bluuebunny/crossref_metadata_2025 huggingface dataset:
Role of diagnosis-to-ablation time in paroxysmal atrial fibrillation: preliminary results of the MULTI AF trial
Authors: Rossi L , Biagi A , Genovese D , Pelargonio G , Devecchi C , Pentimalli F , Bertini M , Bottoni N , Bricoli S , Bolognesi M G , Aschieri D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Diagnosis-to-ablation time (DAT) has been already defined as a predictor of atrial fibrillation (AF) ablation outcome. AF promotes pathological atrial remodelling at electrical, cellular, and structural levels. The aims of this study were to determine the role of DAT in atrial electrical remodelling and its impact on AF recurrencies.

Methods

Between January 2020 and February 2022, 122 patients (62% male, age 63.5±10.8 y) underwent pulmonary veins isolation (PVI) for paroxysmal atrial fibrillation in 7 Italian centres.

For each patient, a high-density bipolar voltage map (BVM) of the left atrium (LA) was acquired by sequential multielectrode mapping in sinus rhythm through the Pentaray™ Catheter and the CARTO3® mapping system. More than 200 voltage points per map were acquired in different segments of the LA (posterior, anterior, lateral, superior, septal and inferior ). The procedural endpoint was PVI by circumferential ablation around the pulmonary vein antra. On top of PVI no "adjunctive" ablations, were performed. All patients were monitored as outpatients for AF recurrence.

Results

For the 122 patients enrolled the mean DAT was 37.6±35.2 months. Two groups were identified according to DAT: 51 patients in Group A with DAT ≤ 12 months and 71 patients in Group B with DAT > 12 months. The two groups have similar clinical, electrocardiographic and echocardiographic characteristics. Intraprocedural pulmonary vein isolation was achieved in all patients.

At the high-density left atrial BVM a concealed electrical remodelling was detected in group B in each LA segment (Fig.1), with the mean global LA voltage amplitude significantly lower in patients with DAT>12 months (group A 2.32±0.81 mV vs group B 1.47±0.74 mV, p<0.01).

After a median follow-up of 11.9±9.4 months, 14 patients (11.4%) had AF recurrencies following the first ablation procedure. A significant lower rate of AF recurrence was found among patients with DAT < 12 months (Fig. 2): 2 patients in group A vs 12 patients in group B (4% vs 18.2%, p<0.01).

Conclusion

Patients with paroxysmal atrial fibrillation with DAT>12 months have significantly lower bipolar LA voltages, revealing a concealed atrial remodelling. Furthermore, DAT>12 months is associated with poor AF ablation outcome.
Insights into level of pulmonary vein isolation using pulsed-field ablation for atrial fibrillation and unexpected effects in the posterior wall
Authors: Osca Asensi J , Izquierdo M T , Navarro J , Cano O , Pimenta P , Ayala H , Jover P , Martinez-Dolz L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Pulse field ablation (PFA) has emerged as an effective, safe and efficient tool for pulmonary vein isolation (PVI).

Purpose

We studied the extent of PVI, specifically the isolation of PV antrum, carina and left atria’s posterior wall after PFA with an ultrahigh density mapping (UHD).

Methods

We involved the first patients referred for atrial fibrillation (AF) ablation treated with a PFA multispline catheter. PFA-lesion extension was assessed with a voltage-map UHD mapping performed before and immediately after PVI.

Results

Sixty-one consecutive patients underwent PVI with PFA (62±10 year old, 23 women, 39 paroxysmal AF). Four out of 61 patients were excluded because their posterior wall was isolated with extra aplications on purpose. Acute results involved a 100% success of PVI and the only safety issue was a pericardial effusion in one patient managed conservatively. Mean procedure and fluoroscopy times were 59±39 min and 16±5 min, respectively. UHD immediately after PVI revealed early reconnection just in one vein (1/228 veins). PFA created wide antral circumferential lesions without electrical activity registered by UHD mapping inside the isolation area. There were no notch-like normal voltage areas at the anterior or posterior side of carinas. As a result of the PVI with this technology, it was observed the existence of a narrow corridor in the posterior wall in 8 patients (14%) and in another 8 cases right and left antral ablation converged at the posterior wall creating an unexpected isolation area. There was a significant relationship between LA posterior inter-carina distance and posterior wall´s level of isolation (77,1±7mm, no affectation; 68,8±7mm narrow corridor; 60,3±1mm posterior wall isolation (fig 1); p=0.036). Finally, it was a significant linear correlation between posterior inter-carina distance and the distance between the ipsilateral, antral levels of isolation at the posterior wall (fig 2, r=0.79, p=0.001)

Conclusion(s)

PFA creates wide antral circumferential PVI lesions involving the ipsilateral veins carina. Nevertheless, in small left atria it can create an undesired isolation or a narrow corridor in the posterior wall.
Patient perspectives on same-day discharge following catheter ablation for atrial fibrillation: results from the FAST AFA trial
Authors: Koenig S , Wohlrab L , Leiner J , Pellissier V , Nitsche A , Hindricks G , Bollmann A
Published: May 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was financially supported by Biosense Webster.

Introduction

Same-day discharge (SDD) protocols following catheter ablation (CA) of atrial fibrillation (AF) were already introduced in selected facilities in Europe but a widespread implementation has not yet succeeded. Data on patients’ perspectives to support early discharge regimens is lacking. Therefore, we conducted a survey to address patients’ beliefs towards SDD and identify variables that are associated with their evaluation.

