVp in sinus rhythm, with higher percentage differences in low voltage regions, leading to smaller endocardial dense scar (2.3 [2.7] vs. 12.1 [17] cm2, p<0.01) and border zone (3.2 [7.4] vs. 4.8 [20.1] cm2, p=0.03) regions in microbipolar maps compared to standard bipolar maps. At sites of VT termination (n=14), μBE were of higher amplitude (0.9 [0.8] mV versus 0.4 [0.2] mV, p<0.01), longer duration (117 [66] ms versus 74 [38] ms, p<0.01), and with greater number of peaks (4 [2] versus 2 [1], p<0.01) in sinus rhythm compared to BE.

Conclusions

Microelectrode mapping is more sensitive than standard bipolar mapping in the identification of viable myocytes in SR, and may facilitate recognition of targets for catheter ablation.
Clinical outcomes and procedural characteristics of ventricular tachycardia ablation in patients with or without electrical storm
Authors: Nagy Z , Szonyi M , Csakany L , Major T , Mladoniczky S , Kassa K , Som Z , Foldesi C , Kardos A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Electrical storm (ES) is a life-threatening clinical condition characterized by the recurrence of three or more episodes of ventricular tachycardia (VT) and/or ventricular fibrillation within 24 hours, leading to ICD therapy. Catheter ablation of VT in patients with ES is a high-risk procedure but has been shown to reduce VT recurrence and the number of appropriate ICD therapies in patients with structural heart disease.

Purpose

Our study aimed to compare the characteristics and outcomes of VT ablation in patients with or without ES.

Methods

Our single-center study included a cohort of 39 consecutive patients (31 men, mean age=60.9±18.4 years) who underwent VT ablation between January 2020 and January 2022, 21 of them (53.8%) due to ES and 18 patients (46.2%) had an elective procedure. Clinical and procedural characteristics, VT recurrence, and mortality rates were compared between the two groups.

Results

Patients with ES were older than patients without ES (67.8 vs 54.2 years, p=0.004), they were mainly presented with ischaemic cardiomyopathy (85.7% vs 27.8%, p<0.0001), had a higher prevalence of congestive heart failure (90.5% vs 44.4%, p=0.001) and a more severe left ventricular dysfunction (LVEF: 30.8% vs 46.9%, p=0.002). During the procedure, in the ES group, all of the patients had left-sided ablation (transaortic: 80.9%, transseptal: 19.1%), while in patients without ES, 72.2% of the procedures were left-sided (p=0.04). In 8/39 patients (20.5%) endo-epicardial access was needed. The number of RF ablation points was significantly higher in the ES group (64.1 vs 36.1 points, p=0.01). Complications were detected only in the ES group: intraprocedural death occurred in one case due to an ES and consequently cardiogenic shock, and one patient had a dissection of the right femoral artery. There was no significant difference regarding procedure time, fluoroscopy time, and radiation exposure. The in-hospital 30-day mortality was 8/21 (28.6%) in patients with ES, while no patients died in the non-ES group. During longer clinical follow-up, there was no significant difference in the recurrence of VT episodes and mortality.

Conclusion

Patients presented with ES are a more vulnerable population with many comorbidities. Catheter ablation of VT in patients with ES is a more complex procedure with a higher complication rate and these patients have a higher risk of in-hospital mortality. Further studies are needed to determine the optimal timing of VT ablation in this patient population.
Omnipolar mapping in ventricular tachycardia: will it be a game changer?
Authors: Ascione C , Kowalewski C , Bouyer B , Tixier R , Chauvel R , Yokoyama M , Cohet H , Duchateau J , Pambrun T , Derval N , Tondo C , Hocini M , Haissaguerre M , Jais P , Sacher F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular tachycardias(VT) are life-theatening cardiac arrhythmias. Catheter ablation, the standard approach to VT is relying heavily on maps depicting intracardiac signals. The current mapping approach was based on bipolar electrograms, which are massively influenced by the direction of the underlying tissue activation. The omnipolar (OT) electrogram method was recently proposed to generate orientation-independent electrograms and has shown improved results in recent publications (1-2). We describe the first cohort of patients ablated for VT with the help of an OT-enabled catheter.

Purpose

To evaluate acute and mid-term follow-up of patients ablated for VT using an OT enabled mapping system.

Methods

Eighteen patients (age 65 ± 19; 2 females, 32% nonischemic, median ejection fraction 40), underwent catheter ablation for scar-related VT. 50% (9) n patients had previous ablation, 4 of which underwent epicardial access. High-density omnipolar maps were obtained with an HD-grid catheter after which ablation was performed with an irrigated-tip catheter. In all patients the ablation was primarily substrate-based with the support of CT scan scar visualization. In 18 patients local abnormal ventricular activities (LAVA) ablation was performed (3), while one patient showed no LAVA. In 7 patients VT mapping was possible due to stable blood pressure during the tachycardia. The median radiofrequency application duration was 36 min. While all patients except one were inducible at the beginning of the procedure, only 3 patients were inducible at the end with a protocol using up to 3 extrastimuli. Follow-up was available in 13 patients (7.1 ± 2.5 months) with 66% freedom from VT recurrence (60% in redo cases and 71% in first procedures).

