bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of on-label reduced-dose edoxaban in octogenarian patients with atrial fibrillation
Authors: Lee H J , Lee S H , Kim J W , Kim J Y , Park S J , Park K M , On Y K
Published: May 2024

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are effective in preventing thromboembolisms and reduce the risk of bleeding compared with warfarin. There are few reports on the outcomes of on-label reduced-dose NOACs.

Purpose

The aim of this study was to assess the safety and efficacy of on-label reduced-dose edoxaban in octogenarian patients with atrial fibrillation (AF).

Methods

This study is a multi-center, prospective, non-interventional study to evaluate the safety and efficacy of on-label reduced-dose edoxaban in patients with AF. We evaluated outcomes of major bleeding, stroke or systemic embolism, all-cause death, and composite clinical outcomes.

Results

A total of 2448 patients (mean age 75.0±8.3 years, 801 [32.7%] males) was included in the present study. 932 patients (38.1%) were octogenarians. Major bleeding events occurred at a rate of 1.69%/yr in octogenarian patients and 0.9%/yr in non-octogenarian patients. The event rate of strokes and systemic embolisms was 1.93%/yr in octogenarian patients and 0.66%/yr in non-octogenarian patients The overall net clinical outcomes occurred at a rate of 5.45%/yr in octogenarian patients and 2.24%/yr in non-octogenarian patients.

Conclusions

Reduced-dose edoxaban can be used safely in Asian patients with very elderly patients. Older age was associated with a higher risk of ischemic stroke and composite adverse events.
Left atrial appendage clipping during hybrid atrial fibrillation ablation: a very long-term, single-center experience
Authors: Mouram S , Della Rocca D G , Doundoulakis I , Pannone L , Vetta G P , Stroker E , Almorad A , Sieira J , Sarkozy A , Chierchia G B , La Meir M , De Asmundis C
Published: May 2024

Background/introduction

Epicardial left atrial appendage (LAA) clipping is an effective strategy for stroke prophylaxis in high thromboembolic (TE) and bleeding risk patients with atrial fibrillation (AF). In addition to LAA exclusion from systemic circulation, clipping promotes concomitant appendage isolation, which might have positive impacts on arrhythmia control.

Purpose

The aim of this study was to report safety, success rate, and the long-term clinical outcomes of LAA clipping in a large cohort of AF patients undergoing concomitant hybrid ablation.

Methods

Consecutive patients undergoing hybrid AF ablation between 2013 and 2023 were enrolled. Hybrid ablation was performed in a one-step procedure consisting of thoracoscopic epicardial radiofrequency (RF) ablation followed by endocardial mapping and ablation, if needed. Ablation lesion set included pulmonary vein (PV) and posterior wall (PW) isolation, as well as RF applications to the LAA/posterolateral ridge. LAA clipping was performed via Atriclip exclusion system (Atricure, Inc., The Nederlands) after epicardial ablation. Additional endocardial lesions were performed in case of incomplete epicardial ablation or at physician’s discretion.

Results

A total of 130 patients were included (mean age: 65±9.4; 72.3% males); among them, 19.2% and 55.4% had persistent or long-standing persistent AF, respectively. Mean CHA2DS2-VASC and HAS-BLED were 3.1±1.1 and 2.3+-0.5. Five patients (3.8 %) had absolute contraindication to long-term oral anticoagulation, 3 (2.3%) had previous life-threatening bleeding events, 17 (13.1%) had a previous TE event. The final clip size was 35mm in 90.7% cases. Acute success was achieved in 97.7%; failure was due to LAA size (n=1), proximity to phrenic nerve (n=1), or bypass graft (n=1). One patient had incomplete occlusion due to a large secondary lobe, which required a second clip. No periprocedural complications related to clipping were documented.

At a mean follow-up of 51±35 months, one (0.8%) patient had a stroke and 3 (2.3%) a transient ischemic attack (4 events per 552 patient/years; 0.7%).

One patient had a microreentrant tachycardia mapped from the area near the LAA clipping.

Conclusion

In a large cohort undergoing hybrid AF ablation, epicardial LAA clipping was safe and highly successful. Acute failure was rare and due to LAA morphology or proximity to phrenic nerve and bypass graft. Thromboembolic event rate was very low.
Quality of life in patients with atrial fibrillation and multimorbidity, and their caregivers: results from the AFFIRMO international online survey
Authors: Leo D , Trevisan C , Ravelli A , Graffigna G , Bosio C , Lobban T , Lane D
Published: May 2024

Introduction

Patients with atrial fibrillation (AF) often have additional concomitant chronic conditions that affect their clinical management and quality of life (QoL). The AFFIRMO study aims to examine ways of optimising care and self-management for AF patients with multimorbidity.

Methods

An online survey open to AF patients and their caregivers was distributed to five countries (UK, Italy, Denmark, Romania and Spain) between June 2022 and January 2023. QoL among patients was assessed using the EQ-5D-3L questionnaire, while life changes for caregivers was assessed using the Bakas Caregiving Outcome Scale (BCOS).

Results

659 patients (47.2% males, mean age: 70.9 [SD 10.2] years), and 201 caregivers (26.9% males, mean age 58.3 [SD 15.2] years) participated in the survey. Patients reported significant sex differences in health status (Table 1), with men reporting an overall higher QoL, while women reported greater impairment in mobility and usual activities, with higher levels of pain/discomfort. Patients aged >65 years reported greater impairment in QoL compared to the younger ones, with patients from Southern Europe reporting greater impairment in self-care than those from Eastern or Northern Europe. Patients with higher education reported better QoL.