Methods

As a part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing a left atrial CA for AF or atrial flutter were asked to participate in the survey consisting of a study-specific SDD-questionnaire, the AF knowledge scale and pre-defined patient reported outcome measures. The study cohort was stratified based on SDD willingness and a logistic regression analysis was used to identify predictors for patients’ valuation.

Results

Between 07/26/2021-07/01/2022, 256 of 376 screened patients consented to study participation of whom 248 (median age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%) and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, 52.2% of patients saw no advantages in SDD and expressed concerns including uncertainties with occurring complaints (50.6%), as well as the insufficient recognition (47.8%) and treatment (48.9%) of complications. Symptoms at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not.

Conclusion

We provide a detailed survey expressing patients’ beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts.
Pulsed field ablation for all types of atrial fibrillation single centre experience with individualized approach and medium-term outcome
Authors: Fiala M , Cernosek M , Bulkova V , Bahnik J , Rybka L , Funasako M , Lehar F , Manousek J , Toman O , Kala P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulsed field ablation (PFA) is a promising method to reduce procedure time and improve ablation safety and efficacy in all types of atrial fibrillation (AF).

Purpose

To present ablation approach and medium-term outcomes of PFA in all AF types.

Methods

Between 9/2021-10/2022, PFA using Farawave catheter was performed in 250 patients (63±11 years, 65 females). Patients with paroxysmal AF were basically scheduled for simple pulmonary vein isolation (PVI) (Farawave, ICE), patients with longstanding AF (LSPAF) underwent complex left atrial (LA) PFA (Farawave, CS 10-pole catheter, ICE); ablation extent varied in persistent AF.

Results

Paroxysmal AF (n=131; 115 ablated in SR), persistent AF (n=39; 11 ablated in SR), and LSPAF (n=64) were ablated with procedure times 58±20, 105±28, and 116±32 minutes, respectively, and fluoroscopy times 9±5, 14±7, and 17±7 minutes, respectively. Additional 16 patients underwent PFA for atrial tachycardia (AT). Ongoing AF was terminated by PFA in 13/16 (81%), 16/28 (57%), and 23/64 (36%) patients with paroxysmal AF, persistent AF, and LSPAF, respectively. In groups of paroxysmal AF ablated in SR, paroxysmal AF ablated in AF, persistent AF ablated in SR, persistent AF, and LSPAF, simple PVI was performed in 100%, 50%, 73%, 11%, and 0 patients respectively; and freedom from AF/AT was present in 86/99 (87%), 11/14 (79%), 7/10 (70%), 11/12 (92%), and 40/52 (77%) patients, respectively, of total 187 patients with follow-up ≥3 months (≥6 months in 139 patients). In 8 patients with repeat ablation post-PFA for paroxysmal AF (n=4), persistent AF (n=2), LSPAF (n=2), extra-PV AF/AT sources dominated in all groups. Complications included one tamponade with pericardiocentesis, and prolonged ST elevation with negative coronary angiography.

Conclusion

PFA using Farawave catheter was associated with reduced procedure times and favourable medium-term outcome for all AF types. Early experience specifically suggests improved outcome after extensive LA ablation for persistent AF/LSPAF.
Hybrid ablation of atrial fibrillation: long-term outcomes from a single center prospective experience
Authors: Mouram S , Pannone L , Della Rocca D , Gauthey A , Sorgente A , Del Monte A , Overeinder I , Bala G , Almorad A , Stroker E , Sieira J A , La Meir M , Brugada P , Chierchia G B , De Asmundis C
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/introduction

Hybrid ablation of atrial fibrillation (AF) is emerging as a new technique for rhythm control with good clinical outcomes, especially in patients with non-paroxysmal AF. However, the role of hybrid AF in redo procedures is not clear. Moreover, long term clinical outcomes studies are lacking.

Purpose

The aim of this study is to define the long-term clinical outcomes of hybrid AF ablation in a large cohort from a single high-volume center. Furthermore, a correlation between the timing of hybrid AF and the outcomes is aimed.

Methods

All consecutive patients undergoing to hybrid AF ablation between 2014 and 2020 were enrolled in a prospective fashion. Hybrid ablation was performed in a one-step procedure consisting of: 1) Bilateral thoracoscopic epicardial ablation and 2) Percutaneous mapping and ablation. Pulmonary veins and posterior wall isolation was performed in all patients. Additional lesion set was performed based on physician judgement and clinical indication, including the following: superior vena cava isolation, bicaval line, anterior or posterior mitral line, cavotricuspid isthmus. Hybrid ablation time was analyzed as first hybrid procedure or redo hybrid after previous failed percutaneous procedure.

The primary endpoint was defined as freedom from any atrial tachyarrhythmias (ATas) ≥ 30 seconds after a 90-day post-ablation blanking period.

Results

A total of 120 patients were included, 92 (76.7%) patients with persistent or long-term persistent AF and 28 patients (23.3%) with paroxysmal AF. Hybrid ablation was the first procedure in 85 (70.8%) patients and the second or third procedure (redo or re-redo) in 35 (29.2%) patients. Compared to patients with a second or third hybrid procedure, patients with a first hybrid procedure had more often persistent AF [81 patients (95.3%) vs 11 patients (31.4%), p<0.001].