Conclusion

OT is a reliable method to visualize signals and perform a substrate-based ablation in with good acute and mid-term outcomes. Future studies will evaluate the impact on long term outcomes.
The phospholamban (PLN) p.Arg14del risk model; Longitudinal validation and reevaluation of predictors regarding sudden cardiac death (SCD)
Authors: Van Der Heide M Y C , Verstraelen T E , Van Lint F H M , Bosman L P , De Brouwer R , Proost V M , Germans T , Dickhoff C , Schoonderwoerd B A , Houweling A C , Gimeno-Blanes J R , De Boer R A , Cox M G P J , Van Tintelen P , Wilde A A M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): PSIDER (ZOn-MW)

PREDICT2 (Hartstichting)

Background

The PLN p.Arg14del risk model is a mutation-specific risk model developed to predict individual malignant ventricular arrhythmia (VA) risk to inform decision-making for primary prevention implantable cardioverter defibrillator (ICD) implantation. While the risk model has proven to be valid, two main points of criticisms remain to be discussed: first, the risk model is only validated at baseline and second, appropriate ICD therapy and sustained ventricular tachycardia (VT) <250 bpm is an imperfect surrogate outcome for SCD.

Purpose

To evaluate the diagnostic performance of the PLN p.Arg14del risk model longitudinal at 3 year follow-up and to reevaluate the predictors regarding SCD.

Methods

Clinical data of 278 PLN p.Arg14del mutation carriers with no history of malignant VA at both baseline and 3 year follow-up were collected. During a median follow-up of 4 years (Interquartile range (IQR) 1.8-6.5), 31 (11%) carriers experienced malignant VA, defined as sustained VA, appropriate ICD intervention, or (aborted) SCD. The reevaluation of the predictors with the 3 year follow up data revealed hazard ratio’s (HR) that were similar to the baseline PLN p.Arg14del risk model for left ventricular ejection fraction (HR 1.10 [95% CI, 1.06-1.12], p<0.001), low-voltage ECG (HR 12.24 [95% CI, 5.21-28.8], p<0.001) and the PVC count per 24h (HR 1.51 [1.15-1.98], p=0.003). The 5-year malignant VA risk was divided into tertiles of predicted risk. The tertiles clearly demonstrated good discrimination between risk group as shown in figure 1 and this resulted in an C-statistic of 0.85 (95% CI 0.78-0.92).

To reevaluate the predictive performance of the PLN p.Arg14del risk model for a more strict surrogate of SCD we redefined the outcome as VT >250 beats per minute sustained (lasting ≥30 seconds) or terminated by ICD, ventricular fibrillation, aborted SCD and SCD. We included 669 PLN p.Arg14del carriers with no presentation or history of sustained VA or (aborted) SCD. During a median follow-up of 4.75 years (IQR 1.9-7.9), 33 (5%) carriers experienced the outcome. Results of the univariable analysis are shown in table 1. The PLN p.Arg14del risk model yielded a C-statistic of 0.75 (95% CI 0.70-0.80). Adding risk factors sex, age and sustained VT <250 bpm did not change its performance.

Conclusion

The PLN p.Arg14del risk model was validated longitudinal at 3 year follow-up and it held its performance with a more strict definition of SCD.
Biventricular strain dyssynchrony analysis of left bundle branch area pacing: a prospective, observational study
Authors: Dell'era G , Ghiglieno C , Degiovanni A , De Vecchi F , Porcellini S , Santagostino M , Veroli A , D'amico A , Spinoni E G , Patti G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Left bundle branch pacing (LBBAP) seems to carry advantages compared to His bundle pacing, such as superior electrical performances and less steep learning curve. Aim of this study was to evaluate technical feasibility, safety, electrical parameters and ventricular synchrony with LBBAP.

Methods

We prospectively enrolled patients receiving LBBAP, such as those with preserved (>50%) left ventricular ejection fraction (LVEF) and narrow QRS, with preserved LVEF and wide QRS, and with LVEF <50%. Electrocardiogram and electrical parameters were evaluated at implant, 24 hours and 3 months. Echocardiographic evaluation was carried out at baseline and after 3 months. Ventricular synchrony was analyzed by time-to-peak-standard-deviation (TPSD) of strain curves of both ventricles.

Results

We enrolled a total of 58 patients, in whom, according to currently validated criteria, LBBAP was successful in 56 (97%) patients. In the overall population mean baseline QRS duration was 124.1±30.7 msec, while paced QRS duration was 107.7±13.6 msec (p < 0.001). LVEF improved from 52.9±10.5% to 56.9±8.4%, (p=0.004). Improvement was also observed for interventricular synchrony, by reduction of TPSD difference between LV and RV from 27.9 (10.2–41.5) to 13.9 (4.3-28.7) (p=0.001), and for LV synchrony, by decrease of TPSD delta between LV segments from 38.2 (13.6–53.9) to 15.1 (8.3–31.5) (p <0.001). Ameliorations were consistent in all patient subgroups, irrespective of QRS duration or LVEF.

