bluuebunny/crossref_metadata_2025 huggingface dataset:
Multipolar pulsed-field ablation for the treatment of left atrial reentry tachycardia
Authors: Kueffer T , Seiler J , Madaffari A , Muehl A , Noti F , Haeberlin A , Servatius H , Tanner H , Baldinger S , Reichlin T , Roten L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

A multipolar pulsed field ablation (PFA) catheter was recently introduced for pulmonary vein isolation and combines the benefits of high procedural efficacy and safety. It may also be used to treat left atrial (LA) reentry tachycardia.

Purpose

To describe our initial experience using a multipolar PFA catheter for the treatment of LA reentry tachycardia.

Methods

We included all patients with LA reentry tachycardia treated with a multipolar PFA catheter at our institution. Using 3D electro-anatomical mapping (3D-EAM), we identified the tachycardia mechanism and applied linear lesions either at the left atrial roof, mitral isthmus or on the anterior wall, as appropriate. Positioning of the PFA catheter was verified by integration into 3D-EAM. Applications were performed using 2.0kV with the catheter in basket or flower configuration, depending on ablation site. Bidirectional block across linear lesions was verified using standard criteria. Additional focal radiofrequency ablation (RFA) was used to achieve bidirectional block if necessary.

Results

We treated 17 LA reentry tachycardia with a multipolar PFA catheter in 13 patients (median age 69 (59-73) years; 5 females). The tachycardia mechanism was identified as roof-dependent in five, peri-mitral in eight and anterior scar-related in four cases. PFA lesion sets consisted of 12 posterior wall isolations (i.e. roof lines), four mitral isthmus lines (MIL) and eight anterior lines. For ablation of the mitral side of the anterior line, we always used the PFA catheter in basket configuration, while we targeted the posterior wall and the superior side of the anterior line exclusively with the catheter in flower configuration. To ablate the MIL we used both flower and basket configurations. Three roof-dependent, six peri-mitral, and four anterior scar-related tachycardias were successfully terminated by PFA (76%). Additional RFA was necessary for two MIL, two anterior lines and no roof line (17%). Finally, we achieved bidirectional block across all lines. PFA triggered, vagal-mediated and reversible AV block was observed in one case. Otherwise, there were no acute procedural complications.

Conclusion

Linear lesion sets are feasible and safe using a multipolar PFA catheter. Posterior wall isolation by PFA for the treatment of roof-dependent LA reentry tachycardia is highly efficient while anterior lines and MIL remain challenging and may need complementary RFA or a PFA catheter designed for focal or linear ablations.
Comparison of intracardiac echocardiography-guided versus conventionally performed cavotricuspidal isthmus ablation in patients with atrial flutter
Authors: Janosi K , Debreceni D , Turcsan M , Simor T , Kupo P
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Cavotricuspidal isthmus (CTI) is the target of the catheterablation for patients with typical atrial flutters. Intracardiac echocardiography (ICE) allows safe, real-time visualization of the anatomical structures thus can help reduce the use of fluoroscopy and improve procedural outcomes.

Purpose

We aimed to compare procedural and follow-up data of ICE vs. only-fluoroscopy guided procedures for CTI ablation in patients who underwent catheter ablation due to atrial flutter in our Institute.

Methods

154 consecutive patients were enrolled in our single-center retrospective study. In 70 patients, procedures were performed using fluoroscopy guidance only, while 84 patients underwent ICE-guided CTI ablation.

Results

ICE-guidance significantly reduced fluoroscopy time (137 ± 60.2 s vs 918 ± 609.5 s; p<0.01), fluoroscopy dose (2.23 ± 1.44 mGy vs. 44.09 ± 25.23 mGy; p<0.01) and total procedure time (67.6 ± 25.8 min vs. 79.6 ± 23.9 min; p<0.01). Total ablation time (826 ± 445 s vs. 978.5 ± 676.8 s; p<0.01) and the time from the first to last ablation (25 ± 14 min vs. 43 ± 26.5 min; p<0.01) was also shorter in the ICE-guided group. Acute success rate was 100% and no major complications occurred in either group. Long-term success rate was 90.9% during the 2.13 ± 1.17 years follow-up period and did not differ between the groups (ICE-guided group: 94.1%, fluoroscopy-only group: 87.1%; p=0.14).

Conclusion

ICE-guidance for CTI ablation can significantly reduce fluoroscopy exposure, procedure time and ablation time compared to the traditional, fluoroscopy-only approach.
Long-term outcomes in patients with potential reversible causes of bradycardia
Authors: Passos M , Fialho I , Lopes J , Mateus C , Beringuilho M , Baltazar J , Santos M , Augusto J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Hyperkalemia and negative chronotropic drugs are well known causes of reversible bradycardia. Their synergic combination may result in BRASH syndrome (Bradycardia, Renal failure, Atrioventricular blockade, Shock, and Hyperkalemia), a consequence of the vicious cycle between bradycardia, renal failure and worsening hyperkalemia, leading ultimately to multiorgan dysfunction. In potentially reversible bradycardia, drug discontinuation or metabolic correction is recommended before permanent pacemaker (PPM) implantation.

Objectives

To determine the long-term prognosis in patients with potentially reversible symptomatic bradycardia.