At a mean follow-up of 52.1 months ± 29.0 there were 36 (30%) ATas recurrences, Figure 1. There was no significant difference in ATas free survival between patients with a first hybrid procedure and patients with a second or third hybrid procedure (69.4% vs 71.4%, Log-Rank p=0.81), Figure 2. Patients with a second hybrid procedure had higher ATas free survival compared to patients with a third hybrid procedure (86.4% vs 46.2%, Log-Rank p=0.01)

Conclusion

In a large cohort undergoing to hybrid AF ablation, the recurrence rate was 30% at a long-term follow-up of more than 4 years. Timing is of utmost clinical importance as delaying hybrid approach might be associated with worse clinical outcome.
Optimal anticoagulation intensity with warfarin for the prevention of thromboembolism with minimal bleeding in Asian patients with atrial fibrillation: multi-center, randomized controlled trial
Authors: Lee K H , Shin S S Y , Koh K J S , Park Y M , Lee J M , Kim S S , Kim J H , Kim D M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Korean Society of Cardiology

Background

Anticoagulation with warfarin in Korean patients with atrial fibrillation (AF) often has been decreased as an international normalized ratio (INR) of prothrombin time between 1.6 to 2.6 for the fear of bleeding, although universal criteria recommends to adjust it between 2.0 to 3.0.

Methods

In this randomized, open-label trial, we compared low intensity anticoagulation (INR 1.6 to 2.6) with standard intensity anticoagulation (INR 2.0 to 3.0) with warfarin in 616 patients with AF and at least 1 risk factor for stroke. The per-protocol, intension-to-treatment analysis was designed to determine whether low-intensity anticoagulation (n=308) was non-inferior to standard-intensity anticoagulation (n=308) with warfarin for the primary end point of net clinical outcomes defined as the sum of stroke, systemic embolism, major bleeding and death.

Results

The median follow-up duration was 1.8 years. Baseline characteristics of the two groups were comparable. Median value of INR was significantly higher in standard-intensity group than low-intensity group (2.19 vs. 2.07, p=0.002), whereas that of time in the therapeutic range was comparable between the 2 groups. The rate of primary outcome was 1.55% per year in low-intensity anticoagulation, as compared with 2.46% per year in standard-intensity anticoagulation (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.22 to 1.74, p for non-inferiority <0.001, p for superiority = 0.365). New-onset stroke occurred in 2 patients (0.52% per year) in low-intensity group and in 5 patients (1.23% per year) in standard-intensity group (HR 0.42, 95% CI 0.08 to 2.17, p for non-inferiority <0.001, p for superiority = 0.297). Major bleeding occurred in 4 patients (0.88% per year) in low-intensity group and 5 patients (1.23% per year) in standard-intensity group (HR 0.84, 95% CI 0.22 to 3.17, p for non-inferiority <0.001, p for superiority = 0.796). Major and minor bleeding occurred in 37 patients (9.58% per year) in low-intensity group and in 40 patients (9.85% per year) in standard-intensity group (HR 0.97, 95% CI 0.59 to 1.58, p for non-inferiority <0.001, p for superiority = 0.899).

Conclusion

In Korean patients with AF, low-intensity anticoagulation with warfarin as INR 1.6 to 2.6 was non-inferior to standard-intensity anticoagulation with warfarin as INR 2.0 to 3.0 for the prevention of net-clinical outcome, and stroke or systemic embolism. There was no significant difference for the risk reduction of major bleeding.
Long-term effectiveness and safety of non-vitamin K antagonist anticoagulant in real world practice
Authors: Roh S Y , Kim D Y , Yoon E L , Lee H , Lee K N
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Backgrounds

Novel oral anticoagulants (NOACs) are effective to prevent stroke in patients with atrial fibrillation. Real world long-term data on the efficacy and safety of NOACs compared to warfarin in Asians are lacking.

Purpose

We aimed to explore the effectiveness and safety of NOAC in Asian patients with atrial fibrillation.

Methods

The medical records were reviewed in registry of four tertiary referral hospitals between January 1, 2012, and December 31, 2020. The primary outcome was the composite of thromboembolism, major bleeding and all caused mortality.

Results

Data were analyzed for 19,994 participants with oral anticoagulant and atrial fibrillation (median age, 72 years; female, 41.5%; warfarin, 35.5%; median CHA2DS2-VASc score, 3). The rate of the primary outcome was 5.5% per year in the NOAC group, as compared with 6.0% per year in the warfarin group (HR with NOAC, 0.70; 95% confidence interval [CI], 0.63 to 0.77; P<0.001 for superiority). The rate of ischemic event was 2.2% per year in the NOAC group, as compared with 2.8% per year in the warfarin group (HR, 0.56; 95% CI, 0.48 to 0.65; P<0.001). The rate of major bleeding was 1.9% per year in the NOAC group, as compared with 2.2% per year in the warfarin group (HR, 0.69; 95% CI, 0.58 to 0.82; P<0.001), and the rates of all caused death were 1.9% and 3.2%, respectively (HR, 0.85; 95% CI, 0.71 to 1.02; P=0.08).

conclusion

In Asian patients with atrial fibrillation, NOAC was effective and safe to prevent thromboembolic events with less bleeding compared to warfarin.
Acute kidney injury following percutaneous left atrial appendage occlusion: results from an international multicentre registry
Authors: Della Rocca D , Magnocavallo M , Gilhofer T , Van Niekerk C , Ha G , D'ambrosio G , Galvin J , Urbanek L , Schmidt B , Lakkireddy D J , Mansour M , Saw J , Horton R , Gibson D , Natale A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Acute kidney injury (AKI) is a serious complication after invasive cardiac procedures and has been associated with a higher incidence of periprocedural complications and increased mortality. Data on the occurrence of AKI associated with left atrial appendage occlusion (LAAO) are very limited.

Purpose

To report the incidence, predictors, and clinical implications of AKI following percutaneous LAAO.

