bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical features and prognosis according to genotype variation in hypertrophic cardiomyopathy
Authors: Kim S H , Jeong J H , Kim H J , Choi J I , Choi Y , Kim S H , Park S Y , Oh Y S
Published: May 2024

Background

Hypertrophic cardiomyopathy (HCM) is a common inherited cardiac condition with many identified disease-causing genetic variants. However, little is known about the clinical course based on the genotype. This study investigates the relationship between the genotype and clinical outcome in patients with HCM.

Method

A total of 127 patients diagnosed with HCM and underwent genetic testing using a next-generation sequencing panel included ≥30 cardiomyopathy-related genes at two tertiary hospitals. The genotype-positive group (N=51) with pathogenic/likely-pathogenic variants and the genotype-negative group (N=76) were compared in terms of imaging phenotypes and clinical outcomes. The primary outcome was a composite of sudden cardiac death (SCD) and ventricular arrhythmia.

Result

Among the genotype-positive group, MYBPC3 (37%), MYH7 (29%) and TNNI3 (16%) variants were predominantly identified. The genotype-positive group was diagnosed at a younger age (51.1 ± 14.0 vs 59.7 ± 11.7, p<0.001), showed a higher maximal ventricular wall thickness (17.2 ± 5.1 vs 14.2 ± 4.0, p<0.001), and a higher prevalence of late gadolinium enhancement on cardiac magnetic resonance imaging (86.5% vs 54.4%, p=0.003) compared to the genotype-negative group. The genotype-positive group had a higher incidence of the primary outcome (39.2% vs 9.2%, p<0.001).

Conclusion

The patients with pathogenic/likely pathogenic variants exhibited morphological characteristics associated with a high risk of SCD, and experienced worse clinical outcomes.
Demographics, clinical features and genetics of inherited arrhythmias in Oman
Authors: Alazri K , Alabri I , Al Shehhi M , Alhinai M , Alamri T , Alsheala N , Alshabibi A
Published: May 2024

Background

Inherited arrhythmia syndromes (IAS) are a group of rare disorders that result from genetic mutations in several genes encoding ion channels causing disruption in its structure and function and predispose affected individuals to various symptoms including sudden cardiac death (SCD). They include congenital long QT syndrome, Brugada syndrome (BrS), progressive cardiac conduction disease, short QT syndrome and Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT). There have been few reports of long QT syndrome from the Arabian Gulf region but this is the first comprehensive review of multiple inherited arrhythmia syndromes in the region.

Objectives

Our objective are to describe the demographics of children and adults with inherited arrhythmia syndromes, report the presenting clinical features, genetic mutations and management strategies. Also, to report some unique and rare genetic findings in our population.

Methods

This is a descriptive retrospective study that included children and adults with inherited arrhythmia syndromes diagnosed and treated at a national heart center over 16 years, between 2006 to 2022. Data collected included patient demographics, geographical distribution, clinical features, genetic reports and management strategies.

Result

One hundred and six patients were included in the analysis. Sixty-six (62.3%) were males, and 68 (64.2%) were adults and 38 (35.8%) were children. Three inherited arrhythmia syndromes were found in our population that included Long QT, Brugada and catecholaminergic polymorphic ventricular tachycardia (CPVT), which accounted for 58 (54.7%), 39 (36.8%) and 9 (8.5%), respectively. Seventy-six (71.7%) of the patients were reported to be from consanguineous families. Most children, 31 (91.4%) had long QT, whereas most adults, 39(54.9%) had Brugada. The clinical features varied based on the type of arrhythmia. There were 28(26.4%) asymptomatic individuals who were diagnosed incidentally. Syncope was the most common presenting symptom in patients with Long QT, 24(41.4%) and Brugada syndrome, 20(51.3%). Palpitations, 4(44.4%) and bradycardia, 4(44.4%) were the predominant presenting features in patients with CPVT. The treatment modalities included beta blockers and antiarrhythmics, implantable cardioversion defibrillators(ICDs), pacemakers, and left sympathetic ganglionectomy(LSGs). We identified 36 individuals with pathogenic or likely pathogenic variants and 12 VOUS(variants of uncertain significance) in different genes of IAS.

Conclusion

This is the first comprehensive study on the inherited arrhythmia syndromes in Oman and the Arabian Peninsula. We provided insights about demographics, clinical, genetic profile and the treatment strategies of the most common IAS in the region. Tis study hat will help in early detection of the different types of arrhythmias and early intervention to prevent sudden cardiac death in patients and their relatives.
Does ChatGPT-4 succeed in the ECG interpretation: friend or foe to cardiologists?
Authors: Lisicic A , Serman A , Jordan A , Jurin I , Novak A , Benko I , Pavlovic N , Manola S , Zeljkovic I
Published: May 2024

Background/Introduction

Artificial intelligence (AI) and large language models (LLMs) are increasingly being tested for medical purposes, especially in clinical settings and one of the most well-known LLMs is OpenAI’s ChatGPT-4. Recent explorations have considered using ChatGPT to answer medical questions, and the new ChatGPT-4 also allows graphical inputs, which could aid medical doctors in interpreting electrocardiograms (ECGs) in everyday practice. AI-powered ECG interpretation has shown promising results, improving the detection of arrhythmias, ST-segment changes, QT prolongation, and other ECG abnormalities. However, whether ChatGPT4’s interpretation of ECGs is comparable to that of experienced cardiologists has yet to be established.

Purpose

We sought to test whether ChatGPT-4 could analyze and interpret ECGs similarly to experienced cardiologists.

