bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison between cryoballoon and radiofrequency for atrial fibrillation ablation in patients with heart failure
Authors: Dural M , Sener YZ , Yalcin MU , Ates AH , Yorgun H , Aytemir K
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Radiofrequency (RF) and cryoballoon (CB) ablation are the most commonly performed methods for catheter ablation in patients with atrial fibrillation (AF). However, data regarding AF ablation in patients with reduced left ventricular ejection fraction (LVEF) is scarce.

Purpose

We aimed to compare the safety and efficacy of RF and CB AF ablation in heart failure (HF) patients with LVEF <50%.

Methods

HF patients whose LVEF < 50% were included in this retrospective study. Transthoracic echocardiography (TTE) was performed to evaluate LVEF by using Modified Simpson method before and after the procedure. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of AF, atrial flutter, or atrial tachycardia (≥ 30 s) after a 3-month blanking period.

Results

Eighty-nine (n = 42 CB and n = 47 RF) HF patients were enrolled and baseline characteristics were listed in Table-1. There was no significant difference in AF recurrence rate between the groups [16 (38.1 %) in CB and 12 (25.5 %) in RF, respectively, P = 0.296] during the follow up of median 16.5 (10.25-24) and 11 (9-17) months (Figure-1). There was significant increase in LVEF (39.52 ± 7.77 vs. 46.30 ± 10.95, P < 0.001) and decrease in brain natriuretic peptide (BNP) [230 (10-1653.10) vs. 163 (10-1653.10), P = 0.003] levels after ablation. The changes in LVEF (P = 0.370) and BNP (P = 0.772) were similar between the CB and RF ablation groups.

Conclusion

Our findings demonstrated that AF ablation using either CB or RF was associated with an improvement in LVEF and neurohormonal profile in AF patients with reduced LVEF.
Clinical outcomes associated with left atrial appendage occlusion via implanted device in atrial fibrillation:a Nationwide Matched Control Study
Authors: Maille B , Defaye P , Herber J , Clerc JM , Cuzol F , Deharo JC , Fauchier L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction / Background

Left atrial appendage occlusion (LAAO) has emerged as a nonpharmacological alternative for stroke prevention in patients with atrial fibrillation (AF). Contemporary data regarding the characteristics and outcomes of patients undergoing this procedure compared to a control group not treated with LAAO are limited.

Purpose

Our objective was to compare outcomes following first LAAO implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals with AF from January 1, 2015 to January 1, 2020, who underwent a LAAO implantation were identified. Owing to the non-randomized nature of the study, and considering for significant differences in baseline characteristics between AF patients treated with LAAO and no LAAO, propensity-score matching was used to control for potential confounders of the treatment outcome relationship. The primary outcome was a composite of ischemic stroke, major bleeding (Bleeding Academic Research Consortium ≥3) or all-cause mortality during follow-up.

Results

After propensity score matching 2,682 patients with LAAO were matched 1:1 with 2,682 AF patients not treated with LAAO. Baseline characteristics of matched patients are illustrated in Figure 1. Mean follow-up was 7 months (median 5, interquartile 1-11 months). As illustrated in Figure 2, AF patients treated with LAAO had a significantly lower risk of the primary composite outcome as compared with patients not treated with LAAO (hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.52 to 0.68). Total events and event rates per 100 patient-years were (LAAO vs. no LAAO) 315 vs. 591 and 20.6%/year vs. 36.1%/year, respectively. The risk of ischemic stroke was comparable between groups (HR 1.06, 95% CI: 0.75 to 1.17), while risk of major bleeding (HR 0.49, 95% CI: 0.37 to 0.65) and all-cause mortality (HR 0.57, 95% CI: 0.48 to 0.67) were significantly lower in patients treated with LAAO.

