bluuebunny/crossref_metadata_2025 huggingface dataset:
Rest and stress aortic flow analysis by CMR in MyoFit46
Authors: Varma A , Webber M W , Captur G C
Published: May 2024

Background

Aortic stiffness is a strong predictor of future cardiovascular events and all-cause mortality. Aortic stiffness has never been measured during adenosine stress perfusion before, and may provide valuable relationship about this relationship.

Aim

To investigate if there are differences between aortic stiffness and conditions of rest and stress perfusion, in an older age-homogenous population-based cohort.

Methods

203 participants from the longitudinal 1946 Medical Research Council National Survey of Health and Development British birth cohort were included. Cardiovascular Magnetic Resonance (CMR) imaging was performed at rest and during adenosine stress perfusion. 3 established and validated biomarkers of aortic stiffness were reported - pulse wave velocity, distensibility and beta stiffness, at rest and stress perfusion. All variables were non-normally distributed, therefore the Wilcoxon signed-rank test was used to look for significant differences between rest and stress.

Results

Aortic stiffness increased significantly during adenosine stress perfusion, shown by all biomarkers of aortic stiffness used: pulse wave velocity (p = <0.001), distensibility (p = <0.001), and beta stiffness (p = <0.001). However, the aortas of participants with a higher resting aortic stiffness at baseline were less dynamic (little if any aortic stiffness change with stress) when compared to those with low resting aortic stiffness.

Conclusion

It is feasible to measure aortic stiffness during adenosine stress perfusion. In healthy aortas, aortic stiffness increases in the acute phase of adenosine stress suggesting a new potential mechanism for the body response to adenosine – peripheral chemoreceptor reflex activation. Stiffer arteries at baseline are less modifiable and stress aortic flow CMR has the potential to identify these persons permitting early targeted therapy. Change in aortic stiffness, measured by stress aortic flow CMR is therefore a potential non-invasive biomarker of aortic health.
The impact of comorbidities and substance use on heart failure events and major ventricular arrhythmias in phospholamban p.(Arg14del) positive individuals
Authors: Van Der Heide M Y C , Verstraelen T E , Mahmoud B , Van Drie E , De Brouwer R , Proost V M , Houweling A C , Dickhoff C , Germans T , Te Riele A S J M , Van Spaendonck-Zwarts K Y , Cox G P J , Van Tintelen J P , Zwinderman A H , Wilde A A M
Published: May 2024

Background

Patients with the phospholamban (PLN) p.(Arg14del) variant can develop a severe cardiomyopathy, characterized by progressive heart failure (HF) and major ventricular arrhythmias (VA). However, there is a marked variability in disease expression among affected individuals. There is still a considerable gap of knowledge regarding the influence of comorbidities and substance use on disease progression.

Purpose

The aim of this study is to investigate whether specific comorbidities and substance use are associated with HF events or major VA events in PLN p.(Arg14del) positive individuals.

Method

Logistic regression analysis was conducted was conducted in a retrospective cohort of 880 PLN p.(Arg14del) positive individuals (N=847 without heart failure at baseline, N=810 without major arrhythmia at baseline and N=780 without both). Comorbidities and substance use at baseline were assessed in univariable and multivariable models with respect to HF events, major VA events, and a composite endpoint of these two referred to as ‘severe phenotype’. Heart failure was defined as heart failure hospitalization, left ventricle assist device implantation, heart transplantation or HF-related death. Major VA was defined as sustained VA, appropriate implantable cardioverter defibrillator intervention, or (aborted) sudden cardiac death.

Results

Of all tested comorbidities, only renal dysfunction defined as an eGFR (CKD-EPI) <60 ml/min per 1.73 m² was significantly and independently associated with all endpoints (p<0.001). In the substance use analysis, prior history of smoking was associated with heart failure and a severe phenotype (p<0.002 and p<0.021), however actively smoking was not associated with both endpoints.

Conclusion

Renal dysfunction and a history of smoking were the only factors identified to be associated with worse outcomes in PLN p.(Arg14del) positive individuals. Whether renal dysfunction signifies a risk factor or an early manifestation of disease has to be further elucidated.
Machine learning for development of ECG-based prediction models for atrial fibrillation, thromboembolism and mortality in patients with heart failure
Authors: Huang T H , Ahlgrim C A , Mueller-Edendorn B M E , Pilia N P , Eichenlaub M E , Allgeier J A , Keyl C K , Neumann F J N , Trenk D T , Westermann D W , Arentz T A , Jadidi A J
Published: May 2024

Background

Heart failure (HF) is a worldwide epidemic affecting more than 64 million people. Given its massive burden both socially and economically, early identification of individuals at risk for complications is important.

Purpose

To test the predictive performance of non-invasive models from 12-lead digitalized electrocardiography (ECG) and cycle ergometer for adverse outcome in individuals with heart failure.

Methods

598 Patients scheduled for right heart catheterization due to unexplained dyspnea were screened. All ECG recorded at admission were further analysed using the software "ECG-Precision-Analysis V-1-2023" to measure the duration of amplified p-wave (APWD at 175mm/sec, 80mm/mV) and to confirm the diagnosis of inter-atrial block. Ergometer was performed in a supine position with increasing intensity adapted to individual capacity (25 or 50W). The maximum physical capacity (Watt-max) was determined. Follow-up (FU) was scheduled at 12-,36-, 60- and 120-month after discharge with the primary endpoint as MACCE (a composite of new onset of AF, ischemic stroke and peripheral embolism) in at baseline event-free patients and the secondary endpoint as all-cause mortality in the total cohort. Three machine learning (ML) algorithms (COX regression, BSR and LASSO regression) were used to select candidate variables and establish predictive models for MACCE and all-cause mortality. Model evaluation was performed in terms of discriminatory power using C-statistics for each endpoint.

