bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of Alkali Metal Ions on the Mechanisms and Outcomes of Radical-mediated Organic Reactions
Authors: Ye Ziqi , Liao Jia-Bin , Gong Lei
Published: May 2024

Radical chemistry, a rapidly growing field in organic synthesis, offers numerous innovative approaches for the cleavage and construction of challenging chemical bonds. Recent findings have underscored the pivotal contributions of alkali metal ions in radical-driven reactions, where they play a crucial role in lowering the energy barriers required to initiate these processes and in stabilizing vital transient radical species. These properties contribute significantly to the advancement of next-generation synthetic techniques. This article offers a concise yet thorough examination of the roles alkali metal ions assume within radical chemistry, with a specific focus on their diverse modes of activation and the associated mechanistic contexts. Our objective is to encourage and expand their strategic use across various facets of organic synthesis, catalysis, and environmentally conscious green chemistry applications.
Comparative analysis of intraoperative and imaging features of invasive growth in pituitary adenomas
Authors: Hladik Mirko , Nasi-Kordhishti Isabella , Dörner Lorenz , Kandilaris Kosmas , Schittenhelm Jens , Bender Benjamin , Honegger Jürgen , Behling Felix
Published: May 2024

Background

Most pituitary adenomas (PAs), also termed pituitary neuroendocrine tumors, are benign in nature and can be treated effectively by surgical resection, medical treatment, and in special cases by radiotherapy. However, invasive growth can be an important feature of a more aggressive behavior and adverse prognosis. The extension of PAs into the cavernous sinus can be categorized according to the Knosp criteria on magnetic resonance imaging (MRI). Comparative analyses of MRI features and intraoperative findings of invasive growth regarding different clinical factors are still scarce.

Materials and Methods

We performed a retrospective single-center analysis of 764 PAs that were surgically treated between October 2004 and April 2018. Invasive growth was assessed according to the surgical reports and preoperative MRI (Knosp criteria). Clinical data, such as patient age at diagnosis and gender, histopathological adenoma type, and extent of resection, were collected.

Results

Invasive features on MRI were seen in 24.4% (Knosp grades 3A-4, 186/764) of the cases. Intraoperatively, invasion was present in 42.4% (324/764). Complete resection was achieved in 80.0% of adenomas and subtotal resection, in 20.1%. By multivariate analysis, invasion according to intraoperative findings was associated with the sparsely granulated corticotroph (SGCA, P = .0026) and sparsely granulated somatotroph (SGSA, P = .0103) adenoma type as well as age (P = .0287). Radiographic invasion according to Knosp grades 3A-4 correlated with age (P = .0098), SGCAs (P = .0005), SGSAs (P = .0351), and gonadotroph adenomas (P = .0478). Both criteria of invasion correlated with subtotal resection (P = .0001, respectively).

Conclusions

Both intraoperative and radiographic signs of invasive growth are high-risk lesions for incomplete extent of resection and occur more frequently in older patients. A particularly high prevalence of invasion can be found in the SGCA and SGSA types. Cavernous sinus invasion is also more common in gonadotroph adenomas. Usage of the Knosp classification is a valuable preoperative estimation tool.
Strike early–strike strong lipid-lowering strategy with proprotein convertase subtilisin/kexin type 9 inhibitors in acute coronary syndrome patients: real-world evidence from the AT-TARGET-IT registry
Authors: Gargiulo Paola , Basile Christian , Galasso Gennaro , Bellino Michele , D’Elia Debora , Patti Giuseppe , Bosco Manuel , Prinetti Matteo , Andò Giuseppe , Campanella Francesca , Taverna Giovanni , Calabrò Paolo , Cesaro Arturo , Fimiani Fabio , Catalano Angelo , Varbella Ferdinando , Corleto Antonella , Barillà Francesco , Muscoli Saverio , Musumeci Giuseppe , Delnevo Fabrizio , Giallauria Francesco , Napoli Raffaele , Porto Italo , Polimeni Alberto , Quarta Rossella , Maloberti Alessandro , Merlini Piera Angelica , De Luca Leonardo , Casu Gavino , Brunetti Natale Daniele , Crisci Mario , Paloscia Leonardo , Bilato Claudio , Indolfi Ciro , Marzano Federica , Fontanarosa Sara , Buonocore Davide , Parlati Antonio Luca Maria , Nardi Ermanno , Prastaro Maria , Soricelli Andrea , Salvatore Marco , Paolillo Stefania , Perrone-Filardi Pasquale , Cuomo Gianluigi , Testa Crescenzo , Passaretti Gianluca , Vallefuoco Giuseppe , Romano Annalisa , Dell’Anno Raffaele , Merolla Aurora , Iannone Francesca Paola
Published: May 2024

Aims

No data are available on early initiation of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in patients with acute coronary syndrome (ACS) in the real world. This study investigates the effects of PCSK9i started at time of ACS hospitalization on lipid control and major cardiovascular (CV) events in the real world.

Methods and results

The lipid control outcome was the percentage of patients reaching the LDL-C target of <55 mg/dL at first lipid control. The clinical outcome was the incidence of composite major CV events (all-cause death, non-fatal MI, non-fatal stroke, and ischaemia-driven revascularization) during a follow-up in relation to quartiles of LDL-C at first lipid control. We included 771 patients with ACS from the AT-TARGET-IT registry, receiving PCSK9i prescription during hospitalization or at discharge. Median LDL-C was 137 mg/dL and decreased to 43 mg/dL at first lipid control. 527 (68.3%) patients achieved LDL-C target at the first lipid control at a median time of 37 days from hospitalization; of them, 404 (76.8%) were discharged on statin plus ezetimibe background therapy. Event curves through a median follow-up of 11 months across quartiles of LDL-C showed a stepwise lower risk of 4P-MACE, 3P-MACE, all-cause mortality, and ischaemia-driven revascularization in lower quartile of LDL-C values at first lipid control (<23 mg/dL) and in patients reaching LDL-C < 55 mg/dL.