Methods

This multicenter registry included 2124 patients with successful Watchman implantation. AKI was defined according to the AKI Network criteria as an increase in serum creatinine of ≥0.3 mg/dL or of ≥50% over the course of 48 hours post-procedure. Patients meeting this definition were further categorized in three stages: stage 1, increase in serum creatinine ≥ 0.3 mg/dl (≥ 26.4 μmol/l) or of 1.5 to 2 times compared to baseline; stage 2, increase in serum creatinine of 2 to 3 times compared to baseline; stage 3, increase in serum creatinine of > 3 times compared to baseline or serum creatinine ≥ 4.0 mg/dl [≥ 354 μmol/l] with an acute increase of at least 0.5 mg/dl [44 μmol/l].

Results

Post-procedural AKI was documented in 68 (5.5%) of 1234 patients with creatinine determination between 24 and 48 hours post-LAAO. Among them, 63 (92.6%) patients had AKI stage 1, 4 (5.9%) had AKI stage 2, and 1 (1.5%) had AKI stage 3.

AKI was associated with higher CHA2DS2-VASc (5.3 ± 1.4 vs. 4.8 ± 1.4; p=0.001) and HAS-BLED (3.8 ± 0.9 vs. 3.5 ± 1.0; p=0.01) scores at baseline, as well as a higher prevalence of diabetes mellitus (p=0.04) and CHF (p<0.001).

At multivariate analysis (Table 1), independent predictors of AKI were CKD stage 4/5 (OR: 1.998; 95% CI: 1.018 – 3.923; p=0.04), and CHF (OR: 2.286; 95% CI: 1.328 – 3.934; p=0.01).

The average follow-up was 13 ± 7 months. The annualized rates of cardiovascular mortality were 5.5% in AKI and 1.0% in non-AKI patients (p=0.01). The annualized rates of overall mortality were 15.1% in AKI and 3.4% in non-AKI patients (p<0.001).

Conclusion

AKI was an infrequent complication following percutaneous LAAO and a powerful predictor of cardiovascular and overall mortality during follow-up.
Brady- and tachyarrhythmias in paroxysmal atrial fibrillation: results from long-term continuous electrocardiographic monitoring in RACE V
Authors: Park Frausing M H J , Van De Lande M , Maass A H , Nguyen B O , Hemels M E W , Tieleman R , Koldenhof T , De Melis M , Linz D , Schotten U , Weberndorfer V , Crijns H J G M , Van Gelder I C , Nielsen J C , Rienstra M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, and grant support from Medtronic to the institution. MHJPF was funded by a grant from the Karen Elise Jensen Foundation. JCN was supported by a grant from the Novo Nordisk Foundation

Background

Atrial fibrillation (AF) has been associated with adverse events and constitutes a significant, global healthcare challenge. Paucity exists on the occurrence of brady- and ventricular tachyarrhythmias.

Purpose

The aim of this predefined sub-analysis of the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilization in the progression of AF (RACE V) study was to examine the prevalence of brady- and tachyarrhythmias using continuous rhythm monitoring in patients with paroxysmal self-terminating AF (PAF).

Methods

We identified 417 patients with PAF and at least two years of follow-up in RACE V; 25 patients with pacemakers at baseline were excluded. All remaining patients (n=392) received an implantable loop recorder and performed daily automated and weekly manual transmissions. Throughout follow-up, all detected episodes of tachycardia ≥182 BPM (cycle length ≤330ms) of ≥24 beats, bradycardia ≤30 BPM (cycle length ≥2000ms) of ≥12 beats, and pauses ≥5 seconds were adjudicated by three cardiologists.

Results

Over 1,272 patient years of continuous rhythm monitoring, we validated 1,940 episodes in 175 patients with paroxysmal self-terminating PAF (45%); 106 (27%) patients experienced AF or atrial flutter (AFL) with a rapid rate, pauses ≥5 seconds or bradycardias ≤30 BPM occurred in 47 (12%) patients (figure 1), and in 22 (6%) patients, both rapid AF/AFL and bradyarrhythmias were observed. No sustained ventricular tachycardias occurred. In the multivariable analysis, age >70 years (HR 2.4, 95% CI 1.4-3.9), longer PQ interval (HR 1.9, 1.1-3.1), CHA2DS2-VASc score ≥2 (HR 2.2, 1.1-4.5), and treatment with verapamil or diltiazem (HR 0.4, 0.2-1.0) were significantly associated with bradyarrhythmia episodes. For tachyarrhythmia episodes, age >70 years was associated with a significantly lower tachyarrhythmia risk (HR 0.4, 95% CI 0.2-0.7) in the multivariable analysis.

Conclusions

In a cohort exclusive to patients with self-terminating PAF, severe bradyarrhythmia episodes or AF/AFL with rapid ventricular rates occurred in 45% of patients. Our data highlight a higher than anticipated bradyarrhythmia risk in PAF.
Catheter ablation without fluoroscopy in pregnant with supraventricular tachycardia: substrate characterization and outcomes
Authors: Abdrakhmanov A , Ainabekova B , Nuralinov O , Smagulova A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmia is a common extra genital pathology in pregnant. Catheter ablation without fluoroscopy demonstrated similar efficacy and safety to fluoroscopy-based procedure. However, data on pregnant population is limited.

Purpose

To evaluate the arrhythmias substrate and outcomes of catheter ablation without fluoroscopy in pregnant with supraventricular tachycardia.

Methods

44 pregnant with drug refractory supraventricular tachycardia (Mean age 26.4±3.1 years, mean gestation age 22.8±2.1 weeks) undergoing catheter ablation. The substrate characteristics, course of pregnancy, outcomes and arrhythmia recurrence documented during 24 months follow-up.