Methods

We tasked ChatGPT-4 with interpreting, for scientific purposes, 12-lead ECGs, from 150 patients included in our prospective CaRD registry, presenting with various cardiac pathologies, including acute coronary syndrome, arrhythmias (primarily atrial fibrillation), conduction abnormalities, pacemaker rhythms and normal ECGs. Four experienced cardiologists reviewed the ECG interpretations provided by ChatGPT-4. The model provided information on rate, rhythm, axis, P-wave, PR interval, QRS complex, ST segment, T wave, differential diagnoses, most likely diagnosis and further diagnostic step.

Results

In this observational study, ChatGPT-4 demonstrated low overall accuracy in interpreting ECGs, with only 24% of the most likely diagnosis being correct. ChatGPT-4 performed the best when interpreting normal ECGs with sinus rhythm, achieving 62% accuracy rate, followed by 17%, 10% and 7.3% for ECGs with arrhythmias, acute ischemic changes, and conduction abnormalities or pacing rhythms, respectively.

Conclusion

ChatGPT-4 exhibited very low accuracy in interpreting different categories of pathology in 12-lead ECG, yielding less than 20% success rate. While the use of AI in medical diagnostics is an appealing concept in theory, the results suggest that, in its current state, ChatGPT-4 would not provide significant aid to experienced cardiologists in clinical settings.
PET-MRI Imaging to assess severity and distribution of atrial fibrosis in atrial fibrillation
Authors: Wang H , Po S , Zhang Y
Published: May 2024

Background

Atrial fibrosis is a major determinant of atrial fibrillation (AF) susceptibility and ablation targeting fibrotic areas to suppress AF revealed by magnetic resonance imaging (MRI) was considered a promising approach to treat persistent AF; however, its outcome has been disappointing. We sought to develop a new imaging modality to detect the severity and distribution of atrial fibrosis.

Methods

This study enrolled 19 healthy volunteers and 85 patients with various cardiovascular (CV) diseases of whom 22 had persistent AF. Each patient underwent 18F-labeled aluminum fluoride targeting fibroblast activation protein inhibitor (18F-AlF-FAPI)-positron emission tomography - magnetic resonance imaging (PET-MRI). Left atrial appendage tissue biopsied at 18F-FAPI-uptake positive and negative sites was stained with Masson trichome to detect fibrosis (N=10). We compared cardiac atrial 18F-AlF-FAPI-PET-MRI imaging among healthy individuals, patients without AF and patients with persistent AF as well as patients developing and not developing postoperative AF (POAF).

Results

Degree of fibrosis based on Masson staining was consistent with 18F-FAPI-uptake (P<0.05). Whereas 18F-FAPI uptake was essentially undetectable in healthy volunteers, in patients with CV diseases, 18F-FAPI uptake was present in all atrial chambers. Patients with persistent AF had the greatest and most widespread uptake (P<0.001), including left atrium (P=0.001), right atrium (P<0.001), left atrial appendage (P=0.007), right atrial appendage (P<0.001), and left atrial posterior wall (P=0.004). 18F-FAPI-uptake did not differ between those with versus without POAF.

Conclusions

18F-AlF-FAPI-PET-MRI imaging detected atrial fibrosis in patients with various CV diseases; patients with persistent AF exhibit severe and widespread fibrosis, while POAF is not associated with increased 18F-FAPI uptake.
Use of class IC antiarrhythmic drugs in patients with structural heart disease and implantable cardioverter defibrillator
Authors: Zylla M M , Wolfes J , Schleberger R , Lawin D , Kieser M , Reinke F , Eckardt L , Rillig A , Stellbrink C , Thomas D , Frey N , Lugenbiel P
Published: May 2024

Background

Due to suspected pro-arrhythmic effects and increased mortality associated with class-IC antiarrhythmic drugs (AADs) in previous trials, AAD-therapy in structural heart disease (SHD) is mainly restricted to amiodarone. In the presence of diagnostic and therapeutic advancements in cardiovascular medicine, it remains unclear if previous studies adequately reflect contemporary patients. In clinical practice, class-IC-AADs are occasionally used in individual cases, particularly in patients with an implantable cardioverter defibrillator (ICD).

Methods

This study retrospectively investigated outcome in ICD-carriers with SHD in whom class-IC-AADs were used as an individualized therapy due to failure, side effects, or unacceptable risk of alternative therapeutic options.

Results

Fifty patients from four tertiary centers were included (median age 48.5 years; 52% female). The most common underlying SHD were dilated (42%) or ischemic cardiomyopathy (26%) (median LVEF=45%). Indications for AAD were sustained ventricular arrhythmias (VA) (58%), symptomatic premature ventricular contractions (26%), or atrial arrhythmias (16%). Median follow-up was 27.8 months. Freedom from sustained VA was 72%, freedom from ICD-therapy was 80%. In 19 patients (38%) AAD-therapy was terminated. The most common reason was insufficient efficacy (n=8). Pro-arrhythmia was suspected in three patients. Five patients died during follow-up (10.0%), two of cardiovascular cause (4.0%).

Conclusion

In a multicenter cohort of ICD-carriers with SHD, class-IC-AADs were associated with a low rate of pro-arrhythmic effects or cardiovascular mortality. The majority of patients remained free from sustained VA during a follow-up of >2 years. Further efforts should be made to evaluate the safety of class-IC-AADs in SHD-patients receiving contemporary cardiovascular therapy.
Staged hybrid convergent procedure versus pulsed field ablation for pulmonary veins and posterior wall isolation in the treatment of atrial fibrillation
Authors: Zito E , Bianchini L , Schiavone M , Vettor G , Tondo C
Published: May 2024

Background

There are limited effective treatment options for persistent atrial fibrillation (AF) patients, with pulmonary veins (PV) isolation alone being considered suboptimal for many patients. Hybrid convergent ablation has been shown to improve clinical outcomes when compared to an endocardial-only radiofrequency (RF) strategy. Pulsed field ablation (PFA) has recently gained growing interest for its efficacy and safety profile in PV and posterior wall (PW) ablation.