Results

Prediction models developed using machine learning (ML) algorithms (COX regression, BSR and LASSO regression) identified Watt-max and/or APWD as core components for MACCE and mortality prediction . APWD and Watt-max were key components of ML models for prediction of thromboembolic risk and AF (MACCE) and reached accurate diagnostic performances (C-statistics up to 0.74), moreover, another model consisted of APWD and aIAB (advanced inter-atrial block) was established to serve as a reference to ML models with moderate performance for MACCE (mean C-statistics <0.70). All ML models for prediction of all-cause mortality included Watt-max and achieved C-statistics > 0.75.

Conclusions

In patients with heart failure, the combination of APWD, aIAB and maximum excercice capacity allow to identify patients at risk for AF and stroke, whereas mortality is predominantly predicted by maximum exercise capacity but not APWD.Kaplan-Meier curves for MACCE/MortalitytimeROC curves for MACCE/Mortality
Preliminary implantation experience in Europe with a novel insertable cardiac monitor
Authors: Fareh S , Diamante A , Nardi S , Luzzi G , Scarano M , Sangiuolo R , Silvetti M S , Porcelli D , Argenziano L , Zanotto G , Charles P , Montoy M , Valsecchi S , Magnocavallo M
Published: May 2024

Background

The LUX-Dx is a new insertable cardiac monitor (ICM) available in the European market since October 2022.

Purpose

To describe the initial experience of LUX-Dx implantation in Europe and report feedbacks from operators and patients.

Methods

The system includes an incision tool and a single-piece insertion tool that is pre-loaded with the small (1.2 cm3) ICM. The implantation procedure is straightforward and comprises the incision, the creation of the device pocket, the insertion of the ICM, the verification of sensing and the incision closure. Following implantation, patients are provided with a mobile device preloaded with the App which connects to their ICM and transmits data daily, or as needed, to the management system. We analyzed data and feedbacks collected at 20 European centers at the time of implantation and before patient discharge.

Results

A total of 175 implantation procedures were performed in 20 European centers. The most frequent indications for ICM implantation were syncope (n = 119, 68%) and cryptogenic stroke (n=15, 9%). Most procedures (157, 90%) were performed in electrophysiology laboratories by expert operators. The procedure was performed under local anesthesia in 169 (97%) patients, and systemic or local antibiotics were used before the procedure in 96 (55%) cases. A surface ECG mapping was performed before 65 (37%) insertions. All ICMs were implanted in the left parasternal region, with an orientation of 45° in 159 (91%) patients. Device repositioning was required after verification of sensing in 6 (3%) patients. The ICM was successfully implanted in all patients and no procedural complications were reported; the median time from skin incision to suture was 4 min (25th-75th percentiles 2-7). The mean R-wave amplitude was 0.38±0.34 mV at implantation and 0.42±0.38 mV before patient discharge (on average after 1 day). The P-wave visibility, i.e., the ratio between the number of clearly identifiable P-waves and the number of heart cycles during 10 sec ECG with a regular 1:1 conduction, was 92±21% at implantation and 93±18% before discharge. Survey questions on the overall operator experience with the implantation procedure are reported in Figure 1 and those on the patient experience are reported in Figure 2.

Conclusions

Implantation of the LUX-Dx seems fast and uncomplicated; operator and patient feedbacks are positive. Post-implantation sensing values, i.e. R-wave sensing and P-wave visibility, are good.Figure 1Figure 2
Utilization of implantable cardiac monitors in detecting type 1 patterns in brugada syndrome
Authors: Dinatale A , Crocamo A , Bearzot L , Gonzi G , Guidorossi A , Giacopelli D , Bassini M , Grassini D , Niccoli G , Ardissino D , Notarangelo M F
Published: May 2024

Introduction

In individuals with Brugada syndrome, the presence of the type 1 pattern (BP1) is linked to an elevated risk of severe arrhythmias. However, the identification and measurement of BP1 can be challenging due to its intermittent nature. Implantable cardiac monitors (ICMs) provide extended continuous monitoring, potentially overcoming the limitations of intermittent ambulatory ECG monitoring in detecting spontaneous BP1. Nevertheless, their specific application for this purpose remains unevaluated.

Methods

From November 2022 to September 2023, all patients presenting with pharmacologically induced BP1 were enrolled at our centre. An ICM was surgically placed in the left second intercostal space at a 45° angle, enabling readings with a morphology similar to the right precordial ECG leads during ajmaline testing (AT). Patients were remotely monitored, and in addition to routine automatic transmissions, each patient was provided with a remote control to transmit in case of fever or symptomatic events. Transmissions were scrutinized to detect: 1) ST-segment elevation; 2) ventricular arrhythmias; 3) burden of ventricular extrasystoles (PVC). A reading was classified as positive for BP1 if it bore a similar morphology to that recorded during AT. The frequency of BP1-positive transmissions was evaluated across four hourly intervals.