Conclusion

Intensive and early lipid-lowering therapy using PCSK9i in patients with ACS (strike early–strike strong strategy) is safe and effective in clinical practice and associated with a reduction of residual CV risk.
Comparative effectiveness of different management strategies for left atrial appendage thrombus in patients on optimal NOAC therapy
Authors: Komlosi F , Toth P , Santa H , Arnoth B , Szakal I , Bohus G Y , Vamosi P , Szucs A , Apor A , Bartha E , Liptai C S , Geller L , Merkely B , Nagy K V
Published: May 2024

Background

Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Novel oral anticoagulants (NOACs) effectively reduce the prevalence of LAA thrombosis and stroke risk. Nonetheless, there is no clear advice for patients with a NOAC-resistant thrombus, necessitating individualized decision-making without strong support of the current guidelines.

Aims

To analyze patients diagnosed with an LAA thrombus despite adequate NOAC therapy and to compare the efficacy of various therapeutic strategies in achieving thrombus resolution.

Methods

We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 who were diagnosed with LAA thrombus despite being on optimal NOAC therapy. These patients underwent follow-up transesophageal echocardiography (TEE) or cardiac CT angiography. Changes in treatment modalities were divided into four groups: transition to an alternative NOAC, switch to a vitamin K antagonist (VKA), the addition of an antiplatelet agent, or the deliberate maintenance of the current treatment.

Results

We analyzed the data of 90 patients comprising 103 cycles of treatment. The patients were either on rivaroxaban (41%), apixaban (32%), dabigatran (15%) or on edoxaban (12%) at the time of the initial TEE. A change to a different NOAC was observed in 37% of cases, transition to a VKA in 22%, supplementation with antiplatelet therapy in 16%, while deliberate absence of treatment modification in 25% of cases. Subsequent follow-up TEE (or CT angiography in a minority of cases) was performed at a median of 68 [43 – 94] days from the baseline evaluation. Successful thrombus resolution was achieved in 72% of cases. Evaluation of therapeutic strategies revealed that any modification of treatment was three times more effective than deliberate no change in treatment; thrombus resolution was observed in 60 (81%) vs. 17 (59%) cases (OR 3.03 [1.18 - 7.75], p = 0.021). Nevertheless, no particular strategy demonstrated superior efficacy over others.

Conclusions

Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the prior anticoagulation strategy; however, none of the commonly employed strategies appears to exhibit distinct superiority over the rest.
Agreement of left atrial pressure with clinical risk scores and echocardiographic features in patients with atrial fibrillation referred for catheter ablation
Authors: Gawalko M , Adriaans B , Habibi Z , Weerts J , Verhaert D V M , Chaldoupi S M , Ter Bekke R M A , Den Uijl D W , Luermans J G L M , Van Empel V P M , Schotten U , Vernooy K , Linz D
Published: May 2024

Background

Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The diagnosis of HFpEF in AF is difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se. Left atrial pressure (LAP) ≥15 mmHg has been used to confirm the diagnosis of HFpEF.

Purpose

We aimed to 1) determine LAP measurements in patients with AF undergoing catheter ablation; 2) assess the agreement between LAP measurement HFpEF risk scores and 3) determine the association between LAP measurement and clinical and echocardiographic features.

Methods

Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Participants were considered to have HFpEF if the mean LAP was ≥15 mm Hg. The LAP was measured only in sedated patients with spontaneous breathing. Participants had high probability of HFpEF if scored >5points in H2FPEF and/or ≥5 points in HFA-PEFF score.

Results

Of 107 participants, 29 (27%) had HFpEF according to mean LAP and 32 (30%) had high probability of HFpEF according to HFpEF scores. The highest agreement of HFpEF risk scores relative to elevated LAP was observed for H2FPEF score; among patients with mean LAP ≥15 mm Hg, 38% [n=11/29] of them had also high risk of HFpEF based on H2FPEF score, whereas only 10% [n=3/29] had high risk of HFpEF based on HFA-PEFF score. In multivariable analysis, the independent predictors of HFpEF were left ventricular ejection fraction (LVEF; OR 0.77, 95%CI 0,.64-0.91), intraventricular septum diameter (IVSd; OR 1.75, 95%CI 1.11-2.74), global longitudinal strain (GLS; OR 1.24, 9%CI 1.05-1.48).

Conclusions

More than one-fourth of patients scheduled for catheter ablation had HFpEF according to elevated LAP. The highest agreement to elevated LAP was observed for the H2FPEF score. Predictors of HFpEF diagnosis were lower LVEF, higher IVSd and GLS.
Rate control with Landiolol in atrial tachyarrhythmias and comorbid left ventricular dysfunction: a systematic review and meta-analysis
Authors: Nasoufidou A , Papazoglou A S , Stachteas P , Karagiannidis E , Samaras A , Alexiou S , Kassimis G , Fragakis N
Published: May 2024

Backround

Atrial tachyarrhythmias (ATs) are frequently inter-related with heart failure (HF). ATs exacerbate HF, while the existence of chronic HF precipitates the occurrence of ATs. Landiolol, a highly selective and exceptionally-short acting beta-1 blocker has been used in patients with ATs and HF, where evidence on the available treatment options is limited.