Objectives

To compare clinical outcomes of hybrid convergent RF ablation versus endocardial PFA for PV and PW isolation in patients with persistent AF.

Methods

From July 2022, 86 persistent AF consecutive patients, receiving endocardial PFA of PV and PW (PFA group, N = 44) or receiving hybrid convergent RF ablation (Hybrid group, N = 42) at our institution were enrolled. Recurrence was defined as any atrial tachyarrhythmia following the 3-month blanking period.

Results

No differences were found between PFA and Hybrid groups regarding age (PFA 66.0±7.4 years vs Hybrid 63.9±10.6 years; p=0.193) and left atrial volume index (PFA 45.5 [36.7-57.2] ml/m² vs Hybrid 45.0 [39.2-59.7] ml/m²; p=0.920). Differences regarding left ventricular ejection fraction were borderline significant among groups (PFA 55.0 [49.5-62.0]% vs Hybrid 60.5 [52.3-65.0]%; p=0.048), both showing an overall normal LV function. There were no significant differences regarding AF duration (PFA 38.0 months [IQR: 19.2 to 99.0 months] vs Hybrid 70.0 months [IQR: 46.0 to 118.0 months]; p = 0.063). Redo ablation patients’ rate was higher in the hybrid group (PFA n=16, 36.4% vs Hybrid n=28, 66.6%; p<0.001). Procedure duration was Ionger in the hybrid group (179.9±60.1 minutes) compared to PFA endocardial ablation (PFA 106.2±30.7 minute; p<0.01). After a median follow-up of 233.0 [179.0–331.8] days, there was no difference in atrial tachyarrhythmias recurrence rate (PFA n=11, 25.0% vs Hybrid n=10, 23.8%; p=0.897); no difference in the antiarrhythmic drug use rate was found (PFA n=24, 54.5% vs Hybrid n=19, 45.2%; p=0.388).

Conclusions

PFA of PV and PW, compared with the hybrid convergent ablation strategy, is an endocardial-only, less invasive, and faster procedure. 6-month rhythm outcomes were similar in both groups.
Predictors of neuromodulation during single-shot thermal atrial fibrillation ablation: a computed tomography imaging analysis
Authors: Nakasone K , Del Monte A , Della Rocca D G , Pannone L , Gauthey A , Overeinder I , Bala G , Sorgente A , Sieira J , Almorad A , Sarkozy A , Chierchia G B , De Asmundis C , Tanaka K , Stroker E
Published: May 2024

Background

Ganglionated plexi (GPs) are part of the cardiac autonomic nervous system (CANS), which play an important role in the induction and maintenance of atrial fibrillation (AF). Because of the anatomic proximity of the pulmonary veins with GPs, pulmonary vein isolation (PVI) using thermal (radiofrequency (RF) or cryo) ablation, has been shown to concomitantly affect the GPs, as suggested by increased heart rate (HR) after ablation. Right superior pulmonary vein (RSPV) isolation has been reported to have the most evident inhibitory responses to the CANS via modulation of the anterior right ganglionated plexus. Nonetheless, there are also cases with little to no effect on neuromodulation post-ablation.

Purpose

To assess the clinical and anatomical predictors of thermal ablation-induced CANS changes, as assessed via variations in resting HR post-ablation.

Methods

We retrospectively analyzed consecutive patients with symptomatic paroxysmal AF who underwent first-time PVI by cryoballoon (CB) or RF balloon (RFB) between January 2022 to November 2022. Patients who were not in sinus rhythm, had cardiac implantable electronic devices, or did not have a contrast-enhanced computed tomography before the ablation were excluded. Pre-ablation and 24-hour post-ablation ECGs in sinus rhythm were collected and analyzed to assess HR.

Results

A total of 83 patients (CB group, n = 43 vs RFB group, n = 40) were included in the analysis. Baseline patients’ characteristics were similar between the two groups (Table 1). A significant HR increase (ΔHR ≥ 15 bpm) at 24h post-ablation occurred in 31 patients [CB group 16 (52 %), RFB group 15 (48 %)]. Predictors of increased HR were the distance between superior vena cava (SVC) and RSPV (OR 0.51, CI 0.35 - 0.75, p value < 0.01) and age (OR 0.94, CI 0.89 - 0.99, p value < 0.01) (Table 2).

Conclusions

Single-shot thermal PVI influences the CANS, especially in patients with a shorter SVC - RSPV distance and in younger patients.Table 1Table 2
Evaluation of left atrial function and tissue after pulmonary vein isolation - initial results of The EVALUATE-PVI STUDY
Authors: Van Pouderoijen N , Hopman L , De Groot J R , Tahapary G J M , Kemme M J B , Gotte M J W , Allaart C P
Published: May 2024

Background

Pulmonary vein (PV) isolation (PVI) by catheter ablation is a well-established treatment for atrial fibrillation (AF). Currently, the direct and long-term impact of ablation injury on left atrial (LA) function and tissue is poorly understood.

Purpose

The aim of this study is to evaluate the acute and long-term impact of radiofrequency (RF) PVI ablation on LA function and corresponding tissue changes as assessed with cardiac magnetic resonance imaging (CMR).