Methods

We retrospectively reviewed 176 patients who presented to the emergency department with symptomatic bradycardia, between January 2015 and August 2016. Patients without any reversible cause of bradycardia were excluded. Participants were stratified into three groups according to the reversible causes of bradycardia: patients with hyperkalemia, with or without acute renal injury (ARI) (group 1); patients taking negative chronotropic drugs, with or without ARI (group 2); patients with BRASH syndrome (combination of hyperkalemia and negative chronotropic drugs, with or without ARI) (group 3). The primary endpoint was PPM implantation after discharge. Secondary endpoints included: bradycardia-related rehospitalization, heart failure (HF) hospitalization, all-cause mortality and a composite of all the previous endpoints.

Results

A total of 105 patients were included (52.4% female; mean age 79.8±8.6 years). Group 1 was comprised by 15 patients (14.3%), group 2 by 69 patients (65.7%) and group 3 by 21 patients (20%, figure 1). The incidence of each event is presented in figure 2. During a mean follow-up of 3.2±2.1 years, PPM was implanted in 60 patients (57.1%) – 51 during hospital stay (85%) and 9 after discharge (15%). Across all groups, approximately 50% of the patients needed PPM implantation at some point, without significant differences between groups (p=0.508). Group 3 had the lowest need of in-hospital PPM (38.1%) but the highest bradycardia-related readmissions (9.5%). Nevertheless, post-discharge PPM implantation was still higher in group 1 (33.3%), followed by group 3 (22.2%). There were no significant differences in the post-discharge PPM implantation rate between groups (p=0.76). In groups 1 and 3 the composite endpoint (73.3% and 76.2%, respectively) was significantly more frequent than in group 2 (44.9%, p=0.046 and p=0.012, respectively).

Conclusions

Nearly half of the patients with an episode of reversible bradycardia needed a PPM at some point. Given the advanced age of most patients with bradycardia secondary to metabolic derangement and/or drug toxicity, it is possible that this unveils underlying conduction system disease, which is likely to recur without PPM implantation.
Heart rate acceleration during cardioneuroablation is a weak predictor of significantly reduced parasympathetic modulation of sinus node
Authors: Stiavnicky P , Wichterle D , Jansova H , Stojadinovic P , Haskova J , Peichl P , Cihak R , Kautzner J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Ablation of superior parasympathetic ganglia is associated with acceleration of sinus rhythm (SR). This has been considered a favorable sign during cardioneuroablation (CNA) for the treatment of functional bradyarrhythmias.

Aim

We studied whether the relative increase in SR frequency (DeltaSR) during CNA is a reliable predictor of significantly reduced parasympathetic modulation of the sinus node (SAN).

Methods

In patients undergoing CNA under general anesthesia, the gradual reduction in parasympathetic modulation of SAN during the procedure was assessed by extracardiac right vagal nerve stimulation (ECVS). The response to ECVS was quantified by the ratio of the maximum P-P interval (induced by ECVS) and the baseline SR cycle length (MaxPPratio). The ECVS was performed repeatedly after partial ablation steps, and therefore several pairs of DeltaSR and MaxPPratio values were obtained in the course of the single procedure. A MaxPPratio <1.5 was arbitrarily chosen as the criterion of significant attenuation of vagally induced responses. The optimum dichotomy of Delta-SR for the prediction of the MaxPPratio <1.5 was found according to the criterion of the minimum distance of the ROC curve from the point (0; 1).

Results

The study included 64 patients (mean age: 42 ± 16 years, 48% men). A total of 188 intraprocedural pairs of DeltaSR and MaxPPratio (2.9 ± 2.1 pairs per procedure) covering the wide distribution of their values (19 ± 14 bpm for DeltaSR and 2.9 ± 2.8 for MaxPPratio) were obtained. One half of ECVS tests (51%) met the criterion of MaxPPratio <1.5. In the analysis of receiver operating characteristic, DeltaSR as a predictor of significantly reduced parasympathetic modulation of SAN showed an area under the curve (AUC) of 0.69 with 95% confidence interval (CI) of 0.62 - 0.77 (Figure). The optimum cut-off (DeltaSR ≥20 bpm) had a sensitivity (SENS), specificity (SPEC), positive (PPV), and negative predictive value (NPV) of 61%, 78%, 75%, and 66%, respectively.

Conclusion

Acceleration of SR during CNA is not a relevant surrogate of significantly reduced parasympathetic modulation of SAN. Elimination or significant suppression of responses of SAN to ECVS serves as an excellent procedural endpoint that might contribute to the favorable clinical outcome of the CNA.
Optimal catheter-tissue contact value for ablation of ventricular arrythmias originating from the left ventricular papillary muscles
Authors: Baran J , Skrzynska M , Piotrowski R , Sikorska A , Krynski T , Kulakowski P
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Good catheter-tissue contact is mandatory to create effective ablation lesions. The minimal contact force (CF) value for successful ablation of arrhythmias originating from the left ventricle (LV) was reported at the 8-10 g level, however, optimal CF values for ablation of arrhythmias arising from papillary muscles (PM) are not known.

Purpose

To determine optimal CF value for ablation of arrhythmias from LV PM.

Methods

Twenty-four consecutive patients (mean age 57,9 ± 11,9 years, 16 males) who from May 2017 to June 2020 underwent ablation of premature ventricular complexes (PVC) originating from LV PM were included. The primary endpoints were an acute procedural success (total elimination of PVC) and long-term success (median 27 months). Ablation was performed with the use of the CARTO electro-anatomical system and intracardiac echocardiography (ICE).