Among caregivers (Table 2), men reported less negative life changes compared to women, with the latter also reporting more pain/discomfort. Caregivers aged <65 years reported greater impairment in mobility and usual activities than those aged ≥65 years, and those aged <50 years reported a higher level of anxiety/depression. Caregivers aged <75 years reported greater negative life changes than those aged ≥75 years. Caregivers from Spain reported less negative life changes compared to caregivers from other countries. Caregivers with further education level reported better overall quality of life and greater negative life changes compared to caregivers with lower levels of education.

Conclusions

The QoL of patients with AF and multimorbidity seems to be compromised especially in females and in the older ones. The caregivers of these patients also experience negative life changes, in particular those with younger age. The results of the AFFIRMO study will help in the development of better clinical and self-management strategies for AF patients with multimorbidity to reduce the negative impact on QoL.Differences in patients' QoLDifferences in caregivers' QoL
Evaluating left atrial wall thickness: a new frontier in predicting atrial scar and reentrant tachycardia
Authors: Aytemir K , Coteli C , Kilic G S , Yorgun H
Published: May 2024

Background and Objective

Reentrant atrial tachycardias (AT) are commonly observed in patients with atrial scar. These scars form a substrate in the atrium, characterized by areas of slow conduction, crucial for initiating reentrant cycles. During these cycles, zones of slow conduction often act as critical isthmuses (CI), becoming prime targets for ablation. Late potential mapping is a technique used to identify these slow conduction zones. Moreover, recent advancements in imaging software now allow for the precise measurement of myocardial wall thickness, aiding in the identification of thin myocardial areas that could potentially have the CI of AT.

Methods

We conducted a retrospective study of patients who underwent catheter ablation for AT. The study focused on patients who either presented with AT or in whom it was induced and who had undergone late potential mapping of the left atrium. To identify deceleration zones (DZ), we created voltage maps and isochronal late activation maps (ILAM) during sinus or paced rhythm. Electrograms exhibiting a continuous-fragmented morphology were explicitly marked. Upon induction of AT, activation mapping was employed to pinpoint the CI of the tachycardia circuit. Additionally, the thickness of the left atrial (LA) wall and LA volume were measured using ADAS3D software.

Results

A total of 39 patients, with 25 (65.1%) being female, were enrolled in the study. The mean age of the participants was 62.5 ± 9.5 years. The average volume of the left atrium was measured at 124.8 ± 35.5 mL, and the mean thickness of the LA wall was 1.58 ± 0.2 mm. In most patients (16, 41.0%), the septal wall was the thinnest part of the left atrium. However, significant thinning of the LA wall was observed predominantly on the anterior wall in 29 patients (74.2%) and on the LA roof in 18 patients (46.2%).

The sensitivity and positive predictive value (PPV) of thinning in the LA anterior wall in detecting late potentials were 74.1% and 68.9%, respectively. For detecting critical isthmuses, these values were 76.9% (sensitivity) and 66.7% (PPV). Regarding the LA roof, the diagnostic value for thinning in detecting late potentials and critical isthmuses showed a sensitivity of 57.1% and 57.9%, respectively, and a PPV of 57.1% and 52.4%, respectively.

Conclusion

Evaluating LA thickness represents a novel approach that can potentially identify LA scars and late potentials before the procedure, particularly in the LA anterior wall. While the observed positive predictive values are acceptable, the negative predictive values and specificity are relatively low. Future advancements in imaging software, along with the development of standardized cardiac computed tomography protocols, can potentially enhance these outcomes. Consequently, preprocedural computed tomography could become increasingly significant in managing and treating AF and AT beyond LA anatomy evaluation.TablesLeft Atrial Wall Thickness
Simplification of resetting response in slow/fast atrioventricular nodal reentrant tachycardia: the 3 catheters approach
Authors: Abu-Alrub S , Finet F , Boudias A , Catalan P A , Jean F , Eschalier R , Massoullie G
Published: May 2024

Background

The resetting response is a maneuver that helps identify the anterograde limb of slow/fast atrioventricular nodal reentrant tachycardia (AVNRT). The actual described maneuver involved a 5 catheters approach, and the related complications are poorly described.(1)

Purpose

We describe a simplified approach with 3 catheters and the related complications of the maneuver.

Methods

A quadripolar catheter was placed in the His bundle region; a decapolar catheter in the coronary sinus (CS) and a 4 mm tip non irrigated or irrigated catheter was used for pacing and ablation. An 8.5 French Sl0 sheath was used to ensure contact and stability. In confirmed slow/fast AVNRT using the fast pathway as the retrograde limb (earliest retrograde atrial activity located in the parahisian region), a single decremental atrial extrastimulus was delivered at the lower part of the triangle of Koch and 2-3 cm inside the CS on the roof. Pacing maneuver was started near the end of the QRS complex and decremented by 10 ms per interval. The higher atrial signal with the best A/V ratio on the CS catheter was used as sense reference for resetting response. The end point of ablation was non inducibility.

Results

Ten patients were included in a 4-month period, comprising 2 redo procedures. The maneuver was not performed in 4 patients (40%) due to non-sustained tachycardia. Atrial fibrillation was induced in 2 patients (20%) during the maneuver systematically due to an atrial extrastimulus preceding the H potential (negative HA interval). In the 4 remaining patients with successful resetting response, the HA interval in successful ablation spot varies between 31 to 82 ms. The involved anterograde limb was the right extension in 3 (75%) and the left extension in 1 (25%).

Conclusion

Resetting response can be performed with a 3 catheters approach, the main limitation is non sustained tachycardia, and atrial fibrillation induced by short coupled extrastimulus.Resseting response in LIE and RIE
Familial aggregation of sinus node dysfunction indicating pacemaker implantation: A nation-wide cohort study
Authors: Christiansen M K , Parner E , Johansen J B , Nielsen J C , Jensen H K
Published: May 2024

Background

Rare genetically inherited forms of sinus node dysfunction (SND) have been described but the significance of a family history of SND and the associated prognosis remains unknown.