Methods

Seventeen patients (76.5% male, 60.8±9.7 years) with AF who underwent primo RF PVI as part of the EVALUATE-PVI STUDY underwent three sequential CMR scans prior to PVI, and <72 hours and 3 months after PVI ablation. T2-weighted turbo spin echo imaging was applied to assess post-ablation edema. High-resolution three-dimensional (3D) late gadolinium-enhancement (LGE) images were acquired to study acute LA wall injury and chronic fibrosis formation. LA volume and function were derived from two-chamber and four-chamber SSFP cine images. Maximum and minimal LA volume was indexed to body surface area to compute LAVimax and LAVimin. Longitudinal LA strain was calculated using feature tracking, and subdivided into reservoir, conduit, and contractile strain.

Results

Acutely post-PVI, T2w images showed increased signal intensity and thickening throughout the entire LA wall. LGE images showed diffuse increased signal intensity, without distinct focal high signal intensity areas (Fig. 1). Functional assessment at this stage showed significantly reduced LA emptying fraction (EF), LA reservoir, and contractile strain compared to pre-PVI (54.8±11.1% vs. 48.5±7.9%, p=0.01; 18.6±5.6% vs. 14.6±2.0%, p<0.01; 8.5±3.5% vs. 5.2±1.8%, p<0.001, respectively), while LA conduit strain, LAVimin, and LAVimax did not differ significantly (Fig. 2).

The LGE images acquired at 3 months, displayed clear, focal, high signal intensity areas surrounding the PVs. At this stage post-PVI, a significant increase in LA strain was observed (LA reservoir strain 14.6±2.0% vs. 16.9±3.5%, p<0.01; and contractile strain 5.2±1.8% vs. 6.7±2.9%, p<0.01; respectively). LAVimax was significantly reduced at 3 months compared to acutely post-PVI (Fig. 2).

LAVimin and LA conduit strain did not differ between the pre- and post-PVI stages.

Conclusion

PVI ablation resulted in temporary reduced LA function acutely post-PVI, likely due to edema and thickening of the LA wall. At three months, LGE images revealed clearly visible increased signal intensity in the ablated segments. At this stage, LA function improved, though full recovery did not occur as evidenced by the persistent slightly reduced contractile strain, possibly due to the ablation-induced loss of LA myocardium and formation of fibrosis. The decrease in LAVimax indicates reverse remodeling as a result of the ablation.
The new "olive strategy" for pulsed field ablation of atrial fibrillation: procedural data and early follow-up
Authors: Plank K , Schaack D , Tohoku S , Chen S , Urbanek L , Ebrahimi R , Hirokami J , Bordignon S , Schmidt B , Chun K R J
Published: May 2024

Background

Pulsed field ablation (PFA) is a new myocardial-specific ablation technology for atrial fibrillation (AF). Direct current electric energy is applied to cells and disrupts cell membranes by creating pores.

Purpose

The aim of this single-center study was to report procedural data and early recurrence of atrial tachyarrhythmia (ERAT) following a new PFA-based ablation strategy for pulmonary vein isolation (PVI).

Methods

Consecutive patients with symptomatic AF were enrolled to undergo PFA-PVI using the pentaspline catheter. A new ablation strategy was performed: In total 10 applications per pulmonary vein (PV) were delivered. In addition to the conventional four applications in flower- and four applications in basket-configuration, two applications were delivered in a smaller "olive"-configuration. ERAT was defined as any documented AF/atrial tachycardia (AT) lasting more than 30 seconds during a 90-days blanking period. Procedural and demographic data were analysed.

Results

60 patients (37% female, age 67±12, 43% paroxysmal atrial fibrillation [PAF]) were included in this preliminary analysis. 239 PVs were identified, and all PVs could be isolated using solely the PFA device. All PVs were isolated with the first application. 40 applications per patient were delivered. No complications occurred. Procedure time was 30±11 min, fluoroscopy time was 6±3 min. Median follow-up time was 100 days. 20% of patients experienced an early recurrence after a median of 2 days (IQR 1-7.25; 92% AF, 8% AT). Kaplan Meier estimated freedom of AF/AT was 83.3 % at 3 months, 92.3% for PAF and 76.5% for persistent atrial fibrillation (p=0.11).

Conclusions

Our data show feasibility of a new ablation strategy with the pentaspline PFA-catheter. This study indicates high acute efficacy and safety. 83.3% of patients are free of AF/AT at 3 months. Longer follow-up times are needed to assess the clinical outcome and will be available at the time of presentation.
Pulsed field ablation of atrial fibrillation using a large area focal catheter with a novel contact detection algorithm. A first-in-human experience using the QuickShot catheter
Authors: Anic A , Breskovic T , Jurisic Z , Sikiric I , Katic J , Lisica L , Doshi S
Published: May 2024

Background/Introduction

Pulsed field ablation (PFA) is emerging as a safe and effective alternative energy modality for cardiac ablation. Data have shown that while tissue contact is critical for PFA, the amount of contact force is less important. Single-shot catheters have shown comparable results to current thermal methods for pulmonary vein isolation (PVI), however, are limited to anatomical-based ablation strategies and have limited ability to detect tissue contact. The investigational QuickShot™ large-area focal catheter (Galvanize Therapeutics, Redwood City, CA) combines high-density mapping with large-area focal ablation guided by contact detection.

Purpose

The QuickShot PEF-AF study was a prospective, single-arm, first-in-human study performed at a single European center to evaluate the safety and performance of the QuickShot catheter (see Figure 1, panel A) combined with the CE-marked CENTAURI™ System (Galvanize Therapeutics, Figure 1, panel B) for catheter ablation of atrial fibrillation (AF).