Purpose

In this meta-analysis we intended to assess the clinical effects of rate control with landiolol in patients with ATs and comorbid left ventricular dysfunction, who are not septic or in peri-operative stage.

Materials and Methods

We systematically searched PubMed, Scopus and WebofScience up to 14 July 2023. Two independent reviewers screened and selected randomized control trials as well as observational studies according to predetermined eligibility criteria. Risk of bias and quality of evidence were assessed according to Cochrane guidelines.

Results

2278 articles were initially screened and 11 studies were finally included in this systematic review. In 7 of the eligible studies landiolol was compared with placebo, while in the remaining 4 studies landiolol was investigated in comparison with other antiarrhythmic drugs and specifically digoxin and diltiazem. The total sample size included 1876 patients, 75% of whom were classified into III/IV NYHA class. Landiolol treatment reduced patients’ heart rate by a mean of 42 beats per minute (95% CI: 37-47 bpm) while 3 out of 4 treated patients accomplished targeted heart rate, described as an at least 20% reduction from baseline heart rate and final heart rate less than 110bpm. Compared to patients receiving other antiarrhythmic therapy, patients treated with landiolol had increased odds of achieving target heart rate (OR: 5.32, 95% CI: 2.87-10.05). Referring to landiolol safety, 15% of the treated patients encountered an adverse event, more frequently dose-dependent hypotension. Landiolol was discontinued only in a 6% of the treated patients. No difference in adverse events was identified between landiolol and other antiarrhythmic drugs.

Conclusion

In this meta-analysis landiolol has achieved satisfactory levels of efficacy and safety regarding rate control in patients with ATs and left ventricular dysfunction.Prisma FlowchartLandiolol efficacy in single-arm studies
Left atrial strain defines functional and structural remodeling in patients with persistent atrial fibrillation
Authors: Duckwitz N , Herzer L , Kirsch K , Mettke F , Hamadanchi A , Schulze P C , Surber R , Grosse A
Published: May 2024

Background

Left atrial (LA) strain is an echocardiographic method to detect atrial dysfunction as a process of structural and functional remodeling of the atria. In patients with persistent atrial fibrillation (AF), functional changes and an enlargement of the LA due to structural remodeling has been described. The aim of our study was 1) the echocardiographic assessment of LA function using LA strain and 2) to investigate the correlation between LA strain and left atrial size index (LAVI) using 3D reconstruction of the LA from multi-detector computed tomography (CT).

Methods

This study includes patients with persistent AF who underwent LA catheter ablation without prior treatment. All subjects underwent measurement of reservoir (LASr), conduit (LAScd) and contraction (LASct) LA strain using imaging using two-dimensional speckle tracking echocardiography (2D-STE) and cardiac CT. A 3D reconstruction of the LA from the CT was done using EnSite Verismo (Abbott, USA). The LA volume obtained at the end-systole included LA appendage reconstruction and excluded the pulmonary veins. LAVI was calculated by dividing LA volume by body surface area.

Results

The study included 36 patients (mean age 69 yrs [49 to 80 yrs], 27 male, mean LV-EF 56% [40 to 78%).

We found the following LA strain measurement: mean LASr 21% [6 to 52%], mean LAScd -12% [-32 to -0,25%] and mean LASct -9% [-32 to -1%]. LAVI: mean 82 ml/m² [38 to 127 ml/m²].

There is a statistically significant negative correlation between LASr (p = 0.002, r = -0.503) and a statistically positive correlation between LASct (p = 0.003, r = 0.482) compared to the LA volume, whereas there is no statistically significant correlation between LAScd and the LA volume (p = 0.088, r = 0.288).

Discussion

LA strain in patients with persistent AF as an expression of functional remodeling is reduced compared to normal values in literature. Correlation of LA strain and LAVI are statistically significant for LASr as well as LASct. The correlation between LAScd and LAVI did not reach statistical significance but shows a trend towards a positive correlation. Whether early treatment of AF could prevent further fibrotic remodeling with reducing LA volume and improving LA strain needs further research.
Catheter ablation of atrial fibrillation shows pulmonary vein dependent effect on the signal-averaged P-wave morphology
Authors: Fantazi N , Napp A , Berbers J , Emrani M , Hermans B , Zeemering S , Schotten U , Gramlich M , Zink M D
Published: May 2024

Background and Aims

Cryoballoon ablation of atrial fibrillation alters a significant amount of vital myocardium that contributes to its electrical activity. However, the impact of pulmonary vein isolation (PVI) on P-wave morphology is unclear. The aim of this investigation was to quantify whether the contribution of the left or right pulmonary veins (PVs) is greater using means of signal-averaged P-wave analysis.

Methods

Unfiltered high-resolution (2000 samples/second) ECGs were obtained for 5 minutes both pre- and post-isolation of the left and right PVs, with 12 standard and 10 additional leads (x01-x10). Additional lead positions were determined in prior studies for optimal detection of atrial electrical activity not captured by standard leads. Signal-averaged ECGs were computed and analyzed using bespoke software in Matlab. Statistical significance was assessed using a two-tailed paired t-test. A total of 69 participants were screened for the study. For the analysis, 64 participants with sinus rhythm in all ECG recordings were eligible.