Purpose

To investigate the risk of SND indicating pacemaker implantation and mortality in first-degree relatives to patients who received a pacemaker because of SND, and to assess the effect of age of onset on disease risk.

Methods

This was a nationwide retrospective register-based cohort study including all Danish citizens born after 1954. SND was defined to be present when a first pacemaker was implanted on this indication. To establish family structures, we retrieved data from the Danish civil registration registry which contains information on parental links and merged them with the Danish Pacemaker and ICD registry which contains information on all pacemaker implanted because of SND in Denmark. Using Poisson regression, we compared the rates of SND and the risk of all-cause mortality in first-degree relatives of SND patients with the rates in the general population between January 1st 1982 and August 31st 2022. Analyses were adjusted for selected diagnosis- and procedure codes from the Danish National Patient Registry, including hypertension, diabetes mellitus, heart failure, coronary artery disease, atrial fibrillation or flutter, valvular heart disease, stroke, and cardiac surgery.

Results

We included 6,027,090 individuals among whom 2,477 first pacemakers were implanted due to SND in the time period. The adjusted rate ratio (RR) of SND was 2.9 (95% CI 2.4-3.6), p<0.001, for individuals having any father, mother or sibling with SND compared with the general population. This risk was increased in first-degree relatives across all ages of SND onset in the index person but substantially higher if SND onset in the index person occurred ≤50 years (adjusted RR=7.1 (95% CI 3.5-14.3), p<0.001). Comparable risks of SND were observed for first-degree relatives to mothers, fathers and siblings with SND as well as for men and women. Overall, mortality was similar between individuals having any father, mother or sibling with SND and the general population (adjusted RR=1.02 (0.97-1.08), p=0.45). However, there was a trend towards an increased mortality among first-degree relatives to index persons with an early onset.

Conclusions

First-degree relatives to SND patients are at increased risk of SND with risk being inversely associated with age of onset in the index person. Overall, mortality in first-degree relatives was comparable to the general population, suggesting a benign prognosis in the vast majority of cases with genetically inherited SND.Table 1Figure 1
Long-term impact of the implementation of a syncope unit: 14 years of care optimization
Authors: Rodriguez Entem F , Exposito V , Gonzalez Enriquez S , Olalla J J , Zubiaur J , Perez Barquin R , Margarida A
Published: May 2024

Syncope, a prevalent cause of emergency department (ED) visits, often triggers unnecessary hospitalizations due to its intricate management. In recent years, dedicated syncope units (SUs) have emerged, initially showing a reduction in admission rates compared to traditional approaches.

These abstract aims to convey the extended impact of implementing a specialized Syncope Unit (SU) within a hospital setting over 14 years.

This prospective study examines SU outcomes over the first 14 years of operation, with a specific focus on admission rates.

Between 2005 and 2019, our hospital's ED handled 1,835,219 visits, with 16,516 (8.9%) related to syncope. On average, 1,101±60 syncope patients received attention annually, with a slight decrease over the study period. The SU evaluated a total of 3,225 patients, averaging 215±31 patients per year. Notably, the number of SU patients remained consistent, while the number of hospitalized patients steadily declined from 40% in 2005 to 15% in 2019.

In conclusion, the implementation of the SU led to a substantial and sustained reduction in the admission rate for syncope patients, showcasing a lasting positive impact on syncope management within the ED. This positive impact could also be due to indirect benefits resulting from the creation of the SU.
miRNAs as a tool for the diagnosis of suspected Brugada Syndrome
Authors: Cabiati M , Persiani E , Del Ry S , Piacenti M , Rossi A , Zucchelli G , Solrarino G , Nesti M , Notarstefano P , Pieragnoli P , Morales M A , Fernandez S , Vozzi F
Published: May 2024

Background/Introduction

Brugada syndrome (BrS) is a life-threatening arrhythmogenic disease that can lead to sudden unexplained death/cardiac arrest in otherwise healthy individuals. ECG represents the gold standard for the diagnosis. In 30% of cases, however, the syndrome is diagnosed only after a provocative test with sodium channel blockers [1]. Among the different approaches to support diagnosis, circulating biomarkers such as miRNAs may represent a tool that can provide a biological signature of the syndrome in patients with suspected BrS.

Purpose

Within the BrS and Artificial Intelligence Applications to Diagnosis system study, we collected and analyzed blood samples from patients with suspected BrS undergoing provocative tests aiming to assess whether miRNAs may be potential markers to identify the syndrome.

Methods

Patients undergoing provocative tests with sodium channel blockers (i.e., ajmaline, flecainide) were classified as positive (15 patients) and negative (13 patients) based on the test results. Blood samples were obtained when a Type-1 ECG pattern developed (for positive) or at the end of the provocative test without any electrographic changes (negative). miRNAs were extracted from circulating exosomes, obtained by blood samples, using a dedicated and innovative assay (exoRNeasy mini/midi kit, QIAGEN). They were quantified and quality tested by Agilent 2100 Bioanalyzer RNA assay; miRNA-seq was carried out with NovaSeq 6000 (Illumina, San Diego, CA). Data were analyzed through web-based platforms for network visual analytics (mirNET 2.0).

Results

The presence of 8 small RNAs up-regulated was reported in the positive group (hsa-miR-155-5p ,hsa-miR-10a-5p, hsa-miR-29a-3p, hsa-miR-142-5p, hsa-miR-30a-5p, hsa-miR-126-5p, hsa-miR-95-3p, hsa-miR-126-3p), with a log fold-change between 6.4 (as for hsa-miR-95-3p) and up to 615.0 (as for hsa-miR-126-3p) (Table 1). The network analysis results (Figure 1) on this group of miRNAs showed their involvement, among the others, in response to cytokine and muscle development (in terms of function analysis) and Ca2+pathway modulation (in terms of pathway analysis).