Results

The ICM was successfully implanted in 21 patients (male-to-female ratio 1.62:1, mean age 43.9±13.1 years). Over an average follow-up of 168±70.6 days, a total of 7818 transmissions were received, evenly spread across hourly intervals (minimum of 1296 transmissions per interval). Among these, 173 transmissions were identified as BP1 positive (2.2%), originating from 6 patients (28.6% of the total, all newly diagnosed with spontaneous BP1). The median duration between implantation and the diagnosis of spontaneous BP1 was 16.5 days (range 2-23). The median number of days with at least one positive transmission was 30.2 (range 13.4-73.9). The evening period (6 pm to midnight) displayed a significantly higher rate of positive transmissions compared to the morning (p=0.04) and afternoon (p=0.01); however, not in contrast to the nighttime (p=0.8). No sustained ventricular arrhythmias were observed, and there were no significant differences in PVC burden among patients.

Conclusions

The utilization of ICM for continuous monitoring in patients with pharmacologically induced BP1 led to the identification of spontaneous BP1 patterns in almost 30% of cases during an approximately 6-month follow-up. Evening and nighttime periods exhibited the highest incidence of BP1. This methodology shows promise in quantifying BP1 incidence and could serve as a tool for stratifying arrhythmic risk in individuals with Brugada syndrome.
Diagnostic accuracy of smartwatches for automated atrial fibrillation detection over time: insights from the basel wearable study
Authors: Isenegger C , Mannhart D , Weidlich S , Arnet R , Du Fay De Lavallaz J , Krisai P , Knecht S , Kuehne M , Sticherling C , Badertscher P
Published: May 2024

Background

The first smart-watch (SW) able to record a single lead ECG (SL-ECG) with automated atrial fibrillation (AF) detection algorithm was introduced 2018. Multiple other manufacturers followed. While manufacturers claim to continuously improve their devices’ algorithm, little is known about the impact on diagnostic accuracy on AF detection over time in a real-world cohort of patients.

Purpose

To assess if the diagnostic accuracy of algorithm-based AF detection of 5 smart devices has improved over time.

Methods

In this prospective study, consecutive patients undergoing electrophysiological procedures in a tertiary referral center were included between April 2021 to May 2023. Each participant received a 12-lead ECG and 5 SL-ECGs with different smart devices (AliveCor KardiaMobile, Apple Watch 6, Fitbit Sense, Samsung Galaxy Watch 3 and Withings ScanWatch). All SW were continuously updated for newest software or firmware as recommend by the manufacturers. The SW rhythm classification was compared to manual cardiologist-based interpretation of SL-ECGs. The change in number of inconclusive SL-ECGs by manufacturer’s algorithm were investigated over time via Cochran-Armitage test for trend and illustrated over time via logistic regression.

Results

247 participants were included (30% female, mean age 66.3 [IQR: 57-74] years) resulting in a total of 1’235 SL-ECGs. Among these, 202 SL-ECGs (16%) were labeled as inconclusive by at least one smart-device. Inconclusive rates for individual SW ranged from 15% to 19%. When comparing the first and last quintile of patients in the study period, the inconclusive rates for the KardiaMobile were 14% vs. 6%, for the Apple Watch 14% vs. 6%, for the Fitbit Sense 20% vs. 14%, for the Samsung Galaxy 18% vs. 10% and for the Withings ScanWatch 22% vs. 14%, respectively. When assessed continuously over time, we observed a trend towards fewer inconclusive tracings, without reaching statistical significance (Figure 1).

Conclusion

Over 26 months, inconclusive tracings of 5 SW didn’t significantly decrease despite frequent software updates in a real-world patient cohort. Larger, long-term cohorts are needed to assess if automated AF detection has significantly improved over time.Figure 1
The electrical substrate of vectorcardiographic QRS area in cardiac resynchronization therapy: insights from ECG-imaging
Authors: Nguyen U , Smits K , Cluitmans M , Rijks J , Van Stipdonk T , Prinzen F W , Vernooy K
Published: May 2024

Background

The QRS area shows promise as a vectorcardiographic (VCG) marker for electrical dyssynchrony in patient selection for cardiac resynchronization therapy (CRT). Nevertheless, little information is known about the underlying cardiac electrical substrate it may reflect.

Purpose

The aim of this study was to compare the VCG QRS area with measures of cardiac electrical dyssynchrony derived from electrocardiographic imaging (ECG-imaging).

Methods

QRS area from the synthesized VCG (Kors transformation matrix from the 12-lead ECG) was computed for 27 patients who underwent ECG-imaging (11 patients with no history of structural heart disease and 16 consecutive CRT patients). ECG-imaging measures for electrical dyssynchrony analyzed were: ventricular electrical uncoupling (VEU) computed as the difference between the average LV and RV activation times from ECG-imaging, standard deviation of activation times from the left ventricle (LV SDAT, and the maximal activation (Max AT). Pearson correlation analyses between VCG QRS area and ECG-imaging measures of dyssynchrony were carried out for the entire cohort and for patients with a wide-QRS only.

Results

ECG-imaging measures of dyssynchrony compared with QRS area in 11 patients with no structural heart disease with narrow-QRS (blue) and 16 candidates for CRT with heart failure (HF) and predominantly wide-QRS (LBBB [n=6], IVCD [n=8], RVpaced [n=1], and nQRS-HF [n=1]) are provided in Figure 1. QRS area were associated with all ECG-imaging measures of dyssynchrony. However, sub-analysis in only the wide-QRS patients revealed that QRS area exhibited the strongest association with VEU.