Results

Significant postablation changes for various ECG parameters across different lead combinations were found (Table 1). On average, after ablation of the left pulmonary veins (LPVs), there was a reduction in P-wave terminal force (3.07±2.05 mV*ms vs. 2.84±1.88 mV*ms, p = 0.044), P-wave complexity (2.02±0.64 vs. 1.90±0.57, p = 0.047), and sample entropy (0.210±0.039 au vs. 0.197±0.031 au, p < 0.001), whereas P-wave duration (148.24 ms vs. 153.23 ms, p < 0.001) and PQ time (200.41 ms vs. 205.43 ms, p < 0.001) prolonged. However, after ablation of the right pulmonary veins (RPVs), sample entropy decreased (0.196±0.031 au vs. 0.190 ±0.027 au, p = 0.049) and amplitude increased (0.087±0.024 mV vs. 0.091±0.024 mV, p = 0.002).

Conclusion

PVI in atrial fibrillation has a significant effect on signal-averaged P-wave. These effects are more pronounced after ablation of the LPVs than the RPVs. Parameters such as PWTF, PWC and SaE demonstrate potential to assess the effect of catheter ablation and may serve as a potential indicator for a successful procedural outcome.
Echocardiographic follow-up after AV node ablation combined with left bundle branch area pacing for patients with symptomatic atrial fibrillation
Authors: Rijks J , Lankveld T , Manusama R , Broers B , Van Stipdonk A M W , Chaldoupi S M , Ter Bekke R M A , Schotten U , Linz D , Luermans J G L M , Vernooy K
Published: May 2024

Background

AV node ablation combined with permanent pacing is an established therapy for rate control in patients with symptomatic atrial fibrillation (AF) refractory or intolerant to pharmacological rate or rhythm control and not eligible for rhythm control by left atrial catheter ablation. The threshold for performing this so-called "pace-and-ablate" strategy has decreased since the introduction of conduction system pacing, and especially left bundle branch area pacing (LBBAP).

Purpose

To investigate the change of the left-ventricular (LV) ejection fraction (EF) and left-atrial volume index (LAVI) in patients with symptomatic AF, twelve months after LBBAP and AV-node ablation.

Methods

Consecutive patients with symptomatic AF intolerant or refractory to pharmacological rate and symptom control and deemed not eligible for left atrial catheter ablation were included. At baseline, the EHRA score was noted and the LVEF and LAVI were measured echocardiographically. Patients were subdivided in a normal baseline LV ejection fraction (LVEF >50%) or diminished baseline LVEF (LVEF <50%) group. After LBBAP, patients underwent AV node ablation in the same procedure or four weeks later. After twelve months, the LVEF and LAVI were reassessed in the entire cohort and the two subgroups.

Results

Twenty-two patients (68% female, mean age 79±4 years) scheduled for pace-and-ablate therapy were prospectively included. Three (14%) had paroxysmal, sixteen patients (72%) had persistent AF and three patients (14%) long-standing persistent AF. An EHRA class IIb or higher was found in eighteen patients (82%). At baseline, the mean LVEF was 51 ± 7%, the mean LVEDD 47 ± 6 mm and LAVI 54 ± 18 ml/m2. Twelve patients (55%) had a preserved LVEF, whereas ten patients (45%) had an LVEF <50%, fig. 1. After twelve months, the overall ejection fraction increased to 54 ± 5% (p=0.016), fig. 2A. This was mostly attributed to the increase in LVEF to 51 ± 5% in the subgroup with a reduced baseline LVEF (p=0.009 compared to baseline 44 ± 5%), fig. 2A. The LVEF was unaffected in the other group (57 ± 3% vs. 57 ± 4%, p=0.63), fig. 2A. The LAVI was not significantly reduced in the overall cohort or the subgroups (54 ± 18 ml/m2 to 51 ± 19 ml/m2, p=0.16), fig 2B.

Conclusion

AV node ablation combined with LBBAP results in a significant improvement in LVEF at twelve months follow-up. This is mainly driven by an improvement in LVEF in those patients with a diminished LVEF at baseline. The data suggests that the therapy can reverse a tachycardiomyopathy without inducing a pacing-induced cardiomyopathy. No significant reduction in LAVI was found.Baseline characteristicsChanges in LVEF (A) and LAVI (B)
The role of Ranolazine alone or in combination with a Class III anti-arrhythmic drug for DC cardioversion for persistent AF
Authors: Raman S , Rutherford P , Das M
Published: May 2024

Background

Electrical cardioversion (DCCV) is commonly used for rhythm-control in patients with persistent AF. Use of anti-arrhythmic drugs (AADs) increases rates of acute conversion and longer-term maintenance of sinus rhythm (SR) following DCCV. Of these, Amiodarone is the most effective but has a high side-effect burden. Ranolazine, currently licensed for angina, has been shown to have AF-suppressive effects and works synergistically with Class III AADs.

Purpose

We aimed to assess outcomes following DCCV in patients treated with a Class III AAD, Ranolazine or in combination at a single UK tertiary Cardiology centre.

Methods

We retrospectively reviewed DCCV lists from June 2020-February 2022. Patients undergoing DCCV on a Class III AAD (Amiodarone/Dronedarone), Ranolazine or a combination of the two and with documented 1-year follow-up were included. Patients who underwent AF ablation during the follow-up period having remained in SR up to that point were excluded. Acute DCCV success and maintenance of SR at 1-year follow-up were recorded.

Results

A total of 350 patients underwent DCCV during the study period, of whom 102 (29.1%) were on an AAD. After exclusions, 78 patients were included, as follows: Amiodarone - n=30; Dronedarone - n=23; Ranolazine - n=11; combined Ranolazine + Class III AAD - n=14.