Conclusion(s)

In this work, a miRNA analysis of patients undergoing provocative tests for Type-1 BrS diagnosis was performed. Our results show a set of potential miRNAs that could be used to identify Type 1 BrS patients in whom the typical ECG pattern is basally lacking. Although further experiments and validation on a larger number of samples are necessary, our results could identify these miRNAs as potential early markers in patients with a suspected Type-1 BrS diagnosis.Upregulated miRNAs in BrS patientsMiRNA network analysis
Cardioneuroablation for asystolic reflex syncope with or without the use of extra cardiac vagal stimulation-one year follow-up results
Authors: Piotrowski R , Baran J , Sikorska A , Krynski T , Niedzwiedz M , Kulakowski P
Published: May 2024

Background

Extra-Cardiac Vagal Stimulation (ECVS) during cardioneuroablation (CNA) has been introduced to confirm total vagal denervation – a clear intra-procedural end-point. However, whether the use of ECVS is associated with better outcome than simple intra-procedural assessment of CNA-induced changes in basic ECG parameters, has not been established.

Purpose

To compare one-year efficacy of CNA performed with versus without ECVS.

Methods

This retrospective analysis included 90 patients (age: 37±12 years, 39 males) divided into 2 groups: ECVS(+) (n=41, general anesthesia and total muscle relaxation, settings: 50 Hz, 0.05 ms, 1 V/kg (<70V) for 5 s) and ECVS(-) group (n=49, light sedation). CNA strategy was the same in all patients and was based on presumed anatomical localization of ganglionated plexi, combined with identification of ablation targets at sites with fragmented bipolar atrial electrograms. The end-point in the ECVS (+) group was complete vagal denervation, confirmed by ECVS, whereas in the ECVS (-) group - significant (>30%) acceleration of sinus rate. The primary endpoint was syncope recurrence during one-year follow-up.

Results

Both groups were comparable concerning clinical and demographic parameters. Primary endpoint occurred in 4 (10%) patients in the ECVS(+) group and in 7 (14%) patients in the ECVS(-) group (p=0.7481) (Figure). No complications were reported.

Conclusions

These preliminary results suggest that the use of ECVS only slightly improves the one-year CNA efficacy, however, prospective larger studies and longer follow-up are needed to confirm these initial findings.
Repolarization gradient induces local depolarization abnormalities in Brugada Syndrome
Authors: Garibaldi S , Tirabasso D , Latrofa S , Hartwig V , Nesti M , Panchetti L , Mirizzi G , Startari U , Zaurino N , Morelli M S , Passino C , Emdin M , Piacenti M , Giannoni A , Rossi A
Published: May 2024

Background

Transmural voltage gradient in right ventricular outflow tract (RVOT) induces diagnostic ECG-phenotype in Brugada syndrome(BrS). Moreover, RVOT depolarization abnormalities have been described as contributors to BrS phenotype and arrhythmogenesis.

Purpose

To investigate the effect of ajmaline administration on J-elevation of RVOT unipolar signals in BrS patients. Moreover, we wanted to assess whether ajmaline-induced unipolar J-point elevation variations induced local depolarization abnormalities.

Methods

21 BrS patients with spontaneous type-1 ECG pattern were enrolled. Due to the absence of BrS ECG pattern at the study, patients underwent RV endocardial mapping with the CARTO3 system, before (PRE) and after (POST) ajmaline administration. The PRE and POST data were exported from CARTO and converted into Matlab format using OpenEP. J-elevation for each point was calculated as the amplitude of the unipolar signal at J wave with respect to baseline. Activation time (AT) of each point was defined as the difference between local depolarization (minimum dV/dt of the unipolar signal) and surface ECG depolarization (time of the minimum signal on V2). With an automatic algorithm, corresponding PRE and POST points were selected. The difference between POST and PRE of each parameter was calculated to obtain the differential values delta-J and delta-AT. Differential values were then interpolated on the mesh of each subject to obtain 3D maps. The deltaJ map was divided into four intervals based on quartiles. We then selected a ROI 'IN' on a region with the greatest deltaJ variation, and a second ROI 'OUT' on the zone of lowest variation. The same ROIs were applied to the deltaAT map. The mean value of the respective differential parameters was extracted in each ROI.

Results

Greatest delta-J values were found in the RVOT/anterior wall. delta-J in the ROI 'IN' was greater than in the ROI 'OUT' (1.68 [1.11-2.28] vs 0.56 [0.38-0.93] mV, p<0.001). delta-AT in the ROI ‘IN’ was greater than in the ROI ‘OUT’ (27.96 [20.39-44.89] vs 7.62 [4.24-16.69] ms, p<0.001). A good correlation was found between delta-J and delta-AT, considering the data for the two ROIs together (Spearman R coefficient=0.71, p<0.001).

Conclusions

Our study shows that the repolarization gradient, evaluated by localized delta-J increase in RVOT, justifies BrS ECG phenotype and local depolarization abnormalities. A strong correlation was present in these RVOT areas between J-elevation variation and slow conducting zones.
Computed tomography as a predictive tool for ventricular tachycardia
Authors: Kowalewski C , Nunez-Garcia M , Bouteiller X , Vlachos K , Benali K , Monaco C , Bouyer B , Ly B , Sermesant M , Yokoyama M , Pambrun T , Derval N , Cochet H , Haissaguerre M , Jais P
Published: May 2024

Background

Sudden cardiac death is the main cause of mortality worldwide. It is often linked with ventricular tachycardia (VT). To prevent VT, high-risk patients are typically equipped with intracardiac defibrillators (ICDs). Currently, left ventricular ejection fraction (LVEF) is the standard for determining a patient's risk level.