Results

Acute success – complete abolition of PVC, was obtained in 23 (96%) patients. The fluoroscopy time was 3,9 ± 3,5 min and the procedure duration was 114,8 ± 38 min. The mean number of applications was 8,74 ± 6,78 and the mean application time - 518,5 ± 437,25 sec. The mean CF during successful ablations was 3,1 ± 1,5 g, with 3 ± 1,1 g and 3,18 ± 1,8 g for anterolateral and posteromedial PM, respectively (p= 0,809975). The mean CF during one unsuccessful ablation was 3 g. At control Holter ECG, the mean PVC burden in all patients was reduced from 28,36 ± 14,48 % to 2,42 ± 2 %: in the anterolateral PM group from 18 ± 8 % to 2,6 ± 2 % (p= 0,005415) and in the posteromedial PM group - from 34,8 ± 13,7 % to 1,7 ± 1,3 % (p= 0,012694). During long-term follow-up (median 27, IQR 17-34) there was one recurrence among 23 patients who had acutely successful procedures.

Conclusion

The values of CF for successful ablation of PVC originating from LV PM are lower than those for ablation in other parts of LV. The values slightly exceeding 3 g seem to be sufficient to achieve ablation success.
Long-term impact of activation circuit-based ventricular tachycardia ablation on ventricular arrhythmia burden
Authors: Freire Barbas De Albuquerque F , Portugal G , Silva Cunha P , Valente B , Lousinha A , Delgado AS , Paulo M , Rosa T , Bras M , Cruz Ferreira R , Oliveira M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular arrhythmias (VA) are a major cause of morbidity and mortality in heart failure patients. Ventricular tachycardia (VT) ablation is an established treatment for the reduction of recurrent implantable cardioverter-defibrillator (ICD) therapies in this population. In patients with substrate-related VT, mapping of the entire tachycardia circuit, when feasible, may allow for more accurate targeting of the clinical VT.

Purpose

To assess the long-term impact of catheter ablation based on activation mapping of substrate-related VT on VA burden.

Methods

Consecutive patients submitted to VT ablation between January 2013 and October 2021 were included. A comprehensive review of clinical records and device monitoring was performed to assess VA burden, defined as all ICD therapies and clinically documented VTs, before and after ablation. The primary outcome was reduction in the overall burden of VA after ablation. The impact of ablation on VA burden was assessed by fixed-effects Poisson regression; comparison at fixed time intervals was performed with a paired-sample Wilcoxon signed-rank test (STATA 12, JASP).

Results

A total of 134 VT ablation procedures were performed during the study period. Of these, there were 21 procedures where complete mapping of the VT activation circuit was achieved, corresponding to 18 patients. Mean age was 56.7 years, 88% male sex, mean left ventricular ejection fraction 39 ± 13%, BNP 540 ± 627 pg/mL. Etiology was ischemic in 44%, non-ischemic dilated cardiomyopathy in 39%, arrhythmogenic right ventricular dysplasia in 11% and hypertrophic cardiomyopathy in 6%. Mechanical support was in situ in 3 patients (two with temporary VA ECMO and one with LVAD as destination therapy); all but one patient had an ICD. Procedural duration was 209 ± 61 minutes. One patient developed complete AV block; no other peri-procedural complications were observed. During follow-up two patients died due to heart failure, one patient died from refractory cardiogenic shock with refractory incessant VT and one patient underwent orthotopic heart transplant. The mean follow-up time after ablation was 2.2 ± 1.9 years. A significant reduction in VA burden was observed (Figure 1) at 3 months (92.5% reduction, p=0.002) and 6 months after ablation (83.3% reduction, p=0.041). After fixed-effects Poisson regression, there was an estimated long-term reduction of 75% (CI 12-93%, p=0.031) of VA burden after VT circuit ablation.

Conclusion

Targeted circuit ablation is feasible in a subset of patients referred to VT ablation and leads to a significant sustained decrease in VA burden and device therapies.
Establishing safe, effective ablation in the diseased human ventricle: an analysis of generator impedance and electrogram attenuation
Authors: Bates A , Paisey JR , Yue A , Banks P , Roberts PR , Ullah W
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Biosense Webster Inc

Background

Predictors of effective and safe lesion delivery in the human left ventricle have not been established. Generator impedance (GI) drop and electrogram (EGM) attenuation are indices which can be used as surrogates for ablation lesion parameters. Tissue pops are a complication of myocardial overheating preceded by a rise in GI and can have adverse consequences.

Purpose

To establish the relationships between Ablation Index (AI), Force Time Integral (FTI) and contact force with GI and EGM attenuation. To establish factors early in ablation that are predictive of a GI rise.

Methods

Patients undergoing ventricular tachycardia ablation were recruited. All ablations were performed with contact force sensing surround flow catheters. Electrograms were collected pre and post ablation, with GI, AI, FTI measured during. Ablations were divided into low (LVM, < 0.50mV), intermediate (IVM, 0.51 – 1.50mV) and normal voltage (NVM, > 1.50mV) based upon pre-ablation bipolar EGM amplitude. Ablations with a 5% rise in GI from maximal drop were noted and predictors of this explored.

Results

In 15 patients, 402 ablations were analysed. Filtered percentage GI drop correlated with AI and FTI, (p < 0.0005, Spearman’s ρ = 0.522 and 0.524) and reached a plateau at 763AI and 713gs, a filtered GI drop of 7.5% (Figure 1). Shallower curves occurred progressively from NVM to IVM to LVM, (p < 0.0005), (Figure 2)

The bipolar EGM significantly attenuated with ablation, (median attenuation 0.14mV, [29.3%], p <0.0005), but percentage attenuation did not correlate with AI or FTI.