Conclusion

LBBAP improves LVEF and both intraventricular (LV) and interventricular (LV-RV) synchronization, irrespective of pacing indication, baseline QRS duration and LV function.
Depolarization-repolarization synchrony after right ventricular and left bundle branch area pacing
Authors: Sales Belles C , Melero Polo J , Cabrera Ramos M , Minchole Lapuente A , Pueyo Paules E , Ramos Maqueda J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): TED2021-130459B-I00 LMP94_21

Introduction

Left bundle branch area pacing (LBBAP) has been recently proposed to overcome the limitations associated with right ventricular pacing (RVP) and has been suggested as a new physiological pacing form with high feasibility and safety. A greater difference between QRS complex and T-wave angle directions has been proposed as a marker of abnormal electrical activity in several patient populations, but a comparison between these two pacing modalities has never been performed. The total cosine R to T (TCRT) is an ECG descriptor that accounts for depolarization-repolarization synchrony by measuring the difference between their directions. The purpose of this study was to compare TCRT in patients referred for RVP and LBBAP pacing as anti-bradycardia therapy.

Methods

ECG recordings from 134 patients (82 LBBAP, 52 RVP) were classified into two groups, narrow QRS and wide QRS, depending on the patient’s QRS duration prior to implantation. In the post-implantation state, the TCRT index was calculated from a median beat calculated for each patient. Singular value decomposition was applied to the median beat in the eight independent ECG leads (I, II, V1, V2, V3, V4, V5, V6). The QRS complex and T wave loops in a three-dimensional space were determined from the first three components of the decomposition. TCRT was computed as the average of the cosines of the angles between the QRS complex directions and the maximum T wave direction. More positive values corresponded to more synchronized depolarization and repolarization processes while more negative values indicated larger differences in the orientation of the QRS and T wave loops and, therefore, greater dyssynchronization.

Results

showed that TCRT took negative values for both techniques, RVP and LBBAP, and both groups, narrow and wide QRS, indicating that pacing generated dyssynchronization between ventricular depolarization and repolarization. Nevertheless, TCRT values for both groups were significantly more negative (p<0.01) for RVP than for LBBAP. We hypothesize that cardiac memory induced by pacing could account for these negative TCRT values. In any case, LBBAP did not increase the difference in the QRS complex and T wave loop orientations as much as RVP.

Conclusion

LBBAP induces less dyssynchrony than RVP in the depolarization-repolarization process.
Amiodarone does not significantly affect the success rate of ventricular fibrillation induction tests performed during or after ICD implantation. Insights from the German DEVICE registry
Authors: Wiedmann F , Ince H , Stellbrink C , Kleemann T , Eckardt L , Brachmann J , Gonska B D , Kaab S , Perings C A , Jung W , Lugenbiel P , Hochadel M , Senges J , Frey N , Schmidt C
Published: May 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The DEVICE registries were financed by “Stiftung Institut für Herzinfarktforschung (IHF)”, with additional support by grants from Biotronik, Medtronic, and St. Jude Medical.

Background

Experimental data and early clinical trials suggested that amiodarone may alter the defibrillation threshold of ICD systems. However, because of its potent antiarrhythmic effect and lack of alternatives, amiodarone is frequently used for antiarrhythmic therapy in ICD or CRT-D patients, leading to the question of whether ICD testing with ventricular fibrillation induction should be repeated in these patients after starting amiodarone.

Objective

This study was designed to assess the impact of amiodarone therapy on the success of ventricular fibrillation induction tests in this "real life" cohort of ICD recipients of the German DEVICE registry.

Methods

3,680 patients who underwent ICD implantation, revision, or upgrade in 49 centers participating in the German DEVICE Registry were enrolled 03/2007-02/2014.

Results

Intraoperative defibrillation testing was conducted in 2,705 patients receiving only beta-blockes as antiarrhythmic therapy and in 422 patients under betablocker plus amiodarone therapy. With regard to ineffective defibrillation tests, no difference could be described between the two groups (0.6% vs. 0.5%; p=0.77). In a similar fashion 488 patients receiving beta-blockers only and 65 patients under beta-blocker plus amiodarone therapy who were scheduled for postoperative defibrillation testing showed comparable rates of ineffective testing (14.5% vs. 15.4%; p=0.86).

Conclusions

Based on 3,127 intraoperative and 553 postoperative defibrillator testings, our study failed to show a significant association of amiodarone therapy and ineffective defibrillator testings in this "real life" cohort of ICD recipients of the German DEVICE registry. Our results thus underline that, apart from special situations such as right-sided implantation, HCM, extravenous ICD systems, etc., it might not be necessary to perform a DFT test after the start of an amiodarone therapy in ICD patients.
Prediction of all-cause mortality using a multisensor implantable defibrillator algorithm for HF monitoring
Authors: D'onofrio A , Manzo M , Bertini M , Santini L , Savarese G , Dello Russo A , Santobuono V E , Lavalle C , Viscusi M , Amellone C , Calvanese R , Santoro A , Ziacchi M , Valsecchi S , Calo L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The HeartLogic algorithm combines multiple implantable defibrillator (ICD) sensor data and has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Purpose

We determined if remotely monitored data from this algorithm can be used to identify patients at high risk of mortality.