Objective

We hypothesized that the use of imaging software analyzing cardiac CT-scans could enhance the detection of patients with an increased risk of VT.

Methods and Results

In this study, 132 patients with ischemic cardiomyopathy (average age 66.2±11.4 years, with an average LVEF of 36.6±10.3%), all with implanted cardiac devices, underwent CT scans. We developed software to automatically analyze the heart's wall tissue thickness, cardiac fat, and calcification levels (Figure.1.A). A viable cardiac wall thickness of less than 3mm typically indicates a ventricular wall predominantly composed of scar tissue with minimal viable tissue remaining. In contrast, a viable wall thickness of less than 5mm includes regions with more viable tissue and therfore represents the total scar. Over an average follow-up of 6.6 years (79.8 ± 30.5 months) via live telemedicine, we observed that patients with VT had a significant difference in wall thickness ratio (3mm/5mm; no VT 0.31±0.18 vs, VT 0.44±0.18, p<0.01)) and higher calcification (0.10±0.38ml vs. 0.47±1.57ml, p=0.039). The amount of cardiac fat did not significantly differ between the no VT and VT groups (1.14±1.38ml vs.1.21±1.01ml, p=0.771). Logistic regression determined a critical cutoff for wall thickness at a ratio of 0.3 for 3mm and 5mm thickness. Kaplan Meyer analysis contrasted this wall thickness ratio of 0.3 (figure.1.B) against the established LVEF threshold of 35% (figure.1.C) for predicting VT-free survival, revealing a notable disparity favoring wall thickness ratio (p<0.01) over LVEF (p=0.77).

Conclusions

The findings suggest that a higher proportion of regions of thin viable tissue or dense scar in the total scar is a more effective predictor of VT-free survival than LVEF, potentially improving the identification of patients at risk for sudden cardiac death.Figure. 1
Sudden cardiac death as first manifestation of cardiovascular disease - a Danish nationwide study
Authors: Skjelbred T , Warming P E , Kroell J , Andersen M P , Torp-Pedersen C , Winkel B , Tfelt-Hansen J , Lynge T H
Published: May 2024

Background and objective

Sudden cardiac death (SCD) is a leading cause of death and previous studies have shown that approximately half of all cases have no known history of cardiovascular disease (CVD). Epidemiological studies of SCD cases of all ages are sparse. The aim of this study was to examine differences in incidence rates, clinical characteristics, comorbidities, and socioeconomic status between SCD cases with and without a known history of cardiovascular disease.

Methods

All 54,028 deaths in Denmark in 2010 were reviewed. Autopsy reports, death certificates, discharge summaries, and nationwide health and social registries were reviewed to identify cases of SCD. Information on previous history of CVD was extracted from the comprehensive Danish nationwide health and social registries.

Results

A total of 6,867 SCD cases were identified, of which 3,056 (44.5%) had no history of cardiovascular disease and 3,811 (55.5 %) had a history of CVD. Incidence rates of SCD increased with age and were higher in cases of SCD with a history of CVD across all age groups. The difference in incidence of SCD between persons with and without history of cardiovascular disease decreased with increasing age with incidence rate ratios ranging from 11.7 (95 % CI: 5.51 – 25.00) to 3.19 (95 % CI: 2.79-3.64) in those age 0-29 years and >90 years, respectively. Persons living in a low-income household (OR: 0.76, 95 % CI: 0.58-0.98, p=0.037), persons living in rural municipalities (OR: 0.87, 95 % CI: 0.78-0.98, p=0.021), and persons living in single-person households (OR: 0.73, 95 % CI: 0.66-0.82, p=0.037) had a lower likelihood of having a CVD prior to SCD.

Conclusion

This is the first nationwide study of SCD cases with and without history of CVD across all ages. SCD cases with no known CVD were significantly younger, more female and had less comorbidities. Although a substantial amount of SCD cases occur in persons with no known CVD, SCD is more common in the populations of persons with a history of CVD. Socioeconomic factors such as low income, living alone and living in rural communities were associated with a lower risk of having a cardiovascular diagnosis prior to SCD.Crude numbers and incidence rates of SCDIncidence rate ratios
The prevalence and clinical features of syncope in patients with concealed Brugada Syndrome
Authors: Hunuk B , Cagac O , Turan O E , Besiroglu F , Kozan O
Published: May 2024

Background

Brugada Syndrome (BS) is an inherited rhythm-disorder with risk of sudden-cardiac-death defined by a specific ST-segment elevation pattern in precordial ECG-leads either spontaneous or provoked by Na-channel-blocker-drug-provocation-test with Ajmaline. Scarce data denote that the prevalence of non-arrhythmic syncope is high in BS and leads to diagnostic confusions. Head-up tilt test (HUT) is a diagnostic tool used to assess autonomic function in patients with suspicious syncopal events.

Purpose

Our aim was to elucidate the frequency of non-arrhythmic syncope in BS patients, compare it with non-BS population with suspicious syncope and reveal possible clinical relations.

Methods

Adult patients with an history of Ajmaline-induced BS and patients evaluated for suspicious syncope with non-arrhyhtmic-features without BS less than 55-years-old were prospectively and consecutively evaluated with resting and higher-inter-costal-space-ECGs (HICS-ECGs), cardiac-examination and routine HUT in our center. After the exclusion of subjects with resuscitated-sudden cardiac-death/documented-malignant-dysrhythmia, any cardiac-disease, anti-arrhythmic-use, bundle-branch-blocks, pre-excitations and ventricular hypertrophies; 52 BS(+) subjects ([mean±SD] age, 33,6±14, [range]18-55 years) (male n [%overall]:33 [63.2%]) and 35 age-sex matched BS(-)subjects ([mean±SD] age, 34,1±13, [range]18-55 years) were enrolled in the study. All ECGs and HUT test results were interpreted manually by two experienced cardiologists for BS and Brugada-type-ECG-patterns (BTEPs).