Methods

Subjects with paroxysmal or persistent AF underwent a PVI procedure under deep sedation (fentanyl, midazolam, propofol) guided by Rhythmia™ HDx (Boston Scientific, Marlborough, MA, Figure 1, panel D). Irrigation was set to a constant 6 mL/min during the procedure. Focal, monopolar, biphasic PFA lesions were delivered asynchronously at 33 Amps and a 10 mm inter-lesion spacing (center to center with 10 mm lesion tag size). Catheter-tissue contact was confirmed by ICE/fluoroscopy and a novel impedance-based contact detection system (Figure 1, panel C). The acute performance endpoint was PVI, assessed by entrance and exit block using high-density mapping. Procedural safety assessments included microbubble detection via ICE, induction of VT/VF, muscle stimulation, phrenic nerve function, and NIHSS post-procedure.

Results

Twenty (20) subjects (60% PAF, 60 ± 12 years, 75% male, 4.3 ± 0.52 cm LA AP diameter) were enrolled and treated. Acute PVI was achieved in 100% of patients and targeted PVs (82/82), with first-pass isolation in 88% of targeted PVs. The PVI time was 31 ± 10 min with 46.7 ± 11.4 PFA applications. There were no device- or procedure-related adverse events, and no documented incidence of microbubble formation, arrhythmia induction, muscle stimulation, phrenic nerve dysfunction, esophageal injury, or change in NIHSS post-procedure.

Conclusion

The QuickShot catheter enables safe and effective large-area focal PFA for subjects requiring PVI. The catheter design enables efficient and flexible focal lesion placement with the ability to ensure adequate apposition to targeted tissues using its novel contact detection algorithm. Future studies will investigate the use of this novel catheter for PFA strategies beyond PVI.
Electrocardiographic characteristics and catheter ablation of premature ventricular complex- mediated ventricular fibrillation
Authors: Maan A , Iwanari Kawamura I K , Musikantow D M , Stanton E S , Koruth J K , Miller M M , Lampert J L , Whang W W , Dukkipati S D , Reddy V R
Published: May 2024

Background

Premature ventricular contractions (PVCs) can trigger ventricular fibrillation (VF) in patients with/or without structural heart disease. There are limited data on coexisting electrocardiographic (ECG) features and catheter ablation outcomes in these patients which could suggest the concomitant presence of an abnormal electrical and structural substrate.

Purpose

We investigated ECG and electroanatomic characteristics and clinical outcomes in patents who underwent catheter ablation of PVCs triggering VF.

Methods

We analyzed data from a consecutive series of patients who underwent catheter ablation between 08/2019 and 04/2023 for PVCs triggering VF. On the 12-lead ECG, we assessed the following abnormalities: (a) Early repolarization (ER) pattern in either inferior or lateral leads (Figure 1), or (b) QRS Notching of either the native sinus beat or PVC (Figure 2). Post-ablation follow up outcomes were collected using a combination of ICD interrogation, remote transmission and clinical follow up.

Results

The cohort included 15 patients: age 52.1±16.8 years, 46.7% females, and 26.7% presenting with VF storm. On average, there were 3.8 HV shocks/per patient from an ICD prior to the index ablation procedure (range: 0-19 shocks). On the 12-lead ECG, the mean coupling interval of the PVC leading to VF was 204±82 ms, and an overall narrow PVC morphology with a mean QRS duration of 107±17 ms. We observed early repolarization (ER) in 6 (40%) of the cohort. In most patients (n=11; 73.3%), at least one of the 2 ECG abnormalities were present. An endocardial-only approach was adequate in all patients, and during catheter ablation, Purkinje potentials were targeted in 10 (66%) of the patients.

Based on activation and pace-mapping, the PVCs were localized to the following sites: (a) left ventricular (LV) septum in 11 (73.3%), (b) papillary muscles in 2 (13.3%), and (c) other sites such as the Moderator band and right ventricular outflow tract in the remaining 2 (13.3%) patients. The ablation locations on the LV septum extended from basal to mid-septum. After an average of 1.7 ablation procedures targeting PVC-triggering VF, 12 (80%) patients remained free of sustained ventricular arrhythmias and ICD shocks, over a mean follow up of 479±395 days.

Conclusion

In most patients with PVCs-triggering VF, there was an evidence of an ECG abnormality either in the form of an ER pattern or notching of either the Sinus QRS or the PVC complex on pre-ablation ECG. During ablation, Purkinje potentials and PVCs were mapped to and ablated in the region of the LV interventricular septum and papillary muscles. Over long-term follow up, catheter ablation seemed durable and effective in reducing VF episodes and ICD shocks.Presence of Early Repolarization patternPresence of a notching pattern in the Si
Pulsed field ablation-based superior vena cava isolation in the presence of defibrillator leads
Authors: Doundoulakis I , Tsiachris D , Kordalis A , Antoniou C K , Tsioufis P , Laina A , Botis M , Bartsioka L I , Argyriou N , Dourvas P , Oikonomou G , Gatzoulis K , Tsioufis K
Published: May 2024

Introduction

Only a minority of operators in the MANIFEST-PF multinational survey performed superior vena cava isolation by means of pulsed field ablation (PFA). This is the first report of off-label PFA-mediated superior vena cava isolation in the presence of defibrillator leads.

Purpose

Aim of this study was to evaluate the effect of PFA applications in the superior vena cava in the terms of alterations in pacing, sensing, or impedance parameters, inappropriate anti-tachycardia pacing, ICD shock and leads dislodgment.

Methods

Five patients with a history of dilated cardiomyopathy, dual chamber defibrillator implantation, and worsening heart failure because of persistent atrial fibrillation (AF) underwent catheter ablation of AF. Three of the patients had dual coil defibrillator leads. PFA was selected for the index procedure in these decompensated heart failure patients with enlarged atria focusing beyond pulmonary vein isolation in posterior wall and roof ablation as well as in superior vena cava isolation.