Conclusion

Among AF patients with a high risk of bleeding, our nationwide study highlighted a high risk of clinical events during follow-up. Patients treated with LAAO may have similar stroke prevention efficacy but lower risk of major bleeding and mortality when compared to propensity score-matched patients not treated with LAAO.
One-year results from the FLXibility post-approval study: final real-world clinical outcomes with a next-generation left atrial appendage closure device
Authors: Betts TR , Grygier M , Nielsen-Kudsk JE , Schmitz T , Sandri M , Casu G , Bergmann M , Hildick-Smith D , Christen T , Allocco DJ
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Boston Scientific Corporation, Marlborough, MA, USA

Background

The WATCHMAN FLX left atrial appendage (LAA) closure device received CE-mark and FDA approval based on the results of the PINNACLE FLX IDE study, but evidence of outcomes with this next-generation device in everyday clinical practise is limited.

Purpose

The FLXibility Post-Approval Study collected real-world data on patients implanted with a WATCHMAN FLX in a routine clinical practise.

Methods

Patients were implanted with a WATCHMAN FLX per local standard of care, with a subsequent first follow-up visit from 45-120 days post-implant and a final follow-up at 1 year post procedure. A Clinical Event Committee adjudicated all major adverse events and TEE/CT imaging results were adjudicated by a core laboratory.

Results

Among 300 patients enrolled at 17 centres in Europe, the mean age was 74.6±8.0 years, mean CHA2DS2-VASc score was 4.3±1.6, mean HAS-BLED score was 2.6±1.0, and 62.1% were male. The device was successfully implanted in 99.0% (297/300) of patients; 97.0% (289/298) required only 1 device for an implantation attempt and no patient required >2 devices. TEE was used for 78% of procedures and ICE for 22%. The post-implant medication regimen was DAPT for 87.3% (262/300). At first follow-up, among 170 patients with evaluable imaging, 87.6% (149/170) had no leak, 12.4% (21/170) had leak >0mm to ≤5mm with 16 (9.4%) of these <3mm, and no patient had leak >5mm, per core lab adjudication. At 1 year, 93.3% (280/300) patients had final follow-up or death. At final follow-up, 61% of patients were on a single antiplatelet medication, 21% were on DAPT, 6% were on a direct oral anticoagulation medication, and 12% were not taking any antiplatelet/anticoagulation medication. One-year all-cause mortality was 10.8% (32/295), among which 5.1% (15/295) were cardiovascular or unexplained. Disabling stroke occurred in 1.0% (3/295) of patients and nondisabling stroke also in 1.0% (3/295) of patients; all were nonfatal. No patient experienced a systemic embolism. Device-related thrombus was detected in 2.4% (7/295) patients. Pericardial effusion requiring surgery or pericardiocentesis occurred in 1.0% (3/295), with all of these events occurring in the first 7 days post-procedure. Cumulative BARC-3 or -5 bleeding occurred in 3.7% (11/300) of patients from 0 to 7 days, in 7.3% (22/300) at 6 months, and in 8.1% (24/295) patients at 1 year. One patient (0.3%) had a peri-procedural device embolisation, with no subsequent device embolisations or any device migration reported for any patient through 1 year.

Conclusions

The WATCHMAN FLX device had excellent procedural success rates, with high effective LAA closure rates and low serious adverse event rates in everyday clinical practise.
Prevalence and outcomes of hypoattenuation defects and appendage patency on computed tomography after left atrial appendage closure
Authors: Cochet H , Legghe B , Bouyer B , Blanc G , Elbaz M , Thambo JB , Iriart X
Published: May 2022

Funding Acknowledgements

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

Background

Hypoattenuation (HAT) on the atrial aspect of the device and persisting LAA patency are not uncommon on CT images after left atrial appendage closure (LAAC), but their prognostic and therapeutic implications remain unclear.

Purpose

To analyze the prevalence, aspects and outcomes of HAT and LAA patency on CT after LAAC.