Results

The clinical characteristics of patients with and without BS and statistical findings are presented in Table-1. BS(+) patients were slimmer, revealing more BTEPs by baseline HICS-ECGs. Baseline heart-rates were lower, PR-intervals and P-wave-duration were significantly higher in BS(+) patients. HUT-positivity of BS(+) patients were significantly higher [(39% (n: 20 [male n: 13]) vs 19% (n: 7 [male n: 4]) (p= 0,01)] revealing significantly more mixed-syncope and orthostatic hypotension response in BS(+) subjects. No cardioinhibitory response was revealed.

Conclusions

Non arrhtymic syncope is found to be highly prevalent in middle-aged-subjects and especially males with BS (+) without an apparent cardiac-disorder. Knowing this considerably important clinical aspect might effect risk stratification algorithms and might prevent unnecessary high-risk interventions and device decisions. Non-invasive indices regarding the delayed conduction features in ECG characteristics of BS(+) patients and a higher vagal state might be proposed as one of the probable mechanisms revealing the higher prevalence of non-arrhythmic-syncope in BS.Table-1
Clinical validation of a novel digital twin framework for ventricular functional substrate simulation in post-infarction patients
Authors: Parollo M , Biasi N , Seghetti P , De Lucia R , Di Cori A , Segreti L , Grifoni G , Fiorentini F , Torre M , Barletta V , Canu A , Sbragi S , Viani S , Tognetti A , Zucchelli G
Published: May 2024

Background

Catheter ablation is a cornerstone treatment for scar related post-infarction ventricular arrhythmias. Functional substrate driven ablation strategies guided by local activation time (LAT) mapping have been proven as efficient and effective approaches, especially when dealing with large scar areas. In-silico electrophysiological modeling is emerging as a potential tool for procedural planning and guidance.

Purpose

To clinically validate the feasibility, diagnostic performance, and accuracy of a novel late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) based digital twin framework for simulated LAT map generation in post-infarction patients and their integration with CARTO3 EAM suite.

Methods

Five ischemic subjects who underwent CMR-aided scar-related ventricular tachycardia ablation at our referral center were retrospectively enrolled. Their CMR derived 3D pixel-signal-intensity (PSI) maps generated with ADAS3D were processed with novel in-house software to obtain patient-specific ventricular geometry, tissue characterization, and to generate a model of Purkinje system and myocyte fiber orientation. According to local normalized pixel intensity (NPI) values, myocardial regions were marked as healthy, scar, or border-zone. Electrophysiological properties of border-zone (BZ) were modulated according to local NPI. Continuous and 8-steps isochronal endo-epicardial LAT maps were generated and imported in CARTO3 system, aligned with electroanatomical mapping (EAM), and compared at an ASE 17-segments level, in terms of sensitivity, specificity, predictive values, and accuracy to actual high-density LAT maps obtained with a multipolar catheter. Deceleration Zones (DZ) were defined as previously described (>3 isochrones within 1 cm radius).

Results

A total of 85 ASE segments (34 epicardial) were analyzed. 24 EAM segments (28%) held DZs, 40 (47%) segments harbored bipolar scar or BZ. Thirty-seven (44%) CMR segments held scar core/BZ. Thirty (35%) digital model segments harbored DZs. Generated LAT maps were successfully imported and aligned with CARTO3 EAM suite for validation.

In terms of DZ localization prediction, our LAT model showed 83% sensitivity (95% CI 63%-95%), 90% specificity (95% CI 80%-96%), 77% positive predictive value (PPV) (95% CI 56%-91%), 93% negative predictive value (NPV) (95% CI 83%-98%), 88% accuracy (95% CI 79%-94%).

Conclusion

Our newly developed framework for LGE-CMR derived functional substrate simulation in post-infarction patients holds high sensitivity, specificity, predictive values, and accuracy for DZ localization. Further validation, with a larger sample size, is required for evaluating potential implications in clinical practice.
Using cardiac magnetic resonance feature tracking to discover novel abnormalities in patients with idiopathic ventricular fibrillation
Authors: Verheul L , Guglielmo M , Groeneveld S A , Prakken N H J , Velthuis B K , Hassink R J
Published: May 2024

Background

Despite an extensive diagnostic work-up, the underlying diagnosis leading to ventricular fibrillation (VF) remains elusive in patients with idiopathic VF. Emerging diagnostic techniques can be used to discover previously unidentified abnormalities in these patients.

Purpose

The purpose of this study was to investigate the potential of cardiac magnetic resonance feature tracking (CMR-FT) to discover structural abnormalities in idiopathic VF patients.

Methods

Cine CMR images of idiopathic VF patients and age and sex matched controls were analyzed. Left ventricle global circumferential strain (GCS), global longitudinal strain (GLS) and global radial strain (GRS) were determined using Circle Cardiovascular Imaging. Student’s t-test was used to compare means.

Results

In total, 26 idiopathic VF patients (mean age 37 (±13) years, 62% male) and 26 controls (mean age 38 (±13) years) were included. CMR was performed in idiopathic VF patients at a median of 9 [IQR 3 – 15] days after the index event. Left ventricle ejection fraction was 55 ± 6% for idiopathic VF patients, 59 ± 6% for controls, p = 0.04. GCS and GRS were comparable for idiopathic VF patients and controls (-17.36 ± 1.78% vs. -18.04 ± 1.83%, p = 0.182 and 28.28 ± 4.63 vs. 29.29 ± 5.09, p = 0.438, respectively). GLS was lower for idiopathic VF patients compared with controls (-14.85 ± 3.21% vs. -18.44 ± 2.11%, p < 0.001).