Parameters associated with a GI rise during ablation were greater mean CF to maximum GI drop, (p = 0.002), greater initial percentage GI drop at 5 seconds, (p < 0.0005), power of 50W (p = 0.005), and perpendicular orientation, (p = 0.006). Percentage GI drop at 5 seconds was the best predictor of ablations with a GI rise, (AUCROC 0.773; 95% CI 0.708 – 0.838; optimal cut-off 2.44%). Mean contact force to maximum GI drop was a poor predictor of a GI rise (AUCROC 0.647; 95% CI 0.577 – 0.718, optimal cut-off 14.7g).

Conclusion

During left ventricular ablation, AI of 763 and FTI of 713gs should be targeted, with a lower impedance drop observed for more scarred myocardium. A GI drop of <2.5% at 5 seconds and contact force < 15g should be used to optimise ablation safety.
Area weighted unipolar voltage to predict heart failure death in patients with ischemic cardiomyopathy and ventricular tachycardia
Authors: Rademaker R , Kimura Y , Beukers HC , Piers SR , Wijnmaalen AP , De Riva Silva M , Dekkers OM , Zeppenfeld K
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with ischemic cardiomyopathy (ICM) referred for catheter ablation (CA) of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodeling of the left ventricle (LV). Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV mapping derived parameter that corrects for oversampling of the infarct area may reflect the total amount of remaining LV viable myocardium.

Objective

To evaluate if the newly proposed parameter, `area weighted unipolar voltage’ (awUV), can predict HF related death/LVAD/Heart transplant (HFD) in ICM.

Methods

Voltage maps from consecutive patients with ICM referred for CA of VT, were transferred to Paraview after valve area removal. AwUV was calculated by mathematically interpolating all mapping points weighted for relative distances divided by the LV endocardial surface. Unipolar low voltage areas (ULVA, UV<8.27mV) were measured as percentage of the total LV surface. Associations between clinical and mapping derived parameters and HFD (HF-related death/LVAD/heart transplant) were evaluated and validated in a second cohort of consecutive patients.

Results

Eighty-nine patients in the study group (age 68±8; LVEF 33% [IQR 24-40%]; ULVA 64% [IQR 46-86%]; awUV 7.01 [IQR 5.01-8.52]) and 69 patients in the validation group (age 68±9; LVEF 39% [IQR 29-44%]; ULVA 59% [IQR 43-77%]; awUV 7.60 [IQR 6.16-8.69]) were included. Follow-up was 32±17 months in the study group, 28±17 months in the validation group. HFD was 20% in the study group, 10% in the validation cohort. Patients with HFD had lower LVEF and awUV, and larger ULVA than patients without HFD (LVEF 23±10% vs. 35±11%; awUV: 5.12±1.92 vs. 7.75±2.64; LVA 86±21% vs. 60±23%, all P<0.001). Univariable analysis showed that LVEF, ULVA and awUV were associated with HFD (HR and 95% CI: LVEF 1.10 [1.05 – 1.16]; LVA 1.05 [1.02 – 1.08]; awUV 2.18 [1.58 – 3.40], all P<0.01). AwUV was superior to ULVA to predict HFD in likelihood ratio calculations (awUV: LR 5.66, P=0.02; LVA: 1.76 P=0.18) and ROC analysis (AUC awUV: 0.86; LVA 0.78). The optimal cut-off for awUV of<5.27 was highly accurate to predict HFD in the validation cohort (log-rank P<0.001).

Conclusion

The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at risk for HFD.
Stereotactic arrhythmia radioablation in europe: treatment planning benchmark results of the STOPSTORM consortium
Authors: Trojani V , Botti A , Grehn M , Balgobind B , Savini A , Pruvot E , Verhoeff J , Iori M , Blanck O
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EU

Background

In patients with refractory ventricular tachycardia (VT), STereotactic Arrhythmia Radioablation (STAR) showed promising results for otherwise untreatable patients [1]. The STOPSTORM.eu project coordinates European efforts to clinically validate STAR and to refine protocols and guidelines to ensure treatment harmonization.

Purpose

The aim of this work is to present the current clinical STAR practise in Europe based on three examples as baseline for further optimization.

Methods

Target Volumes (TV) and Organs-at-Risk (OAR) were generated from previous consortium benchmarks and consensus definitions for three well-selected STAR cases [1]. Planning Target Volumes (PTV) were generated based on three different compensation strategies for cardiac and respiratory motion [2] and overlapped close OAR like coronary arteries or stomach in some areas. The STOPSTORM.eu members were asked to generate single fraction treatment plans with 25 Gy dose prescription based on ICRU report 91 for each case based on their clinical practise and preferences for STAR including multi-disciplinary discussion and plan approval. Resulting dose distributions were analysed independently using a customized platform for multi-center treatment planning studies [3].

Results

Twenty centers submitted 22, 23 and 22 treatment plans for case 1, 2 and 3, respectively, mostly (75% of all plans) using Intensity Modulated Arc Therapy (IMAT) with 6 MeV FFF beams (73% of the IMAT plans) among other commonly used techniques for stereotactic radiotherapy. At this current stage, used guidelines for STAR treatment planning and OAR dose limits vary greatly and are mostly based on the AAPM TG-101 report or the RAVENTA trial publication [4]. As a major finding, 73% of all plans submitted preferred close OAR sparing over achieving high PTV coverage arguing that lower doses down to 20 Gy may also result in clinical efficiency as recently suggested [5]. As a minor finding, 80% of the centers chose to override strong artifact regions originating from e.g. left ventricular assist devices.