Acute outcomes:

The proportion of patients achieving SR acutely post-DCCV was as follows:

Amiodarone: 27/30 (90.0%)

Dronedarone: 21/23 (91.3%)

Any Class III AAD: 48/53 (90.6%)

Ranolazine: 10/11 (90.9 %)

Combined Ranolazine + Class III AAD: 14/14 (100%).

1-year follow-up outcomes (Figure 1): The proportion of patients who had remained in SR at 1 year (mean follow-up 11±1.9 months – similar for all 4 groups) was as follows:

Amiodarone: 12/30 (40.0%)

Dronedarone: 4/23 (17.4%)

Any Class III AAD: 16/53 (30.2%)

Ranolazine: 3/11 (27.2%)

Combined Ranolazine and Class III AAD: 8/14 (53.3%).

Despite including 5 patients (35.3%) who had previously failed an AAD monotherapy, the group taking a combination of Ranolazine and a Class III AAD were numerically more likely to remain in SR at 1-year follow-up than those on Amiodarone or Ranolazine, though neither reached significance. However, combination therapy was significantly more effective than Dronedarone monotherapy (P=0.03) and there was a trend towards improved efficacy compared to any Class III AAD (53.3% vs. 30.2%, P=0.11). There were no significant differences between the 3 monotherapy treatments.

Conclusion

A combination of Ranolazine and Class III AAD may improve maintenance of SR 1 year post-DCCV compared to a Class III AAD alone. Ranolazine also shows comparable efficacy to traditional Class III agents and could therefore be considered as an alternative for patients in whom a Class III AAD is not desirable. Larger randomised multi-centre trials are warranted to evaluate the efficacy and safety of these treatment strategies.
Different predictors of AF recurrence after pulmonary vein isolation with cryoballoon and radiofrequency ablation: insights from clinical and electroanatomical mapping data of the NO-PERSAF study
Authors: Wollner K , Rossvoll O , Tande P , Solheim E , Schuster P M , Chen J
Published: May 2024

Background

Pulmonary vein isolation (PVI) with cryobaloon ablation (CBA) and radiofrequency ablation (RFA) lead to a similar outcome of freedom from atrial tachyarrhythmia (ATA) during follow-up as showed by the NO-PERSAF study. Analyses of ATA recurrence for these two techniques based on data of electroanatomical mapping (EAM) are scarce from randomized clinical trials.

Purpose

This study aimed to evaluate and compare clinical outcomes and EAM data recorded in the left atrium (LA) during CBA and RFA procedures in patients with persistent atrial fibrillation (AF).

Methods

For the NO-PERSAF study, 101 patients (mean 63.2±8.6 years, 80 male, 21 female) with persistent AF (77 persistent AF, 24 long-standing persistent AF) referred to PVI were randomized (1:1) to CBA or RFA and followed for 12 months. A prolonged 3-year follow-up was carried out. EAM was performed by a circular mapping catheter with a 3-dimensional mapping system in all patients. EAM data were recorded and analyzed off-line. The areas of the LA, posterior wall, low-voltage (<0.5mV) and complex fractionated electrogram (cycle length <120 ms) were measured and corrected by body surface area (BSA). EAM data from 90 patients were qualified for further analysis and the others (5 in CBA and 6 in RFA) excluded because of disqualification or technical failure of recording. Correlation between clinical results of 3-year follow-up and the EAM data were analyzed using univariate cox regression.

Results

After 3-year follow-up, freedom from ATA was achieved in 51 (50.5%) of the 101 patients, 28 (54.9%) out of 51 patients in the CBA group and 23 (46.0%) out of 50 patients in the RFA group and no difference was found (p=0.327). RFA compared with CBA resulted in larger ablation lesions in the LA (23.9% vs. 21.3%; p=0.037) and particularly in the posterior wall (44.2% vs 31.8%; p<0.001).

Compared between the patients with and without recurrence, there was no difference with respect to age, gender, AF history, body mass index, heart disease and CHA2DS2-vasc score. For EAM data, the area of the LA and low voltage were significantly higher in ATA recurrent patients in CBA group, but not in RFA group (Table 1).

Univariate cox regression analyses suggested that 3-year follow-up outcomes were associated with the size of the LA and the amount of low voltage corrected by BSA. The criteria of the LA area >55 cm2/m2 or low voltage area <19 cm2/m2 could predict ATA recurrence after CBA, but not after RFA procedure (Figure 1).

Conclusions

The size of the LA and the amount of low voltage corrected by BSA was associated with the outcomes of PVI during follow-up and could be employed as predictors of ATA recurrence for CBA, but not for RFA procedure.Table 1Figure 1K-M curves after CBA and RFA
A proposed index of myocardial staining for vein of marshall ethanol infusion
Authors: Landra F , Nesti M , Garibaldi S , Mirizzi G , Startari U , Panchetti L , Piacenti M , Taddeucci S , Formichi B , Stefani M , Galiberti S , Lionetti V , Solinas P , Levantesi B , Rossi A
Published: May 2024

Background

Mitral isthmus(MI) conduction block is a fundamental step in anatomical approach treatment for persistent atrial fibrillation(PeAF). However, MI block is hardly achievable with endocardial ablation only. Retrograde ethanol infusion(EI) into the vein of Marshall(VOM) facilitates MI block. Fluorographic myocardial staining(MS) during VOM-EI could be helpful in predicting procedural alcoholization outcome even if its role is qualitatively assessed in the routine.

Purpose

The aim was to quantitatively assess MS during VOM-EI and to evaluate its association with MI block achievement.