Conclusion

Vectorcardiographic QRS area is associated with cardiac electrical dyssynchrony on ECG-imaging, exhibiting a particularly strong association with ventricular electrical uncoupling.
Useful aid or futile hassle - continuous rhythm monitoring following acute myocardial infarction
Authors: Hamacher L , Wessely E , Jost J , Rohla M , Panzer B , Kaufmann C , Pogran E , Burger A , Ahmed A , Freynhofer M , El Kilany N , Tinhofer F , Huber K , Zweiker D
Published: May 2024

Background

Patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) face an increased risk of cardiac events, including arrhythmias. Current guidelines therefore recommend ECG monitoring for at least 24 hours after AMI in patients with ST segment elevation myocardial infarction (STEMI) and high-risk non-ST segment elevation myocardial infarction (NSTEMI). However, in the last decades medical treatment of AMI has been substantially improved, limiting the risk of arrhythmias post-PCI. Furthermore, continuous ECG monitoring puts additional strain on healthcare personnel during an international healthcare crisis.

Purpose

To evaluate the contemporary burden of ventricular arrhythmias (VA) in AMI patients post-PCI.

Methods

This is a retrospective analysis of consecutive patients undergoing PCI for AMI between 2016 and 2020 at a secondary care centre. We defined the primary endpoint as any VA requiring intervention (electric cardioversion or pharmacologic treatment) after PCI. Baseline characteristics and outcome were compared in patients with NSTEMI vs. STEMI.

Results

A total of 931 patients were included in the analysis, with a mean age of 65 years and 28.6% were female. Patients with NSTEMI (47.3%) were older (median 66 vs. 63 years) and had significantly more comorbidities: hypertension (67.5% vs. 52.1 %), diabetes mellitus (25.4% vs. 15.8%), chronic obstructive pulmonary disease (11.5% vs. 6.7%), and peripheral arterial disease (11.4% vs. 5.3%, p<0.05 for all). VAs requiring intervention occurred in 3.6% vs. 7.1% (p = 0.017) before PCI and in 0% vs. 2.2% (p < 0.001) during PCI in NSTEMI vs. STEMI patients. After PCI the primary endpoint occurred in no NSTEMI patient and in 1.6% of patients with STEMI (p = 0.004).

Discussion

In a cohort of contemporary AMI patients, ventricular arrhythmias occurred rarely and significantly less often in NSTEMI patients compared to STEMI patients. Due to the low risk of VAs in patients with NSTEMI after PCI, the need for post-procedural rhythm monitoring in NSTEMI patients may be questioned. The identification of predictors for VA after AMI should be subject for future trials.
Atrial pace mapping using intracardiac pattern matching: feasibility and accuracy
Authors: Willert S , Demmig T , Maslova V , Zaman A , Popera J , Nicholson L , Sprenger L , Kleinhans L , Jahn O , Frank D , Lyan E
Published: May 2024

Introduction

Pace mapping of atrial arrhythmia is a method to localize the origin of usually focal arrhythmias that are unstable or not persisting during EP-study and, therefore not eligible for LAT-Mapping. The technique applies pattern matching of p-waves from surface-electrocardiogram (sEKG) as well as intracardiac signals during atrial tachycardia and pacing from the site of suspected origin. The CARTO® 3 system Version 7.2 applies an automated algorithm for intracardiac pace mapping (ICPM) using the unipolar signal of the reference electrode, usually located in the coronary sinus.

Methods

We examined 12 consecutive patients undergoing RF pulmonary vein isolation (PVI). We performed local pacing at the anterior and posterior wall of the left atrium (LA) and the posterior and lateral wall of the right atrium (RA). The first pacing point was defined as the reference pacing site (RPS). The ICPM algorithm was applied to calculate the similarity of the IC pattern of the RPS to the IC pattern across various distances. The maps, including mesh, point locations and IC pattern similarity of each point, were exported for further analysis in the Python environment. The areas were calculated for the 5% similarity strata.

Results

The study assessed areas with a 95% or higher pattern similarity in different atrial regions, revealing notable differences in pattern similarity. The median area of pattern similarity was 1.48 cm² (IQR: 0.76 - 2.01 cm²) in the LA posterior, 0.62 cm² (IQR: 0.15 - 1.06 cm²) in the LA anterior, 0.60 cm² (IQR: 0.38 - 1.19 cm²) in the RA posterior, and 5.68 cm² (IQR: 2.89 - 11.1 cm²) in the RA lateral wall. Significant differences were found between the posterior and anterior walls of the LA and the RA lateral wall, as well as between the RA posterior and RA lateral wall, indicating variability in intracardiac pattern matching accuracy. Patterns below 2 cm² are acceptable for catheter ablation. An outlier was noted in the RA posterior region.

Conclusion

The intracardiac pattern matching for atrial arrhythmias employing the CARTO-ICPM algorithm is feasible with acceptable accuracy except for the lateral regions of the right atrium. This might be explained by the larger distance to the referent catheter in the coronary sinus and the preferred conduction direction in the crista terminalis. Enhancing localization accuracy may necessitate the adjunctive use of surface ECG-pace mapping or the deployment of an additional multipolar intracardiac reference catheter in the lateral RA.A: IC Pattern, B: Box plots similarity
Risk Assessment in Patients with Symptomatic and Asymptomatic Preexcitation (RASAP)
Authors: Saygi S
Published: May 2024

Background

Controversy remains as to whether exercise stress test (EST) is sufficient for risk evaluation in patients with preexcitation.