Conclusion

From this first STOPSTORM.eu multi-center multi-platform treatment planning benchmark study we obtained important information concerning current clinical preference and practise from major European centers performing STereotactic Arrhythmia Radioablation for VT. Using the individual and strongly varying approaches of the centers, the key task for the STOPSTORM.eu project is now to find consensus in order to harmonize and optimize STAR practise in Europe.
Reversed U-curve mapping and ablation of the left pulmonic cusp for treatment of the left ventricular summit arrhythmias
Authors: Futyma P , Zarebski L , Futyma M , Santangeli P , Kulakowski P
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) of the left ventricular summit (LVS) arrhythmias can be challenging. Close proximity of the left pulmonic cusp (LPC) offers a unique opportunity for targeting the LVS region. Whether LPC can serve as a vantage point for mapping and CA of LVS premature ventricular contractions (PVC) and ventricular tachycardia (VT) has not yet been systematically evaluated.

Methods

This is a retrospective analysis of consecutive patients who underwent CA of LVS PVC/VT and concomitant mapping and/or ablation within the LPC using reversed U-curve technique. PVC/VT activation precocity was determined and CA (unipolar, sequential unipolar and/or bipolar ablation) was performed involving LPC when necessary.

Results

A total number of 18 patients (age 59±15 years, 10 females) were included in this study. LPC mapping using reversed U-curve was successful in 17 (94%) patients. An earliest PVC/VT activation was recorded in LPC in 7 (39%). No early activation in the LPC was found in 5 (28%) patients. Selective LPC ablation (24W, 206s) led to acute suppression with late VT recurrence in one patient, whereas LPC served as an additional ablation target for sequential CA (37±4W, 416±252s) in 11 (61%) patients. 6 (33%) patients required combined sequential unipolar and bipolar CA (37±8W, 690±248s) between LPC and adjacent LVOT and this approach led to PVC/VT elimination in 5 patients. There were no procedure-related complications. During follow up 4 (22%) patients required redo ablation. Ultimately clinical success was achieved in 14 (78%) patients.

Conclusions

LPC mapping of LVS PVC/VT using reversed U-curve is safe and can be helpful for determination of LVS arrhythmia site of origin. While LPC ablation alone is rarely successful in eliminating LVS arrhythmias, it can serve as an anatomical vantage point for additional ablation of LVS PVC/VT as a part of sequential unipolar or bipolar CA.
Left bundle branch pacing preserves ventricular mechanical synchrony better than right ventricular pacing-a two-center study
Authors: Mao YK , Yang Y , Garweg C , Sheng X , Zhang JF , Yang Y , Wang M , Yang Y , Duchenne J , Voros G , Sun YX , Ma MM , Fu GS , Voigt JU
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Left bundle branch pacing (LBBP) has emerged as a novel pacing method. We sought to evaluate left ventricular (LV) mechanical synchrony under permanent LBBP and compare it with conventional and leadless right ventricular pacing (CRVP, LRVP).

Methods

Sixty-four patients with pacing indication for bradycardia were prospectively enrolled. Twenty-two patients received LBBP in the basal ventricular septum. Twenty-three patients received CRVP and 19 LRVP. All patients underwent echocardiography before and after device implantation. Myocardial work was estimated by pressure-strain analysis. Regional work in the septum (SEP) and lateral wall (LW) was calculated as the average from the respective basal and mid-ventricular segments in the apical four-chamber and three-chamber view. The absolute difference between work in LW and SEP (LW-S-work difference) was used as a measure of asymmetry in workload.

Results

Baseline characteristics were similar among the three groups. The electrocardiogram during LBBP showed a right bundle branch block pattern; during CRVP and LRVP a left bundle branch block pattern. The paced QRS duration was 114.27±9.9 ms in the LBBP group, significantly shorter than that in the CRVP and LRVP groups (153.9±25.26 ms and 159.1±13.99ms, respectively, both p<0.001). The SEP work decreased in all groups during ventricular pacing (all P<0.05), while the LW work remained similar. The paced LW-S work difference and work difference change between pacing on and off were more significant in the CRVP (1012.9±566.0mmHg*%) and LRVP group (1066.1±472.6mmHg*%) than the LBBP group (260.5±239.8mmHg*%, both P<0.001). In addition, LW-S work difference during ventricular pacing and work difference change between pacing and baseline were comparable in CRVP and LRVP group.

Conclusion

LBBP causes less LV dyssynchrony than CRVP and LRVP as it preserves a more physiologic conduction pattern. CRVP and LRVP did not differ in this respect. Further studies need to prove that LBBP has advantages over RVP with regards to preservation of LV synchrony and contractility.
Paced P-wave duration as a significant predictor for atrial high-rate episodes in patients with cardiac implantable electronic devices
Authors: Rubio Campal JM , Garcia Talavera C , Bravo Calero L , Lazaro Rivera C , Diaz Cortegana FA , Castellanos Olmedilla A , Sanchez Arjona A , Tunon Fernandez J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial pacing can unmask or aggravate a preexisting interatrial block (IAB).

Purpose

The purpose of our study was to determine whether atrial pacing is associated with the development of atrial high-rate episodes (AHRE) during follow-up.

Methods

Patients with cardiac implantable electronic devices (CIED), no previous documented atrial fibrillation, and with a 6-month minimum follow-up were included. Sinus and paced P-wave duration were measured. AHRE was defined as an episode of atrial rate ≥ 225 bpm with a minimum duration of 5 min, excluding those documented during the first three months after implantation.