Results

Basket configuration and two sets of two lesions at the trunk of the vessel (with rotation between each pair) were used for superior vena cava isolation in the presence of atrial and defibrillator leads, without any impact on device and leads measurements or sinus node function. All patients were in AF and cardioverted into sinus rhythm post- superior vena cava isolation. They remained at sinus rhythm at regular 3-month follow-up while device interrogation revealed intact sinus node function.

Conclusion

PFA applications in the superior vena cava of AF patients with implanted defibrillators confirmed that it is a safe and feasible method regardless of energy application adjacent to the leads.
Catheter ablation of papillary muscle arrhythmias: procedural characteristics and long term outcome
Authors: Moser F , My I , Loeck F , Obergassel J , Rottner L , Lemoine M , Kirchhof P , Reissmann B , Ouyang F , Metzner A , Rillig A
Published: May 2024

Background

Ventricular arrhythmias (VA) originating from the papillary muscles can occur both in patients with and without structural heart disease. Although catheter ablation is the treatment of choice, ablation success remains challenging and long-term outcomes for this origin of VA are still unsatisfactory.

Methods and Results

All patients undergoing catheter ablation for premature ventricular contractions or ventricular tachycardia between june 2009 and november 2022 were analyzed. 66 patients (26 female (39%), mean age 60±15 years) undergoing catheter ablation of VA originating from the papillary muscle were identified. 21/66 (32%) patients had a reduced or mildly reduced left ventricular ejection fraction at time of initial presentation. While mitral valve regurgitation was present in 32/66 (48%) patients, mitral valve prolapse was observed in only 2/66 (3%) patients.

6/66 (9%) patients presented with non-sustained ventricular tachycardia (VT) and 1/66 (2%) patient presented with sustainend VT prior to catheter ablation. 61/66 (92%) patients underwent ablation of PVCs of the left ventricular papillary muscles (22/66 (33%) patients anterolateral; 39 (59%) patients posteromedial). 5/66 patients underwent ablation of premature ventricular complex (PVC) originating from the papillary muscles of the right ventricle. In 13/66 (19.7%) patients only a retrograde approach was used, in 26/66 (39.5%) patients a retrograde and an additional transeptal approach and in only 10/66 (15.2%) patients solely a transeptal approach. Mean PVC QRS duration was 152.5 ± 3.5 msec. Ablation was acutely successful in 44/66 (67%) patients. Mean procedure time was 145.8 ± 63.7 minutes and mean number of radiofrequency applications was 21.3 ± 16.7 (25 to 55 Watts, 37764.2 ± 27824.1 Joules). Overall, procedural complications occurred in 4/66 (6%) patients

Follow up data were obtained from Holter ECGs, review of medical records, patient consultation, or via structured follow-up within the prospective TRUST registry. All information was combined to assess recurrence of PVC/VT. Recurrence of VA originating from the papillary muscles occurred in 11/66 (17%) patients. 9/66 patients (14%) underwent re-ablation due to recurrence of VA originating from the papillary muscles after previous ablation procedures.

Conclusion

Catheter ablation of papillary muscle arrhythmias is associated with a single procedural success rate of 67% with a procedural complication rate of 6%. 14% of patients underwent re-ablation due to recurrence of papillary muscle arrhythmias.
Left ventricular wall thickening predicts left atrial low voltage areas in patients undergoing catheter ablation for atrial fibrillation
Authors: Clemens M , Fodor Z S , Gaal R , Sandorfi G , Nagy L T , Csanadi Z
Published: May 2024

Background

The success rate of circumferential pulmonary vein isolation (CPVI) remains suboptimal in patients with paroxysmal and persistent atrial fibrillation; moreover, the detection of low voltage areas (LVA) in the left atrium does predict an even higher recurrence rate of atrial tachyarrhythmias after the procedure. Left ventricular wall thickening (LVWT) is known to correlate with left atrial volume; however, no data is available whether LVWT is predictive of the presence of left atrial LVA.

Purpose

The aim of this study was to investigate whether LVWT is predictive of left atrial LVA and to verify that the presence of LVA confer a higher arrhythmia recurrence rate after catheter ablation for atrial fibrillation.

Methods

A total of 374 patients who undervent CPVI with the use of 3D electroanatomical mapping system as a primary procedure were enrolled in the study. Transthoracic echocardiography was performed in all patients prior the procedure with measurement of the thickness of the septum and the posterior wall. Patients were classified based on LVWT as normal (females:≤9mm, males:≤10mm), borderline (females:10-11mm, males: 11-12mm) and increased (females:≥12mm, males:≥13mm). A detailed left atrial voltage map was obtained in all patients prior to ablation with the identification of LVA (bipolar voltage <0.5mV with an area >5cm2). Arrhythmia recurrence was defined as documented atrial fibrillation or atrial tachycardia lasting for at least 30 seconds.

Results

Among 374 patients (mean age: 59.0±10.2 years, 131 females) 94, 195 and 85 were considered to be normal, borderline and increased based on LVWT, respectively. LVA were found in 29.9% (112/374) of patients. According to LVWT, LVA were detected in 16.0% (15/94), 31.3% (61/195) and 42.4% (36/85) in patients with normal, borderline and increased wall thickness, respectively, p=0.005. Patients with left atrial LVA had a higher [60.7% (68/112)] arrhythmia recurrence compared to those without low voltage areas [35.1% (92/262)] during a mean follow-up of 2.1±1.9 years, p<0.0001.