Methods

The HeartLogic feature was activated in 568 ICD patients from 26 centers.

Results

During a median follow-up of 26 months [25th–75th percentile: 16-37], 1200 HeartLogic alerts were recorded in 370 (65%) patients. Overall, the time IN the alert state was 13% of the total observation period (151 out of 1159 years) and 20% of the follow-up period of the 370 patients with alerts. During follow-up, 55 patients died (37 in the group with alerts). Experiencing any alert episode was associated with a substantially increased risk of death [hazard ratio (HR): 2.08, 95% confidence interval (CI): 1.16–3.73, P = 0.039]. Additionally, a time IN alert ≥20% was associated with death (HR: 4.07, 95%CI: 2.19-7.54, p<0.001, Figure), even after multivariate correction for age, atrial fibrillation on implantation, chronic kidney disease, ischemic cardiomyopathy (HR: 3.26, 95%CI:1.87-5.70, p<0.001). The rate of death was 0.25/patient-year (95%CI: 0.17-0.34) with the HeartLogic IN the alert state and 0.02/patient-year (95%CI: 0.01-0.03) OUT of the alert state, with an incidence rate ratio of 13.72 (95%CI: 7.62-25.60, p<0.001).

Conclusions

The HeartLogic algorithm provides an index that can be used to identify patients at higher risk of all-cause mortality. The index status identifies periods of significantly increased risk of death.
Device-related infection in a large tertiary center-Benefit of the antibacterial envelope
Authors: Hofer D , Avdi D , Ruegg P , Saguner A M , Molitor N , Breitenstein A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac implantable electronic device (CIED) infection carry a high morbidity and mortality. According to current data, the risk for a device-related infection is in a range of 0.6-3.4 % due to the latest EHRA consensus practical guide (reference 1). The use of an antibacterial envelope was associated with a reduced risk for infection in a large randomized trial (reference 2).

Methods

Retrospective analysis of the one-year risk of device-related infections in a large tertiary center in Switzerland during the time period of 2014-2019 (period A where the antibacterial envelope used only occasionally) in comparison to the risk of infection during the year 2020 (Period B, one year where in all device-interventions an antibacterial envelope was used). The presence of a local or systemic, device-related infection was counted as an infection event.

Results

In this retrospective analysis from two large Swiss implantation centres, a total of 1776 patients were included from the time period 2014-2020. 1’457 derived from period A (2014-2019) where the antibacterial envelope was only used in 2.6 % of the interventions compared to period B with 319 patients where in all interventions the envelope was present. There were no demographic or baseline characteristic differences between the two groups (table 1) except for the presence of a larger population of patients suffering from valvular heart disease (30.3 % during period A versus 10.8 % during period B) but without an relevant difference in the use of anticoagulation. The risk for device-related infection during period A was 0.96 % (N=14) versus only 0.63 % (N=2) during time period B which equals a relative risk reduction of 34.8 %.

Conclusions

The use of the antibacterial envelope during device-interventions was associated with a 34.5% relative risk reduction in a large tertiary Swiss center. Keeping in mind the potential additional burden of device-infection related treatment, it is of paramount importance to reduce the risk for device-associated infections.
A Novel Antibiotic Delivery Approach for Salvage of Cardiovascular-Implantable Electronic Devices with Localized Infection
Authors: Chorin E , Topaz M , Schwartz A L , Hochstadt A , Shotan A , Ashkenazi I , Kazatsker M , Nof E , Beinart R , Glikson M , Mazo A , Milman A , Banai S , Rosso R , Viskin S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Present guidelines endorse complete removal of cardiovascular-implantable electronic devices (pacemakers/defibrillators), including extraction of intracardiac electrodes, not only for systemic infections but also for localized "pocket infections."

Objectives

We evaluated the efficacy of delivering "Continuous, In-situ-Targeted, ultra-high concentration of Antibiotics" (CITA) into the infected subcutaneous the device-pocket, obviating the need for device/lead-extraction.

Methods

The CITA-Group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, nine patients declined lead-extraction because of prohibitive operative risk, and six patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction but opted for CITA treatment, were compared to 81 patients with pocket infection and similar characteristics who underwent device/lead-extraction as primary therapy.

Results

Eighty patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (68/80) patients, who remained free of infection (median follow-up: 3 years, interquartile range 1 – 6.8 years). In the case-control study of CITA vs. device/lead extraction, cure rates were higher after device/lead-extraction than after CITA [96.2%; (78/81) vs. 84.6%; (55/65), p=0.027]. However, rates of serious complications were also higher after extraction [12 (14.8%) vs. 1 (1.5%), p=0.005]. All-cause 1-month and 1-year mortality were similar for CITA and device/lead-extraction (0% vs. 3·7%, p=0·25 and 12·3% vs. 13·6%, p=1·00, respectively). Extraction was avoided in 90·8% (59/65) extraction-eligible patients treated with CITA.

Conclusions

CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction.
Sequential use of different mechanical rotational tools greatly improves success of lead extraction
Authors: Bracke F , Rademakers L M , Verberkmoes N J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Both Evolution RL and Tightrail mechanical rotational tools (MRT) have shown good success rates with low complication rates for lead extraction.