Results

Two hundred twenty patients were included (75 ± 10 years, 61% male). After a mean follow-up of 59±25 months, 46% of patients presented AHRE. Mean paced P-wave duration was significantly longer than sinus P-wave duration (154±27 vs 115±18 ms; p < 0.001). Sinus and paced P-waves were significantly longer in those who developed AHRE (sinus: 119±20 vs 112±16; p = 0.006; paced: 161±29 vs 148±23; p < 0.001). A paced P-wave ≥160 ms was the best predictor of AHRE, especially those lasting >24 h (OR 4.2 (95% CI) [1.6-11.4]; p = 0.004). In a multivariate analysis, a paced P-wave ≥160 ms (OR: 1.84; 95% CI [1.03–3.28]; p = 0.038), a CHA2DS2-VASc score ≥4 (OR: 2.01; 95% CI [1.13–3.55]; p = 0.016), and a LA SI dimension ≥ 55 mm (OR 2.69; 95% CI [1.48–4.90]; p = 0.001) were independent predictors augmenting AHRE.

Conclusion

Atrial pacing significantly prolongs P-wave duration and is associated with further development of AHRE. A paced P-wave ≥160 ms is a strong predictor of AHRE and should be taken into consideration as a new definition of IAB in the presence of atrial pacing.
Comparative of stylet-driven versus lumenless technique for left bundle branch pacing: implant results and follow-up outcomes
Authors: Ramos Jimenez J , Marco Del Castillo A , Paredes Hurtado N , Rodriguez Munoz DA , Fontenla A , Borrego Bernabe L , Lopez Gil M , Salguero Bodes R , Arribas Ynsaurriaga F
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left bundle branch pacing (LBBP) has traditionally been performed with fixed helix lumenless leads. The aim of this work is to compare feasibility and results with an extendable helix stylet-driven lead.

Methods

Unicenter and prospective registry of consecutive cases where LBBP was attempted using 2 different systems:

-B: stylet-driven extendable helix lead guided with preshaped delivery sheath.

-M: lumenless and fixed helix lead guided with preshaped delivery sheath.

Anthropometric, echocardiographic, procedural variables and long-term performance were compared using T-test for continuous variables, and chi-squared for categorical ones. A two-tailed p value <0.05 was considered statistically significant.

Results

134 patients were included. 44% (n=59) underwent the B technique and 56% (n=75) the M technique. Table 1 summarizes baseline, procedural and follow-up results. Implant failed in 4 (6.8%) patients in the B group: 2 because of repetitive entanglement of the helix with the endocardial surface, and 2 because of dislodgment of the lead after slitting the sheath. In the M group only 1 (1.3%) implant failed due to endocardial entanglement precluding correct penetration into the septum. Of the successfully implanted leads, 78.2% (n=43) in the B group vs. 70.3% (n=52) of the M group fulfilled strict LBB capture criteria (p=0.31). Baseline characteristics, fluoroscopy and procedure time showed no differences. After a median device follow-up time of 66 (interquartile range 36-184) days, slightly inferior capture threshold was seen in M group. 2 patients (3.8%) of the B group showed a threshold increase >2.0V, one of them needing intervention due to lack of capture. All M leads performed well during follow-up.

Conclusions

In consecutive patients with comparable baseline characteristics, both B and M technique are equally feasible, with similar LBBP success, procedural outcomes and long-term performance. Larger registries are needed to assess whether implant and long-term failure are also comparable.
Bilateral bundle branch capture during deep septal myocardial and nonselective left bundle branch pacing preserves interventricular synchrony
Authors: Curila K , Jurak P , Waldauf P , Halamek J , Stros P , Smisek R , Plesinger F , Znojilova L , Leinveber P , Viscor I , Herman D , Osmancik P , Prinzen FW
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic

Background

Both left bundle branch pacing (LBBP) and deep septal myocardial pacing (LVSP) are less physiological than His bundle pacing. However, pacing both anode and cathode of the lead that is positioned in the interventricular septum may provide bilateral bundle branch capture, which may result in better interventricular synchrony.

Objective

To use UHF-ECG to compare ventricular activation between HBp and bilateral bundle branch capture during left bundle branch (LBBPbi) and deep septal myocardial pacing (LVSPbi).

Methods

Studies were performed in consecutive bradycardia patients. Bipolar pacing was performed with the lead in the LBBP (pseudo right bundle branch block morphology in V1 + proved LBB capture) and LVSP (pseudo right bundle branch block morphology in V1 without proved LBB capture) positions, with the pacing output leading to bilateral bundle branch capture. QRS duration was measured from the first to the last deflection of the QRS in any lead. UHF-ECG electrical dyssynchrony parameters – e-DYS (difference between the first and last ventricular activation) and local depolarization durations in precordial leads (V1-V8d) were calculated.

Results

In 94 consecutive patients, measurements were performed during HBp (n = 75) and LVSPbi (n = 37) and LBBPbi (n = 64). The average pacing threshold leading to bilateral bundle branch capture was 2.6 V at 0.5 ms. nsHBp led to the shortest QRSd compared to sLBBPbi and LVSPbi (98 vs. 103 vs. 110 ms; p < 0.01). LVSPbi showed smallest e-DYS -2 ms vs. -8 ms during LBBPbi and 11 ms during nsHBp; p < 0.05, but V5-8d were during LVSPbi longer than during nsHBp and LBBPbi (absolute difference 4-9 ms); p < 0.05. No statistical difference in V5-V8d were observed between LBBPbi and nsHBp.