Results

Ablation was performed under the guidance of CARTO (n=20; 45.5%) and EnSite NavX mapping systems (n=24; 54.5%) without fluoroscopy in all cases. In the majority of cases ablated substrate was slow conduction way (n=21, 47.7%). Ablation of accessory pathways performed in 18 pregnant (40.9%).Combination of accessory pathways with slow conduction ways was present in 5 women (11.4%). Accessory pathways located at left free wall (n=8), in right free wall (n=5), right medioseptal (n=5) and posteroseptal (n=5). The median procedural time was 71 minutes (interquartile range 60-89). Acute success rate was 100%. Procedure related complication was observed in one women (2.3%), who developed an ileofemoral thrombosis. There was no termination of pregnancy after ablation. In two women (4.5%) was preterm delivery at 35 and 36 weeks of gestation. In the majority of cases was vaginal delivery (n=35; 79.5%). In two cases were placental abruption and preeclampsia (4.5%). There were 45 live births (in one case were twins) without any malformation. Neonatal outcomes: fetal birth weight was 3198.5±542.5 grams, 5 minute Apgar score was 8.4±1.1. There were no maternal and fetal mortality. At follow up period arrhythmia recurrence was not documented.

Conclusions

Pregnant mostly underwent catheter ablation for atrioventricular nodal reentrant tachycardia. Catheter ablation without fluoroscopy are safe and feasible in pregnant.
Cardiac implantable electronic devices and outcomes in heart failure patients with syncope
Authors: Rattanawong P , Chao C , Sriramoju A , Tagle-Cornell M , Farina J , Beirne E , Koepke L , Fatunde O , Ko Ko N , Shanbhag A , Barry T , Shen W K
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Mayo Clinic

Background/Introduction

Syncope is a common presentation in heart failure (HF) patients. However, the associations between syncope and prognosis in HF patients with the cardiac implantable electronic device (CIED) have not been demonstrated. It is unclear whether syncope increases all-cause mortality in HF patients with CIED.

Purpose

We aimed to examine the association between syncope and all-cause mortality in the largest cohort of HF with reduced ejection fraction (HFrEF), mid-ranged ejection fraction (HFmEF), and preserved ejection fraction (HFpEF) patients with and without CIED.

Methods

A retrospective cohort of patients with HF and syncope at our hospital between 2010 and 2015 were identified, and 1:1 propensity was matched with a control group of HF patients without syncope. A chart review was conducted. The multivariate Cox regression model was applied to estimate the association between syncope and the all-cause mortality endpoint.

Results

3,449 HF patients were diagnosed with syncope (mean age, 72.8±14.5 years; 41.5% women), and the propensity-matched control HF patients without syncope (n=3,449) aged 72.8±14.3 years, and 42.5% women were selected. Cardiac implantable electronic devices were implanted more in HF patients with syncope (32.5% versus 13.7%, p<0.001). Implantable cardioverter defibrillators were implanted more in HF patients with syncope (15.6% versus 8.3%, p<0.001) as well as pacemakers (16.9% versus 7.5%, p<0.001) and cardiac resynchronization therapy devices (6.9% versus 4.8%, p=0.015). Among HF patients with CIED, syncope significantly increased the risk of all-cause mortality in HFrEF patients (hazard ratio [HR]=1.479, 95% confidence interval [CI]: 1.197-1.828, p<0.001) but not in HFpEF (HR=0.980, 95%CI: 0.793-1.210, p=0.849)(Figure 1). Syncope also tended to increase the risk of all-cause mortality in HFmEF patients with CIED but was not significant (HR=1.193, 95%CI: 0.762-1.865, p=0.762)(Figure 1). Among HF patients without CIED, syncope did not increase the risk of all-cause mortality in HFrEF (HR=0.923, 95%CI: 0.806-1.057, p=0.247), HFmEF (HR=1.074, 95%CI: 0.848-1.360, p=0.554), or HFpEF (HR=0.964, 95%CI: 0.883-1.052, p=0.406).

Conclusions

Syncope significantly increased the risk of all-cause mortality in HFrEF patients but not in HFmEF or HFpEF patients with CIED. The association of syncope and increased mortality in HFrEF patients with CIED suggests that syncope may be a marker and a factor of mortality and warrants further investigation.
Prevalence and prognostic value of ventricular conduction delay in heart failure with preserved ejection fraction
Authors: Weerts J , Achten A , Ghossein M , Mourmans S G J , Barandiaran Aizpurua A , Van Stipdonk A M W , Vernooy K , Prinzen F W , Brunner-La Rocca H P , Knackstedt C , Van Empel V P M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation; Health Foundation Limburg

Background

The pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF) is heterogeneous and incompletely understood. Identifying phenotypes of HFpEF is a promising approach to determine the underlying pathophysiological mechanisms and to improve treatment. Patients with electrical ventricular conduction delay (VCD) may represent a separate phenotype.

Objectives

To identify a VCD phenotype in HFpEF through assessment of QRS duration and vectorcardiographic QRS area. Moreover, to determine how differences in these VCD indices relate to adverse outcomes.

Methods

Consecutive patients underwent a comprehensive diagnostic work-up at baseline and were diagnosed with HFpEF. Baseline QRS duration was obtained clinically from a standard 12-leads electrocardiography (ECG). QRS area was derived from vectorcardiography analyses of the baseline ECG. Presence of VCD was categorically defined as QRS duration ≥120ms or QRS area ≥69µVs. Adverse outcome comprised a composite of HF hospitalization and cardiovascular mortality. Patients with cardiac devices before and up until one year after baseline were excluded in prognostic analyses.