Conclusions

Left ventricular wall thickening predicts the presence of left atrial low voltage areas in patients undergoing catheter ablation for atrial fibrillation. Low voltage areas confer a higher arrhyhtmia recurrence rate during follow-up.
Findings at repeat ablation after complex left atrial pulsed field ablation for longstanding persistent atrial fibrillation
Authors: Fiala M , Lehar F , Cernosek M , Bulkova V , Funasako M , Bahnik J , Rybka L , Toman O , Kala P
Published: May 2024

Background

There is a limited knowledge on atrial arrhythmias recurring after complex left atrial (LA) pulsed field ablation (PFA) for longstanding persistent atrial fibrillation (LSPAF).

Purpose

To present recurrent atrial arrhythmias and their sources found at repeat ablation following PFA for LSPAF.

Methods and results

Of 214 patients with LSPAF (age 65±8, 53 females, continuous AF for 30±27 months) with complex LA PFA (Farapulse) in 10/2021-10/2023, 19 patients (64±8 years, 5 females) underwent repeat ablation for recurrent AF or arial tachycardia (AT) in 20 procedures. First PFA procedure included pulmonary vein isolation (PVI), roof/posterior wall, and mitral isthmus/coronary sinus/Ligament of Marshal region (LOM) ablation. At repeat ablation, 3D activation and entrainment mapping and ablation identified the AF/AT sources; ATs sources were classified as macroreentry (MRAT) (perimitral, roof-dependent, typical flutter) or localized (LOCAT) in case of smaller reentry or ectopic origin.

Results

The clinical recurrent arrhythmias included paroxysmal AF (n=1), persistent AF (n=2), paroxysmal AT (n=1) or persistent AT (n=16). At the onset of repeat ablation, persistent AF/AT was present (n=15) or had to be induced (n=5). AF was finally present during the procedure in 8 patients, and was terminated by ablation directly into SR (n=3) or into intermediate AT (n=3) (conversion sites included LA ridge/LOM region 2x, RA septum 1x, RA low lateral 2x, CTI 1x), or required DCC (n=2). Primary recurrent or from AF converted AT was present in 15 patients; only MRAT in 6 patients, only LOCAT in 3 patients, and both AT types in 6 (patients). Of MRAT (N. ATs = 16), there were 12 perimitral ATs, 0 roof-dependent AT, and 2 typical flutters. Of LOCATs, sources were located at LA anterior wall 4x, LA septum 2x, LA roof 1x, LA ridge/LOM 1x, persistent left vena cava 1x, and RA – para SA node 1x. Recurrent AF/AT sources were targeted by radiofrequency or PFA in 16 and 4 cases, respectively, all spontaneous and induced AF/AT were finally terminated into SR in 16 cases, subsequent noninducibility by atrial pacing up to 300 bpn was achieved in 13 cases, and recurrent AF/AT occurred in 3 patients.

Conclusion

At repeat ablation PFA (Farapulse) for LSPAF, recurrent AT dominated over AF, MRAT slightly prevailed over LOCAT, mostly constituted by perimitral AT, while roof-dependent AT recurrence was reduced to zero. A majority of AF/AT sources were located outside prior PFA lesions at the LA anterior wall, septum and the right atrium.
Type of atrial arrhythmias and substrates after convergent ablation procedures
Authors: Robles A G , Prolic Kalinsek T , Podlogar V , Gianfrancesco D , Bartolomucci F , Romano S , Sciarra L , Pernat A , Jan M
Published: May 2024

Background

Convergent epicardial and endocardial catheter ablation had been used for the treatment of persistent atrial fibrillation (PeAF).

Aims

The aims of this retrospective study are to describe the pattern of arrhythmias and substrate findings in patients previously submitted to convergent ablation and showing arrhythmic recurrences (AF/AT/AFL lasting at least 30 seconds) and documented with ILR during follow up.

Methods

From a cohort of 119 patient who underwent convergent ablation, we selected the 55 with arrhythmic recurrences and showing AT/AF/AFL stored in ILR memories to submit them to remap procedure.

Results

We excluded 1 patient who was submitted to ablate and pace without remapping and 1 patient whose data has been lost. Among 53 patients, 69.7% experienced AF (33.9% PAF and 35.8% PeAF), 5.6% typical AFL and 30.2% AT/atypical AFL. As for the substrates found, at detailed high-density mapping we had: 66.9% with veins reconnection (regardless the gaps localization), 37.7% with low-voltage area/abnormal signals on the posterior wall, 11.3% deserving CTI ablation for typical AFL and 28.3% with different LA substrates (septal, anterior, LAA, mitral annulus and 9.4% with gaps at superior surgical line). Notably, overlaps of arrhythmic patterns and substrate were also found in the same patients.

Conclusion

In our study a total of 79.1% patients had substrates related to previous convergent ablation due to gaps at pulmonary veins or superior line. The rest had an arrhythmic substrate in areas not previously ablated like posterior wall or CTI. These findings suggest that a large amount of patients submitted to convergent ablation (up to 80%) may have an arrhythmic substrate and thus potentially recurrences due to previous epi-endocardial ablation.
Reduced heart failure hospitalizations and improved quality of life in cardiac amyloidosis patients undergoing atrial fibrillation ablation
Authors: Pierucci N , La Fazia V M , Gianni C , Torlapati P G , Della Rocca D , Horton R , Al Hamad A , Burkhardt J D , Mariani M V , Chimenti C , Di Biase L , Lavalle C , Natale A
Published: May 2024

Background

Cardiac amyloidosis (CA) has been associated with an increased risk of atrial arrhythmias and development and worsening of heart failure due to infiltration of the amyloid protein in the atrial wall. Few data exist regarding prognosis, symptoms, and quality of life after catheter ablation of atrial fibrillation in this category of patients.

Objective

The study evaluates the outcome of hospitalization for heart failure and quality of life in cardiac amyloidosis patients with atrial fibrillation after catheter ablation.