Conclusion

Bilateral bundle branch capture during LVSP and nsLBBp preserves interventricular synchrony at the same level as HBp and thus leads to more physiological ventricular activation in patients with bradycardia.
Impact of generic ICD programming on clinical outcomes
Authors: Khan P , Jahagirdar N , Laybourn M , Harding I , Cannata A , Bromage D , Shabeeh H , Kabunga P , Petzer E , Murgatroyd F , Scott P A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Generic ICD programming, where shock-reduction programming is extrapolated from trials of one manufacturer to another, may reduce non-essential ICD therapies beyond that seen in randomised trials. The purpose of this retrospective cohort study was to evaluate the impact of a standardised programming protocol, based on generic programming, across manufacturers. We also evalutated the impact of combining different detection rates and detection times.

Methods

We included all new ICDs in a single centre (2009-2019). In 2013 a standardised programming protocol based on generic programming was introduced. Patients were classified into three groups: pre-guideline (PS), post-guideline and guideline compliant (GC) and post-guideline but not guideline compliant (NGC). The end-points were the first occurrence of any device therapy (ATP or shock), ICD shock, syncope and all-cause mortality. Survival analysis was used to evaluate outcomes. A ’’programming score’’ was composed based on detection rate and time. The relationship between this composite "programming score’’ and study end-points was evaluated in multivariable cox proportional hazards models

Results

1003 patients were included (mean follow-up 1519 +/- 1005 days). In primary prevention patients freedom from ICD therapy (91.5% vs. 73.6%, p<0.001) or shock (94.7% vs 84.8%, p=0.02) were significantly higher in GC compared to PS patients, without significant increase in syncope or mortality. In secondary prevention patients freedom from any ICD therapy or any shock were non-significantly higher in GC compared to PS patients. Among primary prevention patients with the highest ’programming score’ (longest detection time and highest detection rates), there was a 82% reduction in risk of any ICD therapy (p<0.001) and a 70% reduction in risk of ICD shock (p<0.001)

Conclusion

A standardised programming protocol, incorporating generic programming, reduced the burden of ICD therapy without an increase in adverse outcomes.
Device-detected sleep-disordered breathing predicts implantable defibrillator therapy in patients with heart failure
Authors: Mazza A , Bendini M , Bianchi V , Esposito C , Calo’ L , Andreoli C , Santobuono V , Dello Russo A , Chianese R , La Greca C , Santoro A , Giubilato G , Strisciuglio T , Valsecchi S , Boriani G
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Sleep-disordered breathing is highly prevalent in heart failure (HF) and it has been suggested as a risk factor for malignant ventricular arrhythmias. The Respiratory Disturbance Index (RDI) algorithm computed by select implantable cardioverter defibrillators (ICDs) can identify severe sleep apnea (SA).

Purpose

In the present analysis we evaluated the association between ICD-detected SA and the incidence of appropriate ICD therapy in patients with HF.

Methods

We enrolled 411 HF patients (age 69±10years, 77% male, ejection fraction 32±8%), implanted with an ICD endowed with an algorithm (ApneaScan, Boston Scientific) that calculates the RDI each night. In this analysis the weekly mean RDI value was considered. The endpoint was the first appropriate ICD shock. The median follow-up was 26 months [25th–75th percentile: 16-35].

Results

During follow-up, one or more ICD shocks were documented in 58 (14%) patients.

Patients with shocks were younger (66±13years versus 70±10years, p=0.038), and more frequently implanted for secondary prevention (21% versus 10%, p=0.026). The maximum RDI value calculated during the entire follow-up period did not differ between patients with and without shocks (55±15episodes/h versus 54±14episodes/h, p=0.539). However, the ICD-detected RDI showed a considerable variability during follow-up. The overall median of the weekly RDI was 33episodes/h [25th–75th percentile: 24-45]. Using a time-dependent Cox regression model, the continuously measured weekly mean RDI≥45episodes/h was independently associated with shock occurrence (HR:4.63, 95%CI:2.54-8.43, p<0.001), after correction for baseline confounders (age, secondary prevention).

Conclusions

In HF patients, patients were more likely to receive appropriate ICD shocks during periods of time when they exhibited more sleep-disordered breathing.
Depressive symptoms and quality of life in patients with heart failure and an implantable cardioverter-defibrillator
Authors: Zormpas C , Kahl K G , Hohmann S , Oswald H , Stiel C , Veltmann C , Bauersachs J , Duncker D
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Heart failure (HF) is associated with development of depressive symptoms and reduced quality of life (QoL). Patients with HF and an implantable cardioverter-defibrillator (ICD) were evaluated regarding depressive symptoms and QoL.

Purpose

Patients with HF and an ICD were prospectively evaluated regarding depressive symptoms and QoL with the intention to elucidate the prevalence of depressive symptoms in this patient cohort and to assess how QoL evolves in the course of the underlying disease. Aim of the analysis is to identify patients in need for supportive care intervention and/or antidepressant therapy.

Methods

The present study included 446 patients with HF and an ICD. Depressive symptoms were assessed using the Patient Health Questionnaire 9 (PHQ-9), QoL was evaluated using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Functional ability and exercise tolerance were assessed at inclusion and after 6 months with help of the 6-minute walking test (6MWT).

Results

Patients included in the study had a mean age of 65.8 years and were predominantly male (83.6%), with mostly ischemic (n = 277; 62.1%) or dilated (n = 150; 33.6%) cardiomyopathy. 193 (43.2%) patients had depressive symptoms, of whom 75 patients (16.8%) were classified as moderate to severe depression according to the PHQ-9 at baseline. Depressive symptoms were associated with low QoL independent of NYHA functional class. High NYHA functional class, high PHQ-9 score, age and body mass index (BMI) were associated with a lower 6MWT at enrollment, while depressive symptoms (expressed as higher PHQ-9 score) and age were associated with a lower 6MWT after 6 months. Patients with history of smoking and a higher BMI showed higher PHQ-9 scores after 6 months. Patients under antidepressant medication showed improved PHQ-9 score after 6 months, indicating controlled/treated depression. However, patients with low QoL at inclusion remained with low QoL after 6 months.