Methods

Consecutive patients from 2 French centers underwent cardiac CT 3 months post-LAAC. All CTs were reviewed by 2 readers in consensus to detect LAA patency and HAT. Linear defects of less than 1mm thickness in continuity with the adjacent LA wall were not considered as HAT but rather suggestive of device endothelialization. Defects >1mm thickness were categorized as low grade HAT (if 1-3mm thick and linear/regular), or high grade HAT (if >3mm and/or nodular/irregular). Patients with HAT underwent trans-esophageal echocardiography and received anticoagulation at the discretion of the cardiologist. We analyzed the relationship between CT findings and patient outcomes at follow-up.

Results

From 2012 to 2020, 412 patients were included (age 76±8 years, 68% males, prior stroke or embolism in 39%, HASBLED 3.1±0.8, CHA2DS2-VASc 4.4±1.3). The devices were Watchman in 175 (42.5%) and Amplatzer in 237 (57.5%). On 3-month follow-up CT, LAA patency was detected in 185 (45%). It related to none of the clinical characteristics, but was more common in Amplatzer devices (52% vs. 35%, P=0.001), particularly when using large Amplatzer devices (P<0.001). HAT were detected in 117 (28%), including low grade HAT in 98 (23.8%) and high grade HAT in 19 (4.6%). Patients with high grade HAT were older (P<0.001), and showed higher CHA2DS2-VASc scores (P=0.03). No relationship was found between high grade HAT and device type (P=0.89). Over a median follow-up of 17 [Q1-Q3: 11-41] months, stroke occurred in 24 (5.8%), and death in 54 (13.1%). On survival analyses, stroke and death did not relate to LAA patency (P=0.69 and P=0.80), low grade HAT (P=0.81 and P=0.38), high grade HAT (P=0.22 and P=0.36), or device type (P=0.36 and P=0.27).

Conclusion: although relatively high rates of LAA patency and HAT are observed on post-LAAC CT studies, these do not significantly relate to adverse outcomes.
Association of epicardial adipose tissue and coronary artery calcium score in patients with atrial fibrillation
Authors: Fernandes S , Ladeiras-Lopes R , Cruz I , Silva G , Silva M , Queiros P , Diaz S , Barros A , Saraiva F , Faria R , Almeida J , Fonseca P , Ferreira N , Primo J , Fontes-Carvalho R
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Both coronary artery calcium (CAC) and epicardial adipose tissue (EAT) had been implicated in coronary artery disease (CAD) and risk of future adverse cardiovascular events. There are scarce data regarding the assessment and association of EAT volume and CAC score (CACS) in atrial fibrillation (AF) patients.

Purpose

To assess the association between EAT volume and the presence and severity of CAC in patients with AF.

Methods

Retrospective and single-centre study including consecutive patients with AF undergoing contrast-enhanced cardiac computed tomography for catheter ablation planning, from 2017 to 2019. Patients with known history of CAD and moderate to severe valvular heart disease were excluded. Baseline clinical and demographical data were collected, as well as their cardiovascular risk, based on the SCORE (Systematic Coronary Risk Evaluation) system and cardiovascular risk categories. We assessed CACS (Agatston method) and EAT volume and analysed their association. EAT was defined as the adipose tissue accumulated between the visceral pericardium and the myocardium and was semi-automatically reconstructed by manually tracing the pericardium. Patients were split into three groups according to CACS: 0, 1-99 and ≥100. A logistic regression (LR) analysis was performed to explore the relationship between EAT volume and the presence of CAC (CACS>0), adjusted for age, gender, obesity, diabetes mellitus and hypertension.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. A CHA2DS2-VASc score ≥2 was present in 130 (37%) patients and most patients had low to moderate cardiovascular risk (n=213, 82%). More than half of the patients had a CACS>0 (n=185, 52%), of which 63 patients (18%) had a CACS≥100. The mean EAT volume was 79 ± 39 ml. There was a significant association between EAT volume and the presence of CAC: CACS=0 69 ± 34 ml vs CACS 1-99 84 ± 38 ml vs CACS ≥100 95 ± 45 ml (p<0.001) (Fig. 1). After covariate adjustment (LR model R2 = 0.373, p <0.0001), the presence of CAC was not associated with EAT volume (OR 1.00, 95%CI 1.00 - 1.01, p=0.2) or obesity, and only with higher age, male gender, hypertension and diabetes mellitus (Fig. 2).