Results

From a total of 346 HFpEF patients included in this study, 71.3% had a QRS duration <100ms compared to 20.1% with QRS duration 100-119ms and 8.6% with QRS duration ≥120ms. Only 3.8% of all patients had a QRS area ≥69µVs, indicating delayed left ventricular lateral wall activation. A history of coronary artery disease was more prevalent in patients with higher QRS duration or larger QRS area. Sex differences were mainly found in those with a QRS duration ≥100ms, which was present in 54.8% of all males and 17.5% of all females.

After a median of 2 years follow-up, 16.4% of the patients had an adverse outcome. Longer QRS duration but not larger QRS area was associated with more adverse outcomes on a categorical scale (Figure). In multivariable Cox-regression analyses adjusted for sex and age, QRS duration was an independent predictor of adverse outcomes (hazard ratio per 1ms increase = 1.017, 95% confidence interval 1.004-1.030, P = 0.012) (Table).

Conclusion

HFpEF patients have a low prevalence of a VCD phenotype, 8.6% have a QRS duration ≥120ms and 3.8% a QRS area ≥69µVs. However, QRS duration >100ms was an independent predictor for adverse outcomes. Thus, future efforts are warranted to understand the biologic and mechanical mechanisms underlying the association of QRS duration and adverse outcomes, and to determine its clinical implications.
Causes and characteristics of sudden cardiac death in octogenarians/nonagenarians
Authors: Perkiomaki J , Puolitaival E , Vahatalo J , Holmstrom L , Haukilahti M A E , Pakanen L , Ukkola O H , Junttila M J , Huikuri H V
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): the Finnish Foundation for Cardiovascular Research

the Sigrid Jusélius Foundation

Introduction

The risk for sudden cardiac death (SCD) increases with ageing.

Methods

We evaluated causes and characteristics of unexpected SCD in SCD victims aged ≥ 80 years in a consecutive series of 5,869 SCD victims who underwent medico-legal autopsy.

Results

Among SCD victims ≥ 80 years, 91.0% of SCDs were due to ischemic heart disease (IHD) determined in autopsy and 9.0% due to non-ischemic heart disease (NIHD), whereas among those < 80 years, only 72.6% of SCDs were due to IHD and 27.4% due to NIHD (P<.001). Severe fibrosis in myocardium was more common whereas heart weight and liver weight, body mass index and abdominal fat thickness, were lower among SCD victims aged ≥ 80 years than among victims aged < 80 years. In those with IHD as etiology of SCD, at least 75% stenosis in one or more major coronary vessels was more common in SCD victims aged ≥ 80 years than among victims aged < 80 years (P=.001). Dying in sauna was more common among those ≥ 80 years than among those < 80 years (5.5% vs. 2.6%, P<.001).

Conclusion

In victims of unexpected SCD aged ≥ 80 years, the autopsy-based etiology of SCD was more commonly IHD than in those aged < 80 years. In SCD victims aged ≥ 80 years, severe fibrosis in myocardium, representing arrhythmic substrate, was more common than in the younger ones.
Effect of infarct size on the risk of ventricular arrhythmias in patients with chronic total coronary occlusion
Authors: Hindi-Assaf A , Van Der Graaf M , Van Boven N , Van Ettinger M J B , Hoogendijk M , Diletti R , Szili-Torok T , Theuns D A M J , Yap S C
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The presence of an untreated chronic total coronary occlusion (CTO) is associated with a higher risk of ventricular arrhythmias (VAs). This increased risk may be modulated by the presence of existing scar. We hypothesize that a larger scar size is associated with a higher risk of VA.

Objectives

To evaluate whether infarct size is associated with VA in patients with an implantable cardioverter-defibrillator (ICD) and an untreated CTO.

Methods

In this retrospective study we included patients with an untreated CTO that received an ICD between 2005 and 2014. Infarct size was estimated using the Selvester QRS score on a baseline 12-lead ECG. The primary endpoint was any appropriate ICD therapy.

Results

Our study population comprised 148 patients (mean age at implantation 64 ± 10 years, 87% men) with an ICD and an untreated CTO. The median infarct size at baseline was 18% (IQR, 9-27%). Patients with a larger scar size (≥18%) more often had a CTO location in the LAD, higher proportion of LVEF <35%, and less hypertension and hypercholesterolemia compared to patients with a smaller infarct size (<18%). During a median follow-up of 35 months (interquartile range [IQR], 8-60 months), 42 patients (28%) received appropriate ICD therapy. The cumulative 5-year event rate was higher in the patients with a large infarct size (≥18%) in comparison to those with a smaller infarct size (<18%) (36% versus 19%, logrank P = 0.038, Figure). Multivariable Cox regression analysis demonstrated that a larger infarct size (≥18%) and a secondary prevention indication were independent factors associated with appropriate ICD therapy. The adjusted hazard ratio of large infarct size (≥18%) for appropriate ICD therapy was 2.34 (95% CI 1.20-4.58, p=0.01).

Conclusion

In ICD recipients with an untreated CTO, a larger scar size is an independent factor associated with an increased risk of VA.
Recurrences of ventricular tachycardia after stereotactic arrhythmia radioablation arise outside the treated volume: analysis of the Swiss cohort
Authors: Herrera Siklody C , Schiappacasse L , Jumeau R , Reichlin T , Saguner A , Andratschke N , Elicin O , Kovacs B , Mayinger M , Huber A , Le Bloa M , Teres Castillo C , Domenichini G , Bourhis J , Pruvot E
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): The project is part of the STOPSTORM.eu consortium and has partially received funding from the European Union’s horizon 2020 research and innovation program

Background

Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter ablation (CA). VT recurrences have been reported after STAR but the mechanisms remain largely unknown.