Purpose

To demonstrate the incremental value of switching between the two MRT devices to improve outcome.

Methods

We performed a retrospective single centre study of consecutive lead extractions from the time when both devices were available, and in whom at least one MRT device was used as primary extraction tool. If the initial MRT device did not show any progress after a prolonged attempt, we switched to the other tool. If still unsuccessful, or leads became unsuitable for MRT extraction, a femoral back up with the Needle’s Eye snare was attempted. We consider the outcome on a per lead basis.

Results

From 1/2015 till 9/2022, at least one MRT device was the primary extraction tool in 162 pts (median age 71.7 [64.1 - 78.5], 28.4% female, 49.9% ICD patients, indication infection 95.7%). MRT was used in 243 of 405 leads implanted for more than 1 year. A Tightrail was used as back up in 15 leads (9.7%) of 155 Evolution attempts, augmenting clinical successful outcome from 81.3% to 91.0%. An Evolution served as back up in 10 leads (11.4%) of 88 Tightrail procedures, increasing clinical successful outcome from 77.3% to 88.6%. After femoral bail out the clinical successful outcome increased respectively to 98.1% and 98.9% for Evolution RL and Tightrail primary attempts. Major complications occurred in 2 pts with the Evolution RL (one intrapericardial tear; the second a late tamponade possibly from a perforated temporary pacing lead), in none with the Tightrail. There were no complications after switching tools.

Conclusion

Switching between MRT devices can be very effective in case of stalled progress during lead extraction.
Comparison between thoracic ultrasound and chest x-ray in non-infective early complications detection after cardiac implantable electronic devices implantation procedures
Authors: Floris R , Guerra F , Dell'era G , Pimpini L , Ghiglieno C , Fais L M , Cucco A , Faggioni A , Claretti C , Orru F , Demontis M V , Dello Russo A , Delogu G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

In the immediate postoperative of cardiac implantable electronic devices (CIED) implantation procedures, literature and practice suggest the use of chest radiography as a gold standard diagnostic tool for early local complications such as pneumothorax, hemothorax and pericardial effusion. The introduction of bedside thoracic ultrasound into clinical practice guarantees a tool that is easy to use and highly appropriate for the early diagnosis of pleural pathologies. However, its use in the context of cardiac stimulation is not yet validated and is not mentioned in international consensus documents.

Purpose

The purpose of this study was to evaluate the rate of early mechanical complications in the post-implantation of cardiac stimulation devices and to compare the diagnostic power of the two methods.

Methods

397 consecutive patients who underwent intracavitary device implantation or upgrade with the puncture of a central venous vessel were prospectively enrolled in a multicenter study from November 1, 2021, to September 30, 2022. In the two days following surgery, all patients underwent chest radiography, when possible in the supine position, and chest ultrasound at the patient's bed to detect early complications of the implantation.

Results

Acute mechanical complications following the implantation of CIED accounted for 5.3%, of which 13 were pneumothorax (3.3%), in over 92% of cases of mild degree. The diagnosis was made by chest ultrasound alone in 10 cases (77%), in 2 cases (15.3%) by radiography alone and in 1 case (7.7%) by both methods (p-value 0.006). In 3 patients it was necessary to place a pleural drainage, in 2 cases the diagnosis was made with ultrasound alone and in 1 case with radiography alone (p=ns).

Eight pericardial effusions (2%) were also observed, all of a mild degree, diagnosed exclusively with ultrasound methods and did not require drainage. No cases of hemothorax were observed.

Conclusion

In our experience, thoracic ultrasound performed at the patient's bed following the implantation of a CIED has a diagnostic power superior to standard chest radiography in diagnosing early mechanical complications of the procedure, without subjecting the patient to early mobilization or ionizing radiation.
Single center experience with a novel short rotating dilator sheath in transvenous lead extraction
Authors: Hofer D , Frei C , Steffel J , Breitenstein A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Transvenous lead extraction has become a frequent procedure in the context of device lead management and various tools are available. The aim of this study was to investigate the efficacy and safety of the novel short rotating dilator sheath TightRailTM Sub-C (Sub-C) designed to facilitate vessel entry in the beginning of a transvenous lead extraction procedure necessitating active mechanical extraction tools.

Methods

For this retrospective single center analysis, we included consecutive patients undergoing transvenous lead extraction using the Sub-C from January 2018 until February 2020 at a university heart center.

Results

A total of 87 leads were extracted within 45 patients using the Sub-C extraction sheath. The mean dwell time of the leads was 112 ± 9.1 months. Complete procedural success was achieved in 95.6% (43/45) and clinical procedural success in 97.8% (44/45). Two major complications (4.4%, 2/45, 1 device pocket bleeding, 1 hemothorax) occurred, but neither were directly related to the Sub-C.