Purpose

This study aims to clarify the usefulness of EST in risk stratification in both asymptomatic and symptomatic patients, presenting with preexcitation.

Methods

This prospective study includes consecutive asymptomatic and symptomatic patients with preexcitation, referred for risk assessment. All participants performed an incremental EST (bicycle), prior to an electrophysiology study (EPS). Primary data from the EST included loss of preexcitation during exercise and from EPS included measurement of accessory pathway effective refractory period (APERP), shortest preexcited RR interval (SPERRI), and inducible arrythmia with use of a beta-adrenergic receptor agonist if deemed necessary.

Results

One hundred and sixty-four patients (59 asymptomatic, 105 symptomatic) completed an EST and EPS. Forty-five patients (27%) demonstrated low-risk findings on EST, of which 19 were asymptomatic and 26 were symptomatic. Six patients with low-risk EST findings had SPERRI/APERP≤250 ms at EPS, two of them were asymptomatic. The sensitivity, specificity, positive and negative predictive value (PPV, NPV) and accuracy of low-risk EST for excluding patients with SPERRI/APERP≤250 ms were 29%, 91%, 80%, 48%, and 55% respectively. The number of patients with inducible arrhythmia at EPS was similar in the asymptomatic 36 (69%) and in the symptomatic 73 (61%) group.

Conclusions

Sudden loss of preexcitation during EST has a low sensitivity and low NPV in excluding high-risk APs. EPS with use of isoproterenol should be considered to accurately assess the risk of patients with preexcitation regardless of symptoms.Figure
Localization of ganglionated plexi by high density mapping: an atropine-response analysis
Authors: Giomi A , Paoletti Perini A , Bernardini A , Padeletti M , Signorini U , Zaccaria C , Ciliberti D , Milli M
Published: May 2024

Introduction

Growing interest has emerged around cardiac autonomic nervous system driven by ablation approaches for the treatment of neurally-mediated syncope (NMS). Ganglionated-plexi (GPs) located in the epicardial fat pads are the main target of ablative therapies, but little is known about the finest method to track their location from the endocardium. Most current techniques rely on empirical research of signal fragmentation and/or vagal response at anatomical landmarks. A poor accuracy in targeting GPs may lead to the risk of incomplete or over-extensive ablation.

Purpose

We analyzed the atrial electrograms (EGMs) in healty subjects and their response to atropine to describe physiological fragmentation and the relationship with vagal output.

Methods

Study partecipants were selected from young patients without structural heart desease who underwent electrophysiological study (EPS) for standard indications. High-density mapping of right atrium was performed before and after administration of 2 mg atropine at the end of the planned procedure. Offline analyses were performed comparing the two maps of each patient focusing on the fragmentation of the atrial EGMs.

Results

The study cohort comprised 10 patients (mean age of 39±11 years, 6 males). The indication for EPS was: supraventricular tachycardia (SVT) ablation in 9 patients, syncope in 1 patient. High density three-dimensional electro-anatomic maps (EAM) were all obtained with a multipolar catheter during sinus rhythm (number of points: 8794±937 in basal maps and 9007±1296 after atropine, p=0,87). The response to atropine was documented by an increase in heart rate (mean increase 59 ± 19% of basal cycle length). All basal maps showed a similar pattern of fragmentation in the posterior-septal wall reflecting the anatomical distribution of right GPs. In particular, three main stations were identified in the supero-, mid- and infero-posterior regions. Fragmentation of EGMs was found to progress from the edge to the core of each area. After administration of atropine, a reduction in fractionated area was observed in all patients. Filtering the maps according to a cut-off of fragmentation ≥ 6 peaks allowed identification of the nucleus with the highest degree of variation after atropine injection (mean basal area = 0,89 ± 0,81 cm2 ; mean atropine area = 0,44 ± 0,56 cm2 p<0,001).

Conclusion

Fragmentation of atrial electrograms is a dynamic property related to vagal output. High density mapping with a high pass filter of 6 peaks allows to identify the smallest vagal sensitive area in the anatomical stations of the GPs.
Trends in adoption of extravascular cardiac implantable electronic devices: the Dutch cohort
Authors: Breeman K T N , Knops R E , Van Der Stoel M D , Boersma L V A , Yap S C , Van Erven L , Van Dijk V F , Maass A H , Wilde A A M , Tjong F V Y
Published: May 2024

Introduction

Conventional implantable cardioverter-defibrillators (ICDs) and pacemakers carry a risk of mainly pocket- and lead-related complications. To avoid these complications, extravascular devices (EVDs) have been developed, such as the subcutaneous ICD (S-ICD) and leadless pacemaker (LP). However, data on the actual adoption of EVDs for patient or center characteristics is lacking.

Purpose

To assess real-world nationwide trends in adoption of EVDs in the Netherlands.

Methods

Using the Netherlands Heart Registration, all consecutive patients with a de novo S-ICD or conventional single-chamber ICD implantation between 2012-2020, or with a de novo LP or conventional single-chamber pacemaker implantation between 2014-2020 were included. Trends in adoption of EVDs are described for different patient and hospital characteristics (tertiles of device-implanting volume and whether cardiothoracic surgery back-up was available). Differences between patients with EVDs and non-EVDs and differences between implanting centers of EVDs and non-EVDs were tested for by Student’s T-test, Chi-square and Fisher’s exact test. Trends in adoption over time were calculated with linear and logistic regression analysis.