Methods

Consecutive patients undergoing catheter ablation for PeAF at our Institution from February 2022 to May 2023 were considered. Patients with identifiable VOM were included. A proposed index of MS(MSI) was retrospectively calculated in each included patient. Correlation of MSI with low voltage zones(LVZ) extension after VOM-EI and its association with MI block achievement were assessed.

Results

42 patients out of 49 (85.8%) had an identifiable VOM. MI block was successfully achieved in 35 patients out of 42 (83.3%). MSI was significantly associated with the occurrence of MI block (OR 1.24 (1.03 – 1.48); p = 0.022). A higher MSI resulted in reduced ablation time (p = 0.014) and reduced radiofrequency applications (p = 0.002) to obtain MI block. MSI was also associated with MI block obtained by endocardial ablation only (OR 1.07 (1.02 – 1.13); p = 0.002). MSI was highly correlated with newly formed LVZ extension (r = 0.776; p = 0.001).

Conclusion

In our study cohort, optimal MSI predicts MI block and facilitates its achievement with endocardial ablation only.Myocardial stainingSpline plots
Intraprocedural and outcome findings in repeat left atrial procedures after pulsed field ablation for pulmonary vein isolation in paroxysmal and persistent atrial fibrillation
Authors: Woermann J , Jueker J , Van Den Bruck J , Filipovic K , Erlhoefer S , Scheurlen C , Dittrich S , Ackmann J , Pavel F , Schipper J , Steven D , Sultan A
Published: May 2024

Background

Pulsed Field Ablation (PFA) has emerged as a promising novel technique for pulmonary vein isolation (PVI) in the setting of atrial fibrillation. First outcome data revealed comparable success rates to radiofrequency and cryoablation. However, data on lesion dimensions and reconnection of PV after PFA potentially causing recurrence of AF is sparse. We, therefore report on pivotal reconnection sites and ablation extend after PFA-PVI.

Methods

All patients after PFA-PVI for paroxysmal or persistent AF at our center between September 2021 and October 2023 were included in this retrospective analysis. Baseline characteristics, procedural and outcome data were obtained. Furthermore, in all redo procedures of these patients lesion dimensions and the occurrence and location of PV gaps were evaluated.

Results

A total of 123 patients with atrial fibrillation underwent successful PFA-PVI during index procedure. The study cohort comprised [n= 52; 42%] paroxysmal and [n= 71; 58%] persistent atrial fibrillation cases. After a median follow-up of 123 (IQR 93-150) days recurrence of atrial arrhythmia (all AF) occurred in 9 [14. 5%] patients. Of these, 6 [9.6%] patients underwent a redo procedure due to recurrence of atrial fibrillation (3 PAF and 3 persAF [50%]; p=1). All left atrial maps and 24 PVs were analyzed. All 6 [100%] patients exhibited electrical reconnection of one or more pulmonary vein. Analysis of redo procedures revealed that the dimensions of PFA-induced lesions varied among patients: The right inferior pulmonary vein (RIPV) showed reconnection in all redo-patients (100%). Also frequent reconnection was observed for the RSPV (3 pts [50%]) and LIPV (2 pts [33%]). The gap size was 66±40% of the circumference in the reconnected RPVs and 61±31% in the reconnected LPVs. A roof-line lesion set was performed in 4 out of 6 pts (67%) due to the initially antral PV lesions affecting the posterior wall and LA roof potentially creating an isthmus for roof-dependent atrial tachycardia (AT).

Conclusion

Outcome data for PFA-PVI are comparable to other energy sources used for PVI. However, reconnection of PV also occurs after PFA-PVI. This retrospective analysis of redo procedures after initially successful PVI identified the RIPV as pivotal for reconnection. Furthermore, map analysis revealed that reconnection gaps extend to up to 2/3 of the initial circumferential PV ablation area. Furthermore, PFA seems to create new critical isthmuses potentially causing AT. No difference in reconnection was seen comparing PAF and persAF.
Impact of pulmonary vein variant anatomy during cryo-ablation in paroxysmal and persistent AF patients: 1-year outcome from a nationwide multicenter clinical setting
Authors: Moltrasio M , Bianchi S , Iacopino S , Tondo C , Agresta A , Pecora D , Narducci M L , Maggio R , Sangiuolo R , Nicolis D , Riva S , Rossi P , Ferraro A , Malacrida M , De Simone A
Published: May 2024

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). While contrast findings exist regarding the influence of variant pulmonary vein (PV) anatomy on predicting AF recurrence, limited data are currently available specifically for cases involving the POLARx cryoablation system during PVI.

Purpose

We report the real-world experience of POLARx in the context of de novo AF ablation in a multicenter Italian registry.

Methods

Consecutive patients undergoing AF ablation from the CHARISMA registry at 10 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. The ablation endpoint was PVI as assessed by entrance and exit block. All patients were followed-up for at least 12 months after the procedure.