Conclusion

The TightRailTM Sub-C appears to be a safe and efficient short rotating dilator sheath for achieving vessel entry in the beginning of a transvenous lead extraction procedure.
Non-invasive electrocardiographic mapping using an endo-epicardial system based on extracellular potentials shows better accuracy for atrial arrhythmias than ventricular arrhythmias
Authors: Parreira L , Carmo P , Marinheiro R , Amador P , Mesquita D , Pinho J , Marques L , Nunes S , Chambel D , Zubarev S , Chmelevsky M , Ferreira A , Adragao P
Published: May 2023

Funding Acknowledgements

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

Background and aim

Electrocardiographic imaging (ECGI) is capable of performing an activation map with a single beat. The endo-epicardial system based on extracellular potentials allows for the reconstruction of endo-epicardial potentials both in the ventricles and the atria. The aim of this study was to compare the accuracy of the system to predict the site of origin (SOO) of ventricular focal arrhythmias (VAs) versus atrial focal arrhythmias (AAs).

Methods

We studied 55 consecutive patients referred for ablation of VAs or AAs that had an ECGI performed before ablation. Ablations were performed with remote magnetic navigation or manually. The localization of the VAs and AAs based on the ECGI and invasive electroanatomic mapping was performed using a segmental model of the atria and the ventricles. A perfect match (PM) was defined as a predicted location within the same anatomic segment, whereas a near match (NM) as a predicted location within the same segment or a contiguous one. The number of leads used for ECGI mapping, the agreement between the ECGI and the invasive map, and the success of the procedure were evaluated.

Results

Ablation was performed in 49 patients. We mapped 54 arrhythmias, 37 VAs (37 patients) and 17 AAs (12 patients). The results according to the atrial or ventricular origin of the arrhythmia are depicted in the table. Patients with AAs were older, no other differences were significant. The ECGI system correctly identified the SOO of both VAs and AAs in the same segment or a contiguous one in 100% of AAs and 97% of VAs, p=1.000. However, the percentage of a PM (Figure) was higher for AAs than for VAs (100% vs 76%, p=0.044).

Conclusions

The endo-epicardial ECGI correctly identified the origin of both ventricular and atrial arrhythmias. However, the accuracy was higher for the latter.
Prediction of early death after atrial fibrillation diagnosis: a french nationwide study
Authors: Bisson A , Lemrini Y , Romiti G , Proietti M , El-Bouri W , Angoulvant D , Lip G Y H , Fauchier L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is associated with important mortality. Dedicated clinical scores to predict mortality have been developed but perform modestly and are not specific for this population. Machine learning models are developing in the field of AF and may be able to outperform existing tools for the prediction of mortality.

Purpose

This study aimed to train and evaluate machine learning models for the prediction death occurrence within this critical period of the year following atrial fibrillation diagnosis and to compare predictive ability to usual clinical scores.

Methods

We used for this purpose a nationwide cohort of 2,435,541 newly diagnosed atrial fibrillation patients seen in all the French hospitals from 2011 to 2019. Three ML models (logistic regression, random forests, deep neural networks) were trained to predict mortality within the first year on a train set (70% of the cohort). The best model was selected to be evaluate on the test set (30% of the cohort). Discrimination of the best model was evaluated using the C index. We finally compared our best model with previously published scores.

Results

Within the first year following AF diagnosis, 342,005 patients (14.4%) died after a mean time of 83 (SD 98) days in whom 107,715 were from cardiovascular deaths (31.5%). Among 110 variables, the 18 most predictive variables were identified and selected using a Random Forest algorithm: age, metastasis, resuscitated cardiac arrest, cancer, congestive heart failure, decubitus ulcers, renal failure, pneumonia, lung disease, difficulty in walking, malnutrition, anemia, impaired mobility, liver disease, renal disease, blood transfusion and urinary tract infection. After training 3 ML algorithms, the best ML model selected was a deep neural network with a C index of 0.785 (95% CI, 0.781-0.789) on the test set. The incidence of all cause death at one year rises in a stepwise fashion from 13.8 per 1000 patients for the first quintile to 352.4 per 1000 for the fifth quintile. Compared to traditional clinical risk scores, the selected model was significantly superior to the CHA2DS2-VASc and HAS-BLED scores, and dedicated scores such as Charlson Comorbidity Index and Hospital Frailty Risk Score to predict death within the year following AF diagnosis (C indexes: 0.597; 0.562; 0.643; 0.626 respectively. P<0.0001) (Figure 1). The ability to predict AF was improved as shown by the net reclassification index and integrated discriminatory improvement increase (P<0.0001, respectively) and decision curve analysis (Figure 2).

Conclusion

Machine learning algorithms predict early death after AF diagnosis with a better ability than previously developed traditional clinical risk scores. A ML approach may help clinicians to better risk stratify AF patients at high risk of mortality.
Artificial intelligence-guided automated measurement of pulmonary vein diameter in patients with atrial fibrillation
Authors: Kwon O S , Yang S , Lim B , Jin Z , Kim D , Park J W , Yu H T , Kim T H , Joung B , Lee M H , Hwang C , Pak H N
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): This research was supported by Basic Science Research Program through the National Research Foundation of Korea(NRF) funded by the Ministry of Education(2022R1I1A1A01071083). This work was also supported by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, the Ministry of Food and Drug Safety) (Project Number: RS-2022-00141473).