Results

From 2012-2020, 2190 S-ICDs and 10683 conventional ICDs were implanted; from 2014-2020, 712 LPs and 11103 conventional pacemakers were implanted. The general adoption of both increased (S-ICDs, 8% to 21%; LPs, 1% to 8%), but the increase seems to reach a plateau (Fig. 1). S-ICD recipients were younger than conventional ICD recipients (p<0.001) and more likely to be female (p<0.001); LP recipients were younger than conventional pacemaker recipients (p<0.001) and more likely to be male (p=0.03). Both S-ICDs and LPs were mainly implanted in high-volume centers with thoracic surgery on-site (Fig. 2).

Conclusions

In this nationwide study we observed a relative quick adoption of innovative EVDs with a plateau after approximately 4 years. The relative adoption of S-ICDs is especially high in younger patients. EVDs are overall mainly implanted in high-volume centers with cardiothoracic surgery available. As LPs can only be implanted in centers with cardiothoracic surgery in the Netherlands, this may have limited its adoption.
Feasibility and safety of cavotricuspid isthmus ablation using exclusive intracardiac echocardiography guidance: a proof-of-concept, observational trial
Authors: Debreceni D , Kristof-Ferenc J , Toth D , Bocz B , Simor T , Kupo P
Published: May 2024

Introduction

Catheter ablation is the preferred treatment for typical atrial flutter (AFl), although it can pose challenges due to anatomical abnormalities. The integration of 3D electroanatomical mapping systems (EAMS) has notably diminished the need for fluoroscopy in AFl ablation procedures. Intracardiac echocardiography (ICE) has also demonstrated advantages in reducing radiation exposure during AFl ablation. Nevertheless, there is a lack of evidence on the feasibility of ICE-guided, zero-fluoroscopy AFl ablation without the use of EAMS.

Methods

In this prospective study, we enrolled 80 patients with CTI-dependent AFl. The initial 40 patients underwent ablation guided by standard fluoroscopy along with ICE (Standard ICE group), whereas the remaining 40 patients underwent zero-fluoroscopy ablation exclusively using ICE (Zero ICE group). Procedure outcomes, including acute success, procedural duration, fluoroscopy duration, radiation dose, and any associated complications, were compared between the groups.

Results

Both groups achieved a 100% acute success rate. In the Zero ICE group, the zero-fluoroscopy approach was successfully executed in 39 out of 40 cases (97.5%). There were no significant differences in procedure time (55.5 (46.5; 66.8) min vs. 51.5 (44.0; 65.5), p=0.50) and puncture to first ablation time (18 (13.5; 23) min vs. 19 (15; 23.5) min, p=0.50) between the groups. The Zero ICE group had significantly lower fluoroscopy time (57 (36.3; 90) sec vs. 0 (0; 0) sec, p<0.001) and dose (3.17 (2.27; 5.63) mGy vs. 0 (0; 0) mGy, p<0.001 compared to the Standard ICE group. Total ablation time was longer in the Standard ICE group (597 (447; 908) sec vs. 430 (260; 750), p=0.02), but total ablation energy (22458 (14836; 31116) Ws vs. 17043 (10533; 29302) Ws, p=0.10) did not differ significantly. First-pass bidirectional conduction block of the CTI and acute reconnection rates were comparable between the groups. No complications or recurrences were noted during the follow-up period.

Conclusion

ICE-guided, zero-fluoroscopy CTI ablation for AFl using only ICE is feasible and safe. This method effectively eliminates radiation exposure without compromising procedural duration, total ablation time, or acute success rates.isthmus ablation by ICE
Impact of interatrial septal thickness and interatrial conduction time on cryoballoon ablation outcome
Authors: Soysal A , Yalman H , Gulfidan A , Sanli S N , Ceviker A , Raimoglu D , Dogramaci E , Atici A , Ikitimur B , Yalin K
Published: May 2024

Introduction

Interatrial septal thickness (IAST) is an indirect measure of interatrial septal fat which is anatomic extension of epicardial fat. Interatrial conduction time (IACT) reflects altered conduction between atria. Both parameters are associated with left atrial (LA) fibrosis and atrial fibrillation (AF). However, limited data exist regarding the influence of IAST and IACT on the outcomes of cryoballoon ablation (CBA). In this study, we aimed to analyze possible effect of IAST and IACT on atrial tachyarrhythmia (ATA) free survival after CBA.

Methods and results

Sixty five patients (34/65, 52.3% male, 53.3±11.0 years old) undergoing first time CBA for pulmonary vein isolation were enrolled. Pre-procedural TEE images were analyzed and bicaval view was used to visualize SVC rim for IAST measurement (Figure 1). IACT was measured from the onset of surface P wave to atrial EGM recorded by distal coronary sinus electrode. After 3 months blanking period all anti-arrhythmic drugs were discontinued. Clinical endpoint was ATA recurrence including AF, flutter or tachycardia lasting more than 30 seconds. After 11.2±4.1 months of follow-up 8 patients (12.3%) had ATA recurrence. IAST (4.4±1.1 vs 3.3±0.6 mm, p=0.007) and LA volume index (37.4±8.0 vs 30.1±12.4 mL/m2, p=0.03) were greater in patients with ATA recurrence than those without. In contrast, patients with and without had similar IACT (85.8±31.1 vs 62.2±23.9 ms, p=0.10).