Conclusion

Depressive symptoms correlate with low QoL and lower long-term functional status in patients with HF and an ICD. Depressive symptoms are associated with smoking and obesity, which themselves are risk factors for a poor prognosis in HF. Only a small fraction of patients with HF and ICD showing depressive symptoms receives appropriate treatment. Assessing depressive symptoms and lifestyle factors should be part of a multimodal treatment plan in patients with HF and an ICD.
Potential for delayed improvement of left ventricular ejection fraction in newly diagnosed heart failure under optimized therapy depends on etiology - data from the PROLONG-II study
Authors: Mueller-Leisse J , Brunn J , Zormpas C , Hohmann S , Hillmann HAK , Eiringhaus J , Bauersachs J , Veltmann C , Duncker D
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with a first diagnosis of heart failure with reduced ejection (HFrEF) have potential for improvement under appropriate therapy. We and others have previously suggested to extend the time of therapy optimization beyond 3 months before considering implantation of a primary preventive implantable cardioverter-defibrillator (ICD), in order to avoid unnecessary ICD implantations. This sub-analysis of the PROLONG-II study sought to investigate which patients show recovery of left ventricular ejection fraction (LVEF) beyond 3 months under optimized therapy.

Methods

Patients with newly diagnosed HFrEF with either ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM), peripartum cardiomyopathy (PPCM) or myocarditis at our center between 2012 and 2017 were included. All patients received a wearable cardioverter defibrillator (WCD) for temporary protection from sudden cardiac death. Follow-up (FU) data were analyzed after 3 months and at last available FU, and included WCD data, clinical status, medication, echocardiography and ECG.

Results

353 patients (69% male) with newly diagnosed HFrEF (LVEF 25±8%) were followed for 2.8±1.5 years: 126 patients with ICM (35%), 169 patients with DCM (48%), 27 patients with PPCM (7%), 24 patients with myocarditis (7%) and 7 patients with other diagnoses (2%). LVEF improvement within the first 3 months was observed in all subgroups but was more pronounced in patients with DCM (9±9%) compared to ICM (5±8%) and in PPCM (20±10%) and myocarditis (15±9%) compared to both DCM and ICM. In patients with DCM and PPCM, LVEF continued to improve significantly beyond 3 months (another 10% each).

Conclusion

Potential for delayed LVEF improvement in newly diagnosed HFrEF under optimized therapy depends on etiology. Patients with PPCM and DCM seem to be particularly eligible for an extended period of therapy optimization and risk stratification before considering an ICD.
Reasons for replacement and extraction of the subcutaneous implantable cardioverter-defibrillator in a large cohort
Authors: Van Der Stuijt W , Pepplinkhuizen S , Smeding L , Olde Nordkamp LRA , Wilde AAM , Knops RE
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is proven to be a safe and effective alternative to the transvenous ICD. However, battery longevity is estimated to be shorter in the S-ICD, although newer generations S-ICD are thought to have an increased battery longevity compared to the first generation. In addition, the S-ICD lacks the option for pacing therapy and may therefore be extracted in patients who later develop an indication for bradycardia pacing, antitachycardia pacing or resynchronization therapy. In this analysis, we aim to evaluate occurrence and reasons for S-ICD replacement and extraction.

Methods

In this retrospective analysis, we collected data on S-ICD generator replacement and extraction from consecutive patients who were implanted with an S-ICD in our tertiary center between February 2009 and December 2021.

Results

A total of 408 patients received an S-ICD, with a median follow-up duration of 4.0 (IQR 1.5-6.8) years. Of the 168 implanted first generation S-ICDs, 123 (73.2%) were replaced after a mean of 5.9 ± 0.8 years, all due to battery depletion. A second generation S-ICD was replaced in 2/40 (5%) patients and a third generation S-ICD in 11/200 patients (5.5%), after a mean of 4.8 ± 0.12 and 3.6 ± 1.6 years, respectively. Two third generation S-ICDs were replaced due to device malfunction, all other replacements (134/136, 98.5%) were due to battery depletion. The S-ICD was extracted in 38/408 (9.3%) patients. The mean time from initial implantation to extraction was 3.7 ± 2.5 years. Reasons for extraction were a newly developed indication for pacing or resynchronization therapy (N = 14), an expired indication for ICD therapy (N = 8), heart transplantation or implantation of left ventricular assist device (N = 4), repeated inappropriate shocks (N = 4), pocket infection (N = 3), pocket erosion (N = 2), lead defect (N = 1), Twiddler syndrome (N = 1) and patient preference (N = 1). A new S-ICD could be re-implanted in 7 patients (18.4%), a cardiac resynchronization therapy defibrillator was implanted in 7 patients (18.4%) and there was a need for a transvenous ICD in 10 patients (26.3%). The remaining 14 patients (36.8%) were not re-implanted with any type of ICD. Reasons for end of S-ICD therapy are presented in the figure.

Conclusion

In this large cohort, a battery longevity of the first generation S-ICD of 5.9 years was reached. After a median follow-up duration of 4.0 years, 17/408 patients received a transvenous device, due to the need for bradycardia or antitachycardia pacing or resynchronization therapy. Importantly, 14/408 patients underwent an S-ICD extraction and were not re-implanted with any type of ICD. These patients may especially benefit from S-ICD therapy, as this device is less complicated to extract compared to a transvenous ICD.