Conclusion

In our cohort of patients with AF undergoing catheter ablation we observed an association between EAT and CACS. Nevertheless, EAT volume was not an independent predictor of CACS and only the classical cardiovascular risk factors remained significant.
Conventional fluorscopy-guided vs zero-fluorscopy catheter ablation of supraventricular tachycardias
Authors: Prolic Kalinsek T , Sorli J , Jan M , Sinkovec M , Antolic B , Klemen L , Zizek D , Pernat A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Traditionally, X-ray fluoroscopy is used during catheter ablation procedures. The utilisation of ionising radiation carries non-negligible stochastic and deterministic risks to the health of both the patient and the professional staff. These effects are cumulative and behave in a linear no-threshold manner and, as such, are especially important in paediatric populations (1). The importance of reducing ionising radiation exposure has been recognised by the American College of Cardiology, which recommends the ALARA (as low as reasonably achievable) principle in all interventional laboratories (2). In recent years, advances in three-dimensional electroanatomical mapping systems and their utilisation have enabled the near-zero and zero-fluoroscopy approaches to be studied (3).

Purpose

The aim of this study was to evaluate the safety and efficacy of zero-fluoroscopy catheter ablation for supraventricular tachycardias (SVT).

Methods

584 consecutive patients referred to our institution for catheter ablation of SVT were analysed. Patients were categorised into two groups; zero-fluoroscopy (ZF) group and conventional fluoroscopy (CF) group. Patient characteristics, procedural information, and follow-up data were compared.

Results

The ZF group had a higher proportion of paediatric patients (42.2% vs 0.0 %; p < 0.001), resulting in a younger age (30.9 ± 20.3 years vs 52.7 ± 16.5 years; p < 0.001) and lower BMI (22.8 ± 5.7 kg/m2 vs 27.0 ± 5.4 kg/m2; p < 0.001). Procedure time was shorter in the ZF group (94.2 ± 50.4 min vs 104.0 ± 54.0 min; p = 0.002). There were no major complications and the rate of minor complications did not differ between groups (0.0% vs 0.4%; p = 0.304). Acute procedural success as well as the long-term success rate when only the index procedure was considered did not differ between groups (92.5% vs 95.4%; p = 0.155; 87.1% vs 89.2%; p = 0.422). When repeated procedures were included, the long-term success rate was higher in the ZF group (98.3% vs 93.5%; p = 0.004). The difference can be partially explained by the operators’ preferences.

Conclusion

The safety and efficacy of ZF procedures in adult and paediatric populations are comparable to that of CF procedures.
Feasibility of open window mapping approach in accessory pathways ablation
Authors: Martinez-Sande JL , Gonzalez-Melchor L , Minguito-Carazo C , Rodriguez-Manero M , Otero-Garcia O , Garcia-Seara J , Fernandez-Lopez XA , Gonzalez-Ferrero T , Gonzalez-Juanatey JR
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction and Objectives

We described a new protocol of open window mapping (OW) in accessory pathways (AP) in CARTO® 3 system. This protocol automatically mapping conventional electrophysiology criteria of AP diagnostic, as shorter local EGM AV interval (extended early meets late tool), earliest local activation time (LAT) and annotation at unipolar signal (wavefront annotation).

Methods

Single center, prospective and observational study of 17 consecutive patients underwent AP catheter ablation.

Results

Mapping was performed in anterograde conduction in 13 patients (76.5%), retrograde in 5 patients(29,4%) and orthodromic tachycardia in 2 patients (11,7%). Mean of numbers of points were 3092±2246, with 30min ± 13min of mapping. Ablation was effective in 17 patients( 100%) and RF time until complete AP elimination was 2.6s. Image 1 show representation of EEML tool, targeting shorter interval EGM AV or VA and color adjust to determine earliest LAT.

Image 1 show representation of EEML tool, targeting shorter interval EGM AV or VA and color adjust to determine earliest LAT.