Conclusion

Pre-procedural measurement of IAST using TEE may provide prognostic information in CBA patients. Increased IAST was found to be associated with ATA recurrence after CBA based PVI and warrants further study.Interatrial septal thickness measurement
Not too old to be treated: electrophysiological study and catheter ablation in eldery patients
Authors: Duran Bobin O , Gonzalez T , Elices J , Gonzalez-Juanatey C
Published: May 2024

Background

The number of elderly patients referred for electrophysiological study (EPS) and catheter ablation (CA) is increasing. These patients are thought to have more complications due to age and comorbidity.

Purpose

The aim of our study was to evaluate the safety (EPS and CA) and acute success (CA) in a group of elderly patients (age ≥75 years old).

Methods

Between August 2020 and September 2023, consecutive elderly patients (32.7% older than 80 years) underwent EPS alone or EPS and CA at our center. Left atrial thrombus was ruled out performing transesophageal echocardiography when indicated. Anticoagulation (ACO) was not interrupted. Femoral veins, arteries and transeptal punctures were performed under ultrasound guidance. A navigation system was used for all CA procedures, except for pulmonary vein isolation, which was performed with a cryoballoon. We analysed procedural complications related to EPS and CA and the acute success of CA procedures.

Results

A total of 104 patients undergoing EPS±CA (79.9±4.6 years, 41.3% female, 75% HTA, 67.3% diabetes type 2, 19.4% COPD, 20.2% chronic renal disease, 25% structural heart disease, CHA2DS2VasC score 3.6±0.8, IMC 27.3±4.5 kg/m2, weight 72.3±13.6 kg, LVEF 52.7±10.8%, 31% history of atrial fibrillation (AF), 47.1% on ACO, 38.5% bundle-branch block, 34.6% first-degree atrioventricular block, 4.8% implanted pacemaker or ICD) were included. Indications for referral (Figure 1) were typical atrial flutter (TAF, 34.6%), atrioventricular nodal reentrant tachycardia (AVNRT, 26.9%), study of syncope (11.5%) atypical atrial flutter or atrial tachycardia (AAF/AT, 10.6%), AF (8.6%, 6 patients for AV node ablation, 3 for pulmonary vein isolation), ventricular tachycardia or ectopy (VT or VE, 5.7%), orthodromic reentrant tachycardia (ORT, 1.9%). 2 patients had TAF and AVNRT, treated in the same procedure. Acute success was achieved in 100% of AF, 94.6% of TAF, 89.6% of AVNRT, 66% of VT/VE, 50% of ORT, 45% of AAF/AT. There were 4 complications (2.9%) in 3 patients, all during the CA procedure: an AV block during an AVNRT ablation, another AV block during an ischaemic septal VT ablation, a femoral artery pseudoaneurism in the same patient (femoral artery approach), and a dislocation of the electrodes from a previous pacemaker during an AT ablation. None of the patients undergoing EPS alone had complications. Weight was the only variable associated with the development of complications (mean difference= -19.8, 95% CI(-38.9-0.7); p=0.04), being higher in those with than in those without complications (91.5±2.2 vs 71.6±13 Kg),(Table 1).

Conclusions

EPS and CA procedures in elderly patients with multiple comorbidities are safe and effective. Acute success and complication rates of CA procedures are substrate-dependent and similar to those reported in the literature for younger patients. We conclude that age is not a barrier to the study and treatment of arrhythmias.
Predictors of low-voltage areas in the left atrium in patients with atrial fibrillation
Authors: Kiliszek M , Beata Uzieblo-Zyczkowska B U Z , Krystian Krzyzanowski K K , Pawel Krzesinski P K
Published: May 2024

Background

Low-voltage areas (LVA) in the left atrium (LA) electroanatomical map are potent predictors of the efficacy of atrial fibrillation (AF) ablation. Clinical factors predicting the presence of LVA have moderate accuracy. The aim of the study was to find clinical and echocardiographic factors predicting the presence of LVA in patients undergoing AF ablation.

Methods

Consecutive unselected patients undergoing AF ablation were included in the retrospective analysis. All patients underwent transthoracic (including LA strains) and transesophageal echocardiography, pulmonary vein isolation and LA electroanatomical mapping using multipolar catheter. LVA were defined as an area greater than 2cm2 with a voltage below 0.5mV (or 0.3mV when measured during AF).

Results

A total of 432 patients were included in the analysis, 107 (24.8%) had LVA. The mean age of the study population was 62.8 years, 185 patients had nonparoxysmal AF (42.8%). In the univariate logistic regression analysis numerous clinical parameters (age, female sex, presence of heart failure, diabetes, coronary artery disease, AF during examination), echocardiographic parameters (LA reservoir strain - LASr, LA emptying fraction, LA volume index, E/e’, LA appendage velocity - LAAV) and mean LA pressure (measured invasively) were significant predictors of the presence of LVA. In the multivariate logistic regression analysis age (HR 1.11 per 1 year increase, p<0.001), LASr (HR 0.89 per 1% increase, p=0.014) and LAAV (HR 0.93 per 1cm/s increase, p<0.001) were significant predictors of the presence of LVA. In receiver-operator curve (ROC) analysis LASr and LAAV were potent predictors of LVA in patients tested on sinus rhythm (AUC 0.86 and 0.87 respectively), while they had moderate predictive value in patients tested on AF (LASr AUC 0.67, LAAV AUC 0.77).