Results

Four-hundred twenty-nine patients were included (n=358, 83.4% paroxysmal AF, n=71, 16.6% persistent AF, mean age 60.7±10 years, 28.3% female, mean LVEF 58±8%). PVI was achieved in all pts using only cryoablation. Twenty-eight (6.6%) patients exhibited an anatomical variant: 17 (4.0%) a common ostium and 11 (2.6%) an adjunctive PV. The mean number of freeze applications per patient was 5.1 (1.2 for LSPV, 1.3 for LIPV, 1.2 for RSPV and 1.3 for RIPV). Over a median of 398[370-461] days of follow-up, 14 (3.2%) patients experienced an early recurrence of AF during the 90-day blanking period. Overall, 63 patients (14.7%) suffered an AF recurrence after the 90-day blanking period (median time to recurrence 342[171-381] days). The proportion of patients exhibiting AF/AT recurrences was higher in the persistent AF group (17 out 71, 23.9%) than in the paroxysmal AF group (46 out 358, 12.8%, p=0.026), with a hazard ratio of 2.02 (95%CI: 1.2 to 3.5, p=0.0137) whereas patients with anatomy variant showed a similar AF/AT recurrence rate (5 out 28, 17.9%) than in the standard anatomy group (58 out of 401, 14.5%) with a hazard ratio of 1.43 (0.6 to 3.6, p=0.441). Four (0.9%) transient phrenic nerve palsy were observed, both with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported.

Conclusion

In this multicenter study, the cryo-balloon system demonstrated safety and efficacy in treating both paroxysmal and persistent AF patients, yielding a low incidence of AF/AT recurrence during follow-up, regardless of the presence of variant PV anatomy.
Effectiveness of a novel integrated dilator-needle transseptal crossing device in atrial fibrillation cryoballoon ablation procedures
Authors: Benezet Mazuecos J , Lozano A , Miracle A , Crosa J , Esteban I , Elosegui C , Illescas C , Iglesias J A
Published: May 2024

Background

In cryoballoon ablation (CBA) procedures, left atrial (LA) access is generally achieved using a standard sheath and needle system that is exchanged for the cryoballoon delivery sheath and dilator over a long wire. Sheath exchange has been related with air embolic events in CBA procedures. A novel integrated dilator-needle system, that can be combined with the cryoballoon delivery sheath allowing direct LA transseptal access, was recently introduced. Figure.

Objective

The purpose of this study is to evaluate the efficacy and safety of this new integrated transseptal access tool compared with the traditional approach in CBA procedures.

Methods

In this prospective single-center study, consecutive patients who underwent AF CBA procedures were randomly assigned 1:1 to undergo traditional transseptal access (t-TSA) or integrated transseptal access (i-TSA). Patients with foramen ovale or interatrial communication, detected on transesophageal echocardiogram prior to the procedure, were excluded. Transseptal access time was defined as time from superior vena cava to LA insertion of the cryoballoon delivery sheath, after sheath exchange (t-TSA) or directly (i-TSA).

Results

We evaluated 82 patients (63 males, mean age 59 ± 10 years) indicated to CBA of atrial fibrillation, 42 patients underwent t-TSA and 40 i-TSA. The baseline characteristics of the study population were comparable between groups. Table. Mean CBS transseptal access time was 5 min 6 sec ± 2 min 5 sec in the t-TSA group and 3 min 5 sec ± 2 min 23 sec in the i-TSA group, P < 0.001. Challenging interatrial septa were noted in 3 patients: 1 in t-TSA (1 aneurysmal/elastic) and 2 in i-TSA group (1 lipomatous hypertrophy, and 1 abnormally thickened/fibrotic). No acute complications related to transseptal access were noted in both cohorts. The CBA procedure time and fluoroscopy time were lower in the i-TSA group. Table. There were 1 temporary phrenic nerve injury and 1 vascular complication, both in the t-TSA group. Importantly, no signs of clinical air embolism were noted in both groups.

Conclusion

This is the first randomized study comparing the traditional approach and the use of a new integrated dilator-needle system. Transseptal crossing in CBA procedures using this integrated tool enables a safe and more efficient workflow, reducing time for transseptal access and avoiding sheath exchange.FigureTable
One-year outcome of wide-area pulmonary vein isolation using the third-generation visually guided laser balloon
Authors: Yamasaki T , Kakita K , Pak M , Hattori T
Published: May 2024

Background

The third-generation laser balloon (LB3) is equipped with an ultra-compliant balloon and a motor-driven laser generator, which contribute to durable and gapless isolated lesion creation. However, the efficacy of wide-area pulmonary vein (PV) isolation (PVI) using LB3 remains to be elucidated.

Purpose

This study aims to investigate efficacy of wide-area PVI using LB3.

Methods

This is a single-center retrospective study. Patients with atrial fibrillation (AF) who underwent LB3 ablation during the period from August 2021 to June 2022 were enrolled. All PVs were electrically isolated only by LB3. After initial circular ablation, LB3 was inflated to a larger size at each PV, and the isolation area was extended. After ablation, voltage maps of the left atrium were obtained by high-resolution mapping catheters to evaluate isolation areas (<0.1mV). Follow-up included a 12-lead electrocardiogram, Holter monitoring, and/or pacemaker/implantable cardioverter-defibrillator interrogation. The efficacy endpoint was defined as freedom from atrial tachyarrhythmia (ATa) between months 3 and 12.

Results

Forty-four patients with paroxysmal AF and 34 with persistent AF (mean arrhythmia duration 12.4 months, range 1–60 months) were included. First pass isolation was achieved in 90.6% (280/309) of PVs. The total laser application time was 24.1±6.4 minutes, and the total delivered energy was 15.3±3.2 kJ. The isolation area at the left- and right-sided PV antrum were 14.2±1.8 and 19.5±1.1 cm², respectively. At the end of the 12 months of follow-up, the freedom from ATa was 78.2% in patients with paroxysmal AF and 78.0% in persistent AF, which indicates ATa free survival at one year was similar in both groups (P=0.91).