Background

In the planning of atrial fibrillation (AF)-related procedures, predicting left atrial (LA) anatomy and pulmonary vein (PV) diameter is important for the effectiveness and safety of the procedures but requires a labor-intensive measurement process. Here, we propose an artificial intelligence (AI) based PV diameter measurement algorithm for the computed tomogram (CT)-based automated PV evaluation.

Methods

We implemented a mesh-based convolutional neural network for the surface segmentation of four PVs and the LA appendage (LAA) in a 3D LA surface mesh. Our algorithm includes two originative methods of surface depth feature and cohesion loss function to improve the performance. We trained the model with the LA mesh of 210 AF patients’ CT scan and validated the accuracy of surface segmentation and PV diameter with independent 158 samples.

Results

Using an AI-based automated LA measurement model, we achieved an average Intersection over Union (IoU) of 83.4% and a regional IoU from 78.4 to 87.2 % in 158 LA meshes. When we added the surface depth feature, the IoU was improved by 31.7% compared to the conventional 3D feature. The cohesion loss function reduced the fragmentation rate of the surface label by 3.2%. Post-processed PV diameters did not differ from manually measured left (P=0.56) and right upper PV diameters (P=0.08) but differed in both lower PVs (p<0.001). The eccentricity variance of the PV ostia did not differ between AI-measured and manually measured PVs (P=0.68~0.84).

Conclusion

We proposed an AI-guided automated algorithm for surface segmentation and PV diameter measurement and validated it at both upper PVs and the eccentricity of the PV ostia. Our algorithm can be applied to the automated sizing of LA appendage and improve labor-intensive manual segmentation.
Impact of coronary artery bypass grafting on ventricular repolarization indexes
Authors: Costa P , Sanchez Mas R , Correa Costa S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Ventricular repolarization indexes (VRI) tend to be altered in patients with chronic coronary artery disease, which are associated with a higher risk of malignant arrhythmias and higher mortality. Coronary artery bypass grafting (CABG) is capable of reducing mortality, as well as improving arrhythmic burden in this population. However, we do not know whether these benefits can be explained by improvement in VRI.

Purpose

To determine whether there is improvement in VRI after CABG, as well as to analyse possible effects of clinical and surgical variables on these indexes.

Methodology

A total of 150 patients who underwent CABG were included. Through the evaluation of preoperative and hospital discharge electrocardiograms, the QT interval, the interval from the peak to the end of T wave (Tp-Te) and the Tp-Te/ QT ratio were analysed. The values obtained before and after CABG were compared, as well as their association with clinical and surgical variables.

Results

The population was predominantly male (77.3 %), mean age of 61.6±8.3 years-old and mean LVEF of 58.8±10.6 %. A reduction in the QT interval (398.93±34.68 vs 365.47±50.38 ms, p < 0.001), in the Tp-Te interval (72.2±17.2 vs 61.6±19.5 ms, p < 0.001) and in the Tp-Te/ QT ratio (0.18±0.17 vs 0.04±0.05, p = 0.004) after CABG. There was no correlation between VRI and clinical and surgical variables.

Conclusion

CABG had a important impact in the reduction of QT and Tp-Te intervals, as well as the Tp-Te/ QT ratio, suggesting that the acute improvement in the coronary perfusion is directly associated with the improvement in these VRI.
Automated atrial fibrillation detection with a smartwatch and smart-ring in individuals with cardiovascular disease
Authors: Briosa E Gala A , Sharp A J , Schramm D , Ries W , Pope M T B , Leo M , Paisey J , Curzen N , Betts T R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Wearable technology is increasingly used to identify episodes of atrial fibrillation (AF). However, most validation studies using single-lead electrocardiograms (ECGs) only included patients with either sinus rhythm or AF and, therefore, likely overestimate the sensivities and specificities of AF detection algorithms.

Purpose

We sought to evaluate the diagnostic accuracy of the Apple Watch and CART-I ring AF algorithms in a broad cohort of patients with pre-existing cardiovascular disease.

Methods

In this single-centre prospective study, individuals with known cardiovascular disease underwent simultaneous 12-lead ECG recordings with a 30-second single-lead ECG from an Apple Watch Series 6 and a CART-I Ring. The order of devices was randomly assigned. Two cardiologists independently evaluated the 12-lead ECGs for the presence of AF; any disagreements were resolved by a third cardiologist. The wearable devices’ algorithm labelled ECGs as "AF", "Not AF" or "Unclassified". Diagnostic accuracy was determined by calculating the sensitivity and specificity for each device and comparing them using McNemar’s test. The primary analysis included Unclassified ECGs, which categorised as false-positive (no AF on the 12-lead ECG) or false-negative (AF on the 12-lead ECG). A separate analysis excluded all Unclassified ECGs.