Purpose

We analyzed recurrences in the Swiss Cohort after STAR for refractory VT in order to assess their location related to the irradiated volume.

Methods

From 09.2017 to 01.2020, 20 patients (68±8y, LVEF 37±15%) suffering from refractory VT were enrolled. The underlying cardiopathy was ischemic in 6, inflammatory in 4, neoplastic in 1 and idiopathic in 9 patients. Sixteen out of 20 patients had a history of at least 1 electrical storm. Before STAR, an invasive electro-anatomical mapping (Carto3) of the VT substrate was performed. A mean dose of 23±2Gy was delivered to the planning target volume (PTV).

Results

The median ablation volume was 26 ml (range 14-115) and involved the interventricular septum (IVS) in 75% of patients. During the first 6 months after STAR, VT burden decreased by 92% (median value, from 108 to 10 VT/semester, p<0.005). After a median follow-up of 25 months, 12/20 (60%) developed a recurrence with 14 sustained VTs and underwent a redo CA. VT recurrence was located in proximity of the treated arrhythmogenic substrate in 9 cases, occurred remote from the PTV in 3 cases and involved a larger substrate over ≥3 LV segments in 2 cases. No recurrences occurred inside the PTV. The estimated dose delivered at sites of VT recurrence was very heterogeneous, ranging from 0.11 to 28.37 Gy, and less than 15 Gy in 12/14 cases. Voltage measurements showed a significant decrease in both bipolar and unipolar signal amplitude.

Conclusion

STAR is a precious new tool available for the treatment of therapy-refractory VT, allowing for a significant reduction of VT burden. VT recurrences are common during follow-up, but no recurrences were observed inside the PTV. Local efficacy was supported by a significant decrease in both bipolar and unipolar signal amplitude.
Incidence of ventricular tachyarrhythmias and clinical outcomes in primary prophylactic ICD patients in relation to localization of myocardial infarction
Authors: Kleemann T , Kouraki K , Strauss M , Mohammad O , Wenz A , Zahn R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

According to current guidelines, primary prophylactic ICD implantation is indicated with a class IA recommendation in patients with severely reduced EF < 35% and ischaemic heart disease. However, it is unclear whether there are differences in patient outcomes related to the localization of myocardial infarction. Aim of the study was to compare the incidence of ventricular tachyarrhythmias and clinical outcomes in primary prophylactic ICD-patients with ischaemic heart disease in relation to the localization of myocardial infarction.

Methods

A total of 448 consecutive ICD patients from a prospective single-centre ICD-registry who underwent primary prophylactic ICD implantation due to ischaemic cardiomyopathy between 1996 and 2021 were analyzed. Patients with previous anterior wall myocardial infarction (AWMI, n = 293) were compared to those with posterior wall myocardial infarction (PWMI, n = 155). Patients with both AWMI and PWMI were excluded. The median follow-up time was 6 years in both groups.

Results

Patients with AMWI were younger, more often female, and less often received cardiac synchronization therapy (Table 1). Patients with previous PWMI more often had ICD therapy during follow-up (Figure 1) due to the higher incidence of ventricular tachycardias (Table 1). The all-cause mortality rate was similar between both groups.

Conclusion

Primary prophylactic ICD patients with previous PWMI have a 10% higher incidence of ventricular tachycardias after 6-year follow-up than ICD patients with previous AMWI. This might be explained by the proximity of the inferior infarction to the mitral isthmus and should be considered when ablating VTs in patients with PWMI.
New imaging techniques in ventricular tachycardia ablation: integration of myocardial thickness analysis software in computed tomography with omnipolar mapping
Authors: Cabrera Borrego E , Sanchez Millan P , Constan De La Revilla E , Tercedor Sanchez L , Alvarez Lopez M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Magnetic resonance imaging (MRI) is very useful for planning the ablation of ventricular tachycardias (VT) related to scar, since it allows identification of anatomy, scar dense/border zone (DZ/BZ) and conduction channels (CC). However, access to this test is limited in many centres and, in addition, artefacts generated by pacing/defibrillation devices (ICDs) can often make it uninterpretable. Multidetector cardiac computed tomography (MDCT) offers the advantages of greater accessibility, better anatomical characterisation and less device artefacts, although there is little experience of its use.

Purpose

The objective is to evaluate the effectiveness of integrating myocardial thickness analysis software with MDCT and omnipolar electroanatomical mapping for VT ablation procedures in patients with cardiomyopathy.

Methods

Single-centre, descriptive study of a serie of patients, ICD carriers, that underwent VT ablation:

- Patient 1- 72-year-old male with ischaemic heart disease.

- Patient 2- 46-year-old male with left arrhythmogenic cardiomyopathy.

- Patient 3- 60-year-old male with biventricular arrhythmogenic cardiomyopathy.

- Patient 4- 28-year-old female with right arrhythmogenic cardiomyopathy.

MDCT was performed on all patients and the images were post-processed using myocardial thickness analysis software. A 3D colour map was created with identification of the DZ, BZ and CC. This map was fused with the electroanatomical map created during the electrophysiological study with omnipolar technology.