Conclusions

Age, LASr, and LAAV were significant predictors of LVA in patients undergoing AF ablation. The predictive value of LASr and LAAV was better in patients examined during sinus rhythm than in patients examined during AF.
First experiences with protected VT ablation using surgical Impella 5.5
Authors: Nentwich K , Ene E , Hijazi H , Berkowitz A , Lenos A , Deneke T
Published: May 2024

Introduction

Ablation of ventricular arrhythmias (VA) is still challenging due to the complex substrate of the underlying heart disease. Depending on specific risk factors acute hemodynamic decompensation during or after VT ablation procedures may occur and hemodynamic support may be required.

Protected VA ablation with different devices has been evaluated but associated complications like bleeding, vascular closure or weaning from the device have been restrictive. We present data on a dedicated approach to patients with anticipated hemodynamic deterioration using preventive surgical Impella support.

Method

5 patients (2 female) underwent protected VT ablation under our standardized protocol. Indication for Impella support was severely impaired left ventricular function and multiple medical therapy refractory ventricular arrhythmias. 4 patients had conventional VT ablation before. Mean age was 66,8 years, mean CHADSVASC 4,4, 1 patient with non-ischemic cardiomyopathy (CMP), 1 with hypertrophic non-obstructive CMP, 3 patients with ischemic CMP. Mean EF was 20%, mean mixed venous saturation was 36 %, mean PAINESD score 27. In all patients a 5.5. Impella was implanted surgically 1 day before planned VT ablation via the right subclavian artery. VT ablation procedure started with substrate mapping, VT induction and activation mapping of the inducible VT to identify the critical VT isthmus. Ablation was directed to dissection of the critical isthmus of inducible VAs and elimination of all late potentials within low voltage areas. The Impella device was explanted after weaning off the hemodynamic support.

Results

Implantation of Impella 5.5 was successfully performed in all patients in general anesthesia without any complication via surgical approach. Specifically, no access site vascular complications were noted. In 4 patients the VT ablation procedure was performed in analgosedation, 1 patient in GA as this patient was intubated due to recurrent VA requiring defibrillation. Mean procedure time was 125 min, radiation time 1,3 min, inducible VTs 1,3 , median 2 morphologies. In all patients all inducible VTs could be eliminated, in 1 patient polymorphic VA was still inducible at the end of the procedure. Impella was explanted after mean 5,2 days (3-11 days). No complications occurred. All patients were discharged alive on heart failure medication and in 2 patients with amiodaron. At a mean follow up of 3.5 months, all patients are alive without VA recurrence and heart failure decompensation.

Conclusion

Surgical Impella implantation for protected VT ablation in severe heart failure patients is feasible and allows for effective VT mapping and ablation. Access site safety and protection for heart failure decompensation in addition to the possibility of individually mobilisation and weaning after the procedure make this protocol an attractive option. Prospective evaluation of standardized indication is needed.
Anatomic-guided ablation of the right ganglionated plexi validated by the automatic fractionation map
Authors: Parreira L , Quintal J , Mesquita D , Marques L , Marinheiro R , Silva J , Chambel D , Encarnacao C , Costa F , Duarte L , Seixo F
Published: May 2024

Background and aim

Cardiac autonomic modulation through endocardial ablation of atrial ganglionated plexi (GP) is an alternative strategy in selected patients with severe vagal induced bradyarrhythmias.

A strictly anatomical approach targeting the right GPs has demonstrated good success rates but is an empirical approach and has yet to be validated. The presence of fractionated electrograms has been associated with the areas of GPs and can be automatically mapped (fractionation map). The aim of this study was to compare the empirical ablated area, to the automatically assessed area of GPs based on the presence of fractionated electrograms (FEs).

Methods

We studied eight consecutive patients referred for parasympathetic modulation. A high-density map of the left and right atria (LA, RA) in sinus rhythm was performed. The settings for the automatic map were as follows: bipolar high pass filter of 500 Hz, a fractionation threshold of 4, and a width of 5 ms. The ablation was empirically performed by an operator blinded to the results of the fractionation map, as per site protocol. The ablation was aimed at the anatomic locations of the right GPs in the LA and RA. At the anterior and inferior aspect of the right superior pulmonary vein and inferior aspect of the right inferior pulmonary vein on the LA, and posterior RA opposite to the LA RF applications and around the coronary sinus ostium on the RA (Figure). Before ablation, 2 mg of atropine was administered in bolus, and the increase in heart rate was registered and repeated at the end of the procedure. After the operator completed the ablation, access to the fractionation map was available, and additional radiofrequency (RF) applications were applied as needed (Figure). The number of additional RF applications to cover all the areas with FEs was assessed. Success was defined as an absence of response to atropine after the procedure.

Results

Three patients underwent autonomic system modulation only, and five underwent additional pulmonary vein isolation (PVI). The mean age was 66 (50-77) years, five males. The median mapping time of the LA and RA was 11 (17-7) and 14 (9-18) min. All patients underwent successful parasympathetic modulation. The initial median (Q1-Q3) increase in heart rate with atropine was 34 (23-39)% versus 0 (0-2)% after ablation, p=0.012. The differences between empiric and FEs map-guided ablation are depicted in the Table. The additional number of points was low. However, a median of 9 (5-15) additional points were added.

Conclusions

A purely anatomic-guided procedure directed only at the atrial right GPs is usually enough as a therapeutic approach for cardiac autonomic modulation, however, the fractionation map tool helped validate the method and ensure success at the first pass.