Results

We enrolled 400 consecutive patients. Seven patients had suboptimal 12-lead ECGs and were excluded from the analysis. The median age was 63 (58-75) years, and 73% of the population was male. Baseline demographics are depicted in Table 1. A total of 1573 ECGs were analysed. Forty-two percent of patients were in AF, 9.9% were in an atrial tachycardia, 3.3% had sinus rhythm with frequent ectopy. If all ECGs were included, the CART-I ring's AF sensitivity was significantly higher than the Apple Watch, at 86.6% (95% CI: 80.6%-91.1%) and 67.4% (95%CI: 60.0%-74.1%), respectively (Fig 1). Similarly, AF specificity was higher with CART-I ring (89.4% [95%CI: 84.7%-92.8%]) when compared to the Apple Watch (74.9% [95%CI 68.9%-80.1%]). The Apple Watch had more Unclassified ECGs than CART-I ring (78 vs. 2, respectively). They were divided into three categories: 14.1% as HR 50 bpm, 10.21% as HR > 120 bpm, and 76.9% as Inconclusive (Table 2). When Uclassified ECGs from the Apple Watch were excluded, AF sensitivity and specificity improved by 16.33% (p=0.002) and 13.38% (p<0.001), respectively.

Conclusion

In patients with cardiovascular disease, the diagnostic accuracy of AF detection from a single-lead ECG was lower than previously reported. The CART-I ring's AF sensitivity and specificity outperformed those of the Apple Watch. One in three patients with AF went undetected by the Apple Watch.
P-wave duration and interatrial block as predictors of new-onset atrial fibrillation: A systematic review and meta-analysis
Authors: Koutalas E , Zagoridis K , Intzes S , Symeonidou M , Zagoridou N , Karagogos K , Spanoudakis E , Kanoupakis E , Kochiadakis G , Dinov B , Dagres N , Hindricks G , Bollmann A , Nedios S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Early detection of atrial fibrillation (AF) could improve patient outcomes. P-wave duration (PWD) and interatrial block (IAB) are known predictors of new-onset AF and could improve selection for AF screening. This meta-analysis reviews the published evidence and offers practical implications.

Methods

Publication databases were systematically searched and studies reporting PWD and/or morphology at baseline and new-onset AF during follow-up were included. IAB was defined as partial (pIAB) if PWD≥120 ms or advanced (aIAB) if the P-wave was biphasic in the inferior leads. After quality assessment and data extraction, random-effects analysis calculated odds ratio (OR) and confidence intervals (CI). Subgroup analysis was performed for those with implantable devices (continuous monitoring).

Results

Among 16.830 patients (13 studies, mean 66 years old), 2.521 (15%) had new-onset AF over a median of 44 months. New-onset AF was associated with a longer PWD (mean pooled difference: 11.5 ms, 13 studies, p<0.001). The OR for new-onset AF was 2.05 (95% CI: 1.3-3.2) for pIAB (5 studies, p=0.002) and 3.9 (95% CI: 2.6-5.8) for aIAB (7 studies, p<0.001). Patients with pIAB and devices had higher AF-detection risk (OR: 2.33, p<0.001) than those without devices (OR: 1.36, p=0.56). Patients with aIAB had similarly high risk regardless of device presence. There was significant heterogeneity but no publication bias.

Conclusion

Interatrial block is an independent predictor of new-onset AF. The association is stronger for patients with implantable devices (close monitoring). Thus, PWD and IAB could be used as selection criteria for intensive screening, follow-up or interventions.
Feasibility and safety of a single patch-based device for 30 days of continuous, uninterrupted ambulatory ecg monitoring
Authors: Turakhia M , Ellis J , Muresan A , Bame C , Wilk A , Crosson L , Clarkson K , Day M , Alexander J , Lenane J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): iRhythm Technologies, Inc.

Background

14-day continuous ambulatory ECG monitoring (AEM) has been shown to have superior diagnostic yield to traditional 48-hour Holter monitoring for paroxysmal or undiagnosed atrial fibrillation and a wide range of clinical arrhythmias. 30-day recordings are typically from event recorders (non-continuous) and require frequent adhesive/electrode and battery replacement, all of which can impair patient compliance, wear time, and diagnostic yield. A new, uninterrupted patch-based AEM with next-generation breathable adhesive, storage, and battery life has received FDA clearance for 14-day wear. We evaluated the safety and feasibility of using this device for 30-days of continuous AEM.

Methods

We enrolled 30 participants with indications for AEM and applied a single Zio Monitor device for 30-days and analyzed wear time, analyzable time, and diagnostic yield, compared to with Zio Monitor 14-day use and with our standard, previous-generation product.

Results

In the cohort (76% female, 35% non-white, age 37±9 years, BMI 30.6±6.8), the median wear time was 29 continuous days (IQR 28-30) with no device changeouts and no clinically significant skin irritation. Although median analyzable times were high and similar across the previous (XT) and next-generation (Monitor) devices, the mean was significantly higher with Monitor, indicating fewer outliers that experienced premature termination of wear time. Arrhythmia yield (AF ≥30 sec, SVT ≥90 bpm & ≥4 bt, VT ≥100 bpm & ≥4 bt, inc PVT/TdP/VF, Pause ≥3 s, and/or AVB (any 2nd Deg or CHB) was significantly higher with the new Zio Monitor Device compared to Zio XT (80.9% vs 77.1%; p=0.017).

Conclusion

The application of a single, continuous, patch-based AEM for 30 days without adhesive (electrode) or battery replacement is feasible and safe. Analyzable time was high for 14-day and 30-day wear. The uninterrupted wear time and high compliance could lead to higher diagnostic yield than with traditional 30-day event recorders.