Conclusions

Wide-area PVI using LB3 may lead to favorable outcomes in patients with AF.Fluoroscopic and endoscopic imageKaplan-Meier curves and voltage map
Cardiovascular magnetic resonance 3D LGE imaging for atrial fibrillation ablation
Authors: Letsas K , Saplaouras A , Mililis P , Kariki O , Dragasis S , Patsiotis I , Bazoukis G , Efremidis M , Nyktari E
Published: May 2024

Objective

To assess feasibility and reliability of cardiac magnetic resonance (CMR) imaging in visualizing left atrial (LA) structural changes that patients with paroxysmal atrial fibrillation (PAF) undergo acutely and long-term post ablation. Two different ablation methods i.e pulsed filed ablation (PFA) and cryoablation were studied.

Background

Pulmonary vein (PV) isolation has become the cornerstone technique for catheter ablation in patients with drug-refractory atrial fibrillation (AF). At present, almost all ablation technologies are mediated by a thermal effect. Recently, pulsed field ablation (PFA) has been introduced as a new energy source. PFA is a non-thermal ablative modality in which high voltage ultra-short pulses are applied to target tissue, while preserving the extracellular matrix architecture, nerves, and microvascular structures. Few data exist showing different structural LA changes between the two methods using Three-Dimensional (3D) Late Gadolinium Enhancement (LGE) Imaging.

Methods

CMR imaging was performed pre-ablation, acutely (<24 h), and 3 months post-ablation in 10 patients with paroxysmal atrial fibrillation (AF) undergoing pulmonary vein (PV) isolation with PFA (n = 5) or cryoablation (n = 5). 3D LGE and T2-weighted images were analysed. We obtained two data sets of 3D whole heart LGE imaging with high resolution, 20minutes post gadolinium injection. Patients underwent two acquisitions: the conventional respiratory navigated, electrocardiographically-gated 3D fast gradient echo (1.3slice thickness, 256x256 matrix acquisition) and the image-navigated isotropic high resolution 3D LGE with Dixon water-fat separation. 3D LGE data were analysed using a dedicated (ADAS LA) software in order to produce a 3D-LA model visualization of LGE areas.

Results

In the acute stage, LGE volume was 50% larger after PFA vs. cryoablation (P < 0.001), and oedema on T2 imaging was significantly smaller (visual estimation) on PFA cases. LGE rings surrounding PV ostia were more homogeneous after PFA, with no sign of microvascular damage or intramural hemorrhage as compared to cryoablation cases. In the chronic stage, the majority of acute LGE had disappeared after PFA, whereas most LGE persisted after cryo-ablation. The two 3D LGE sequences used for analysis showed complete agreement in the visualization of atrial scar with superior image quality of the novel sequence. The mean acquisition time for 3D LGE imaging was 11±4minutes for the conventional fast gradient echo sequence, and 5±2minutes for the novel 3D self-image navigated LGE sequence.

Conclusions

CMR imaging may help in visualization and understanding of LA structural remodeling post different ablation techniques.
First clinical experience using a novel 8-spline ultra high-resolution mapping catheter to guide atrial fibrillation ablation
Authors: Khalaph M , Fink T , El Hamriti M , Bergau L , Moersdorf M , Braun M , Sciacca V , Guckel D , Imnadze G , Sommer P , Sohns C
Published: May 2024

Background

Multielectrode mapping catheters improve the detection of scarred and fibrotic tissue in patients with atrial fibrillation (AF) Recently, a novel multispline mapping catheter with 48 closely spaced microelectrodes has been introduced enabling fast high-resolution electroanatomical mapping.

Objective

This study sought to report our initial clinical experience with the novel Octaray catheter in patients with AF undergoing index ablation and to compare its impact on mapping and ablation with the 5-spline Pentaray catheter.

Methods

The study included consecutive patients who underwent index AF ablation using a multipolar mapping catheter and very high-power-short-duration guided ablation (Q4U-AF workflow; QDot; Qmode+; Biosense Webster) in conjunction with a visualized sheath (Vizigo; Biosense Webster). Arrhythmia recurrence was defined as any atrial fibrillation (AF)/ atrial tachycardia (AT) episode lasting > 30 s after a blanking period of 3 months.

Results

A total number of 183 patients undergoing AF ablation using the Octaray and QDot catheter were compared to a group of 166 matched patients who underwent ablation using Pentary and QDot. Utilization of the Octaray catheter resulted in an increased identification of areas with bipolar low-voltage representing fibrosis/scar or atrial cardiomyopathy (mean amount of left atrial bipolar low-voltage: Octaray 31% vs. Pentaray 18%; p= 0.03) and a higher rate of first-pass isolation (FPI) for the left-sided pulmonary veins (Octaray: FPI rate 73% vs. FPI rate 64% for Pentaray). A significantly higher number of mapping points was acquired using the novel 8-spline mapping catheter (right atrium: Octaray 1936 points vs. Pentaray 903 points; p < 0.001 left atrium: Octaray 5337 points vs. Pentaray 2385 points; p < 0.001). Procedural parameter, radiation time/dosage and acute procedural success were comparable between the two groups. During a mean follow-up of 12 months, the overall procedural success was 86 in the Octaray group vs. 84% in the control group (p=0.9).

Conclusion

The utilization of the novel Octaray mapping catheter resulted in an improved detection of atrial fibrosis and scar as well as a higher rate of first-pass pulmonary vein isolation.

Figure: Institutional Q4U-AF-workflow using a multipolar mapping catheter, the QDot ablation catheter and a visualized sheath. High resolution mapping using the Octaray (A+B) and PentaRay catheter (C+D).