Conclusion

CMR-FT GLS distinguished idiopathic VF patients from controls and could imply subclinical abnormalities in idiopathic VF patients. Future studies with a larger cohort should reveal if this finding can be correlated with an arrhythmic substrate.
Significance of Coherent Mapping in unveiling slow conduction zones of ventricular tachycardia substrate in ischemic cardiomyopathy
Authors: Yalin K , Ikitimur B , Soysal A U , Yalman H , Sanli S N , Baysal E , Bilge A K
Published: May 2024

Introduction

Ventricular tachycardia (VT) presents a formidable challenge, particularly in cases with extensive myocardial scar tissue, complicating critical ablation site identification. Prolonged interventions not only extend procedural durations but also heighten the risk of complications. This study aimed to assess the efficacy of coherent mapping techniques in precisely locating regions of slow conduction within scar tissue and explored potential correlations with electrophysiological markers in scar-related VT.

Methods

Seventeen patients (mean age: 61.6 ± 9.2 years, mean EF: 28 ± 9%) with ischemic cardiomyopathy (ICM) and frequent implantable cardioverter-defibrillator (ICD) shocks underwent high-density (>2000 points) left ventricular (LV) substrate mapping (15 endo, 2 epicardial) during sinus or right ventricular (RV) pacing and ablation. Coherent mapping tool was utilized for the identification of slow conduction, demonstrated by vector thickening. Bipolar low voltage areas (LVAs) below 0.5 mV were defined as dense scar, and bipolar voltage between 0.5 and 1.5 mV was defined as the border zone (Figure, panel A). Late potentials (LPs) and local abnormal ventricular activities (LAVA) were manually identified and tagged. Isochronal late activation mapping (ILAM) was also performed to elucidate the functional properties of the substrate (Figure, Panel B).

Results

LPs and LAVA were identified in all cases, with a mean number of LPs being 10.0 ± 7.1. Of these, 14/17 cases had LPs located in dense scar, while 4/17 cases had LPs in the border zone. The mean area of LAVA was 9.9 ± 7.7 mm², located in dense scar in 6/17 cases and in the border zone in 15/17 cases. Average deceleration zones (DZ, >3 isochrones in 1 cm radius) identified by ILAM was 2 ± 1. Coherent mapping consistently identified slow conduction zones adjacent to LVA in all cases, with these coherent map-based slow conduction zones (CM-SCZ) located in dense scar in 3/17 cases and in the border zone in 14/17 cases. The distance of CM-SCZ to LPs was 12.6 ± 13.9 mm (in 4 cases, LPs were recorded on the spot), and the distance to LAVAs was 18.8 ± 13.7 mm (in 2 cases, LAVAs were recorded on the spot). CM-SCZ was colocalized with DZ in 14/17 of the patients. Ablation lesions covered CM-SCZ in 10/17 cases. Over a mean follow-up duration of 11 ± 6.5 months, 4 patients experienced VT recurrence, with 3 having no ablation lesions covering CM-SCZ, and 2 patients died due to pump failure.

Conclusion

This study underscores the significance of coherent mapping in refining the understanding of VT substrate in ICM. Identifying and ablating CM-SCZ during substrate-based mapping may provide a potential additional benefit for VT ablation. Nevertheless, larger studies are needed to clarify the prognostic significance and validate the clinical benefits of this approach.Figure 1
Cardiac magnetic resonance to evaluate 3D ventricular substrate depth: Prognostic implications for VT ablation approach
Authors: Vazquez-Calvo S , Eulogio-Valenzuela F , Valerio Falzone P , Garre P , Guasch E , Porta-Sanchez A , Tolosana J M , Borras R , Arbelo E , Ortiz Perez J T , Prats S , Perea R J , Brugada J , Mont L , Roca Luque I
Published: May 2024

Background

The decision to perform a high-risk endo-epicardial approach for VT ablation is controversial and mostly based on previous endocardial failure or very specific etiologies. We systematically evaluated the 3D distribution of the automatically-detected conducting channels by CMR with the aim of assessing whether tissue thickness in those areas could allow for an endocardial-only approach independently of the etiology of the cardiomyopathy. This could have an important impact in terms of procedural planning.

Purpose

To study CMR channel depth as a predictor of VT recurrence after endocardial VT ablation.

Methods

Fifty-one consecutive patients with left scar-related VT undergoing ablation after CMR (October 2018 to June 2022) were included (median age 65.56±11.46 years, 94.1% male, median ejection fraction 31.82±8.76%, ischemic cardiomyopathy 72.5%). CMR channels were calculated with ADAS3D software. The depth of CMR channels was assessed based on the involved layers and the total wall thickness (WT) of the affected segment. Patients were prospectively followed for VT recurrence for one year.

Results

One-year VT recurrence was 13.7%. Overall, 159 CMR channels were analyzed (3.10±2.01 channels per patient). Univariate analysis showed that both the maximal depth of channel and the presence of an epicardial channel were the only predictors of VT recurrence during follow-up (OR 1.85 (1.11, 3.13), p=0.02 and OR 1.22 (1.05, 1.41), p=0.04 respectively). The presence of a channel with a maximal depth of more than 7.2mm from the endocardium had a sensitivity= 100%, specificity= 61.36%, negative predictive value (NPV)= 100% and positive predictive value (PPV)=29.0% with an area under the curve of 0.81 for VT recurrence. The presence of an epicardial channel showed, as well, sensitivity=100% and NPV=100% but a worse specificity (27.27%) and PPV (17.95%) compared with maximal depth of the channel. Non-ischemic cardiomyopathy was not significantly associated with a higher risk of VT recurrence after endocardial ablation in our study (OR 2.25 (0.43, 11.66), p 0.34).