Methods

This is a study including 102 consecutive patients from two different centers with an established diagnosis of amyloidosis ATTR that underwent their first AF catheter ablation for persistent AF. They underwent pulmonary vein (PV) isolation + isolation of left atrial posterior wall and superior vena cava. Additionally, extrapulmonary triggers were identified and ablated. Post procedure, patients were followed up routinely with ECG during office visits, 7-day Holter monitor and event recorders during the first year followed by biannual checkups during the remaining part of the follow-up period. Quality of life (QoL) was measured using The Minnesota Living Heart Failure Questionnaire (MLHFQ) before Catheter ablation and after 18 months follow up; QoL was compared with T-test.

Results

102 patients (mean age 72 ± 6) were included in the study. After 18 months follow up, 72 patients (70.6%) remained arrhythmia-free without antiarrhythmic drugs (Group 1), whereas 30 patients (29.4%) experienced recurrence (Group 2). In Group 1, 9 patients were hospitalized for heart failure, in contrast to 18 patients in Group 2, indicating a higher rate of heart failure hospitalizations associated with arrhythmia recurrence (p=0.02). The Quality of life in group 1 was 62 ±12 points before ablation and 63±16 points at 18 months follow up (p=0.17) while in group 2 was 68±16 points before ablation and 86±12 points at 18 months follow up (p<0.001).

Conclusion

Catheter ablation for AF in patients with cardiac amyloidosis is associated with reduced hospitalizations for heart failure, along with improvement in QoL.
Pulsed electric field ablation for perimitral flutter - retrospective comparison of anterior vs lateral mitral block strategy
Authors: Borisincova E , Peichl P , Wichterle D , Stojadinovic P , Stiavnicky P , Haskova J , Cihak R , Kautzner J
Published: May 2024

Introduction

Catheter ablation of atrial fibrillation has become a standard of care for symptomatic patients. Patients with persistent atrial fibrillation might require additional substrate modification on top of pulmonary vein isolation. In case of spontaneous or inducible perimitral flutter, RF ablation to achieve anterior or lateral mitral block is challenging. A pulsed electric field (PEF) is a novel energy source that enables the rapid and safe creation of larger lesions.

Purpose

A retrospective study aimed to compare the safety and early outcome data of either anterior or lateral mitral block strategy performed by PEF using a pentaspline multipolar ablation catheter.

Methods

The population consists of 67 patients (23 women, age: 68 ± 8 years) with either spontaneous or inducible perimitral flutter. Fifty-five percent of patients had previous ablation of atrial fibrillation using radiofrequency energy (2.0 ± 1.2 procedures/patient). Using a pentaspline multipolar catheter, all patients underwent isolation (or reisolation) of pulmonary veins and posterior wall. The same catheter was used for the treatment of perimitral flutter. Creating either anterior (ANTERIOR group) or lateral (LATERAL group) mitral block was selected at the discretion of the operator.

Results

A total of 37 and 30 patients were treated in the ANTERIOR and LATERAL groups, respectively. The perimitral flutter was terminated in all cases. However, complete and persistent block across the ablated region was more likely achieved in the ANTERIOR vs LATERAL group (92 vs 73%, p=0.04). There was one tamponade in the ANTERIOR group. A clinically relevant spasm of the coronary artery was not observed in any patient. At 3-month follow-up, non-significantly more patients were in sinus rhythm in the ANTERIOR vs LATERAL group (81% vs 63%, p=0.1).

Conclusion

Creating both anterior and lateral mitral block for the treatment of perimitral flutter is feasible and safe using a pentaspline multipolar catheter and PEF. Achievement of the anterior mitral block is more likely. Whether this will impact the long-term outcome remains to be determined.
Long-term impact of multiple freezes during cryoballoon pulmonary-vein isolation on atrial arrhythmia recurrence
Authors: Rothe M , Boehmer A A , Nussbaum E , Wiedenmann L , Schneider K , Spork P , Keim C , Dobre B C , Kaess B M , Ehrlich J R
Published: May 2024

Background

Cryoballloon pulmonary vein isolation (CryoPVI) is well established for atrial fibrillation (AF) ablation. Nevertheless, it is still important to identify possible periprocedural factors influencing its efficacy. With difficult anatomical conditions it is currently unclear whether the number of cryoballoon applications needed to achieve complete vein isolation has an impact on the long-term effectiveness of CryoPVI.

Methods

We prospectively analyzed AF patients who underwent first-time CryoPVI in a single center cohort between 2018-2023. The group allocation depended on the number of cryo applications until complete isolation was achieved. CryoPVI was performed in a standardized procedure. Follow-up was performed after 3, 6, 12, 18, 24 and 36 months post CryoPVI. Efficacy endpoint was the occurrence of symptomatic atrial arrhythmia.

Results

A total of 1170 patients were included in the study. Of these, in 610 patients received only one cryoballoon application per pulmonary vein to achieve complete isolation. Gender distribution (56.7% male vs. 43.3% male p=0.09) and AF phenotype (38.5% persistent AF vs. 61.5% paroxysmal AF, p=0.23) did not differ significantly between the two groups, patients who received only cryoballoon application were older (70.1 vs. 68.5, p=0.006) and accordingly had higher CHADS-VASc (2.86 vs. 2.62, p=0.006). After 36 months no difference in the efficacy endpoint was observed between the two groups (47.6% vs. 43.2%, p=0.53). Complications included three major access complications (0.5% vs. 0.5%) and one stroke within the first 30 days after the procedure (0.2% vs. 0.2%) in each group. No pericardial tamponade occurred.

Conclusion

Multiple- freezes during CryoPVI have no influence on atrial arrhythmia recurrence.