Results

In all cases there was a high anatomical correlation between DZ, BZ and CC detected on postprocessed MDCT and the area of pathological voltage and late electrograms of the omnipolar map. In patient-1, the CC detected on CT coincides with the diastolic corridor of clinical VT (image 1A). In patient 2, CT analysis identified the direct relationship of the circumflex artery with the superior region of the DZ (image 1B). In patients 3 and 4, the CT scan identified the relationship of the DZ/BZ in the right ventricular outflow tract with the coronary arteries and phrenic nerve (image 1 C and D).

Conclusions

The computed tomography myocardial thickness analysis software is positioned as an alternative to MRI in VT ablation, as it localises critical anatomical structures and identifies the scar dense/border zone and conduction channels accurately.
Omnipolar technology in ventricular tachycardia ablation: activation and substrate mapping with late activation isochrone analysis under extrastimulus protocol
Authors: Cabrera Borrego E , Sancez Millan P , Constan De La Revilla E , Tercedor Sanchez L , Alvarez Lopez M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The cornerstone of the ablation of eschar-related ventricular tachycardias (VT) is the circumscription of the scar dense zone (DZ)/border zone (BZ) and the identification of regions of slow decremental conduction. The anisotropy of the BZ generates depolarisation waves with rapid changes in their direction that may not be detected by bipolar electrodes, as their identification capacity is orientation-dependent. Omnipolar technology detects the direction and velocity of the wavefront regardless of its orientation.

Purpose

Describe the effectiveness of the use of omnipolar technology for the development of electroanatomical and activation maps during the study of VT related to scar.

Methods

Single-centre, observational, descriptive study of a serie of patients:

- Patient 1- 72-year-old male with ischaemic heart disease.

- Patient 2- 46-year-old male with left arrhythmogenic cardiomyopathy.

- Patient 3- 60-year-old male with biventricular arrhythmogenic cardiomyopathy.

- Patient 4- 28-year-old female with right arrhythmogenic cardiomyopathy.

- Patient 5- 42-year-old male with non-ischemic dilated cardiomyopathy.

- Patient 6 - 73-year-old male with arrhythmogenic right cardiomyopathy.

Omnipolar technology was used for the creation, under sensed extrastimuli in right ventricular apex protocol, of a voltage map, isochrone late activation map (ILAM), slow decremental conduction (SDC) analysis and, in case of VT induction, activation map with real-time visualisation of conduction vectors ("Strategic-multielectrode-positioning" / StaMP-mapping).

Results

In patients 1, 2 and 3 ILAM was performed identifying SDC regions. After induction of VT, StaMP-mapping was performed in these regions with identification of the diastolic corridor (image 1A, 1B, 1C). The corridor was eliminated and, subsequently, arrhythmogenic substrate ablation of late potentials in DZ/BZ was performed.

In patients 4, 5 and 6 an identical protocol was performed, but VT induction was not achieved, so substrate ablation strategy was performed (image 1D, 1E, 1F).

Patient 6 has had a recurrence of sustained VT.

Conclusions

Omnipolar technology, associated with the extrastimulus protocol, allows a more accurate study of scar-related VT, through the identification of SDC regions. These locations are current targets for substrate ablation and, in many cases, the origin of the critical isthmus.
Association between left ventricular wall-thickness by CT and endocardial voltage potentials in patients with ischemic cardiomyopathy
Authors: Gomes D , Cunha G , Freitas P , Guerreiro S , Abecasis J , Rodrigues G , Matos D , Carmo J , Galvao Santos P , Moscoso Costa F , Carmo P , Belo Morgado F , Cavaco D , M Ferreira A , Adragao P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Although cardiac magnetic resonance (CMR) is the gold standard for planning ventricular tachycardia (VT) ablation, its accuracy is hindered in patients with implanted cardiac defibrillators (ICD) and resynchronization therapy (CRT). Cardiac computed tomography (CT) has emerged as an alternative for ablation planning in these patients. This pilot study aimed to evaluate the relationship between wall thickness (WT) on CT and voltage of electrical potentials on endocardial electroanatomic mapping (EAM) in patients with ischemic cardiomyopathy.

Methods

Single centre retrospective study enrolling consecutive patients with ischemic cardiomyopathy referred for endocardial VT ablation that underwent cardiac CT for procedure planning since 2021. Patients were excluded if EAM had < 1000 data points. ADAS 3D® software was used to analyse CT images, automatically segmenting the left ventricle (LV) into the 17 American Heart Association segments and calculating end-diastolic WT for each one. Four standardized views (anterior-posterior, posterior-anterior, superior, and inferior) of the segmented LV on ADAS 3D® were used to aid in manual segmentation of the EAM. The endocardial voltage maps were created using CARTO3® software (Figure 1). For each patient, EAM was interpreted to create 2 different bulls’ eye maps, according to the presence or absence of bipolar potentials < 0.5 (dense scar) or < 1.5mV (low voltage). Only segments with >20% extension of low bipolar voltage were considered as altered.

Results

We included a cohort of 8 patients (mean age 67±12 years, 87.5% male, median LVEF of 32% [IQR 25-49]). All but one patient had implanted cardiac device (6 ICD, 1 CRT-D). Cardiac CT was performed 1 day (IQR 0-2) before the ablation. Overall, 136 segments were analysed, 8 of which did not have voltage information. Of the remaining 128, 51 (39.8%) had dense scar and 57 (41.9%) had low voltage. There was a good correlation between mean WT and the presence or absence of both dense scar (area under de curve (AUC) 0.799, p<0.001) and low voltage (AUC 0.838, p<0.001) in each LV segment.

Conclusion

WT measured by CT appears to have a strong correlation with dense scar and low voltage in EAM in patients with ischemic cardiomyopathy undergoing VT ablation. This technique may be useful to plan interventions in patients in whom CMR is not feasible.