Conclusions

The maximal depth of CMR channels is a predictor of VT recurrence in the follow up in patients with left scar-related VT who underwent endocardial ablation. A cutoff of maximal CMR channel depth of 7.2mm could be a better tool to select VT ablation approach than considering the type of cardiomyopathy or the presence of epicardial substrate.Examples of CMR channel depthProbability of VT recurrence
Rhythm matters: sinus and pace rhythm map significantly differ in endo/epicardial 3D electroanatomic mapping
Authors: Heil E , Gerds-Li J H , Hohendanner F
Published: May 2024

Introduction

Left ventricular substrate assessment utilizing ultra-high density multipolar catheters is frequently used to guide ablation procedures in patients with scar related ventricular tachycardia. However, 3D electroanatomic mapping is often performed during either sinus or paced rhythm. The effect of the modality (sinus vs. paced) used during mapping on substrate assessment remains elusive.

Methods and Results

We compared biventricular endo- and epicardial 3D high-density voltage and activation maps in sinus- and right ventricular-paced rhythm in domestic pigs. Data was acquired using a 20-polar mapping catheter with a cardiac tissue proximity filter based on catheter location and impedance measurements. Ventricular pacing (120 bmp) was performed with a permanent pacemaker electrode in right ventricular septal position, and high-density maps were acquired from the endo- and epicardium in sinus and paced rhythm (criterion for low voltage: <0.5 mV). Electroanatomical voltage and activation high-density (>6500 points per heart) mapping were performed with sufficient coverage in the right and left ventricles and the epicardium. The size of the low voltage area varied significantly between sinus and right ventricular-paced rhythm, particularly in epicardial mapping. In SR, the total low voltage was 7.2 ± 5.8%, while 11.1 ± 0.03% in paced rhythm. SR and paced maps revealed e.g. low voltage areas in the basal to apical anterior wall corresponding to the LAD regions, however, this was especially pronounced in sinus maps (e.g. pig 1: 64.2 cm²) compared to the paced rhythm map (e.g. pig 1: 32.8 cm²).

Conclusion

The extent of low voltage regions differed significantly in RV/LV, endo- and epicardially. Sinus maps showed the most accurate electrical representation of local voltage and corresponded correctly to local anatomical landmarks like e.g. the LAD with its surrounding epicardial fat tissue.3D biventricular epicardial voltage map
Imaging-derived tissue visualization guides catheter ablation of premature ventricular contractions
Authors: Kahle A K , Alken F A , Scherschel K , Meyer C
Published: May 2024

Background

The presence of myocardial scarring is associated with worse outcomes after catheter ablation of premature ventricular contractions (PVCs). Three-dimensional substrate characterization is emerging for peri-procedural ablation guidance, but its value for tissue visualization during PVC ablation is unknown.

Purpose

The aim of the present study was to assess the impact of imaging-derived tissue visualization on lesion planning, procedural and clinical outcomes of PVC ablation.

Methods

Thirteen consecutive patients (92.3% male, 62.2±12.4 years) undergoing unipolar (n=8) or bipolar (n=5) PVC catheter ablation with integrated three-dimensional imaging from multidetector computed tomography or cardiac magnetic resonance imaging were included. All patients presented with assumed myocardial scarring due to an underlying cardiomyopathy and/or after previous ablation.

Results

Among all patients (30.8% (peri-)myocarditis, 20.0% ischemic, 15.4% dilated cardiomyopathy, 15.4% idiopathic, 7.7% nonischemic, 7.7% congenital heart disease) undergoing ablation of 20 PVC morphologies (median 1 (IQR 1-2) per patient; 75.0% non-outflow tract; 70.0% left-sided), myocardial scarring was present in 11/13 (84.6%). Wall thinning <5 mm covering an area of 36.1±17.8 cm² contained the PVC origin in 4/13 (30.8%) patients and was safely targeted with radiofrequency lesions with up to 45 W (maximum power: median 32 W (IQR 30-35)) (Figure 1). Imaging-guided bipolar ablation was performed in 5/8 (62.5%) patients with previously therapy-refractory PVCs including foci at the left ventricular summit and the right ventricular outflow tract each in 2 and the left coronary cusp in one patient (Figure 2). PVCs were efficiently suppressed with less radiofrequency lesions (5.4±3.8 vs. 55.8±36.9; p=0.0160) with shorter duration (4.1±3.2 min vs. 23.3±13.5 min; p=0.0152) compared to prior unipolar ablation. Bipolar lesions resulted in a higher impedance (158 Ω (IQR 101-174) vs. 106 Ω (IQR 99-124); p=0.0025), while requiring a lower temperature (36 °C (IQR 35-38) vs. 39 °C (IQR 36-43); p=0.0001) and less power (26 W (IQR 20-30) vs. 30 W (IQR 25-31); p=0.0376). Complete suppression of the clinical PVC was reached in all 13 patients. During a follow-up of 396.8±299.7 days, PVC burden decreased from 20.1±14.3% to 1.7±1.6% (p=0.0172).

Conclusions

Imaging-derived tissue visualization enables determination of myocardial wall thinning <5 mm as a substrate for recurrent PVCs, which can be safely targeted. Three-dimensional imaging efficiently guides high power lesion application and bipolar ablation of PVCs at anatomically challenging foci.Anatomically challenging fociImaging-guided bipolar ablation