Conclusions

In our experience, automatically mapping of conventional electrophysiology criteria for AP diagnostic is able to localize AP insertion, suggesting an increasing in effectiveness of procedure, a reducing in mapping time, ablation time and X-ray exposure time.
Outcomes of cardiac pacing in patients with myotonic dystrophy type 1: A single specialist centre study
Authors: Zheng Y , Glover O , Walker R , Somani S , Lewis N
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac conduction disease and sudden cardiac death is known to be associated with Myotonic Dystrophy type 1 (MD). Patients often require device implantation to prevent sudden cardiac death. It is not known how frequently device implantation occurs and how quickly conduction disease progresses.

Objective

To define the rate and type of device implantation, rate of pacing and outcome in MD patients managed in a single specialist centre.

Method

Retrospective analysis of pacing and outcome data on consecutive MD patients managed at Specialist Centre in the UK between 2011 and 2021.

Results

24/119 MD patients were implanted with a cardiac device. Male:Female 13:11. At implant, patients had a mean age of 56 (95% CI 52 to 59), mean PR interval 217 ms (95% CI 203 to 230), mean QRSd 123ms (95% CI 109 to 137). Devices implanted included 16 DDDR, 4 CRT-D, 1 CRT-P, 1- ICD and 2 VVI pacemakers. 10 (42%) died during follow up of 10 years. 12 out of 19 (63%) with an atrial pacing lead required a mean increase in atrial pacing of 15% (95% CI 5 to 25) during follow up. 12 out of 24 (50%) of patients required mean increase of 13% (95% CI 5 to 22) in Ventricular pacing. 7 (88%) patients who died had evidence of progressive conduction disease prior to death.

Conclusion

In our cohort of myotonic dystrophy patients 20% required device implantation. There was a higher incidence of progressive atrial rather than ventricular pacing, despite the known concern about progressive AV block. Despite pacing, mortality remained high and was more frequent in patients with progressive conduction disease. Increases in pacing demand could be early indicator of disease progression.
Cardioneuroablation in patients with a prior pacemaker implant
Authors: Jansova H , Stiavnicky P , Peichl P , Stojadinovic P , Haskova J , Cihak R , Kautzner J , Wichterle D
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Cardioneuroablation (CNA) is an alternative therapeutic method for patients with functional bradyarrhythmias, who are otherwise candidates for permanent pacing. In a specific clinical scenario, CNA can also be a treatment option for patients with already implanted pacemakers.

Purpose

We investigated whether CNA could substitute permanent pacing in selected patients in whom pacemaker is associated with complications, technical failures, or decreased quality of life.

Methods

Among 160 patients who underwent CNA by radiofrequency energy between 2014 and 2022, there were 13 patients (8%) with a pacemaker in whom CNA was indicated as a "substitute" treatment. The reasons were as follows: lead failure (n = 6), recurrent decubitus of the device pocket (n = 1), infective endocarditis (n = 1), recurrent syncope even after pacemaker implantation (n = 1) and discomfort associated with the implanted device (n = 4). In 4 patients, the pacemaker was explanted shortly before CNA because of serious complications. Biatrial CNA was guided anatomically with the use of a 3D mapping system and intracardiac echocardiography. Empirical sites of ganglionated plexi were targeted. The procedural endpoint was unresponsiveness of sinus and AV nodes to extracardiac vagal nerve stimulation.

Results

Patients (n = 13, 77% male, age: 41 ± 12 years) had a pacemaker implanted 11 ± 7 years ago. They responded to atropine (2 mg IV) administration by accelerating the sinus rhythm by 55 ± 33%. CNA was technically successful and uncomplicated in all of them. During the follow-up of 29 ± 16 months (range 6 - 56 months), 2 patients (15%) had a recurrence of syncope. In both, the syncope was reproduced by tilt testing and classified as a pure vasodepressor event. In the remaining patients, the follow-up was uneventful. Elective explantation of the pacing system has so far been performed in 3 of 9 patients, while this is planned in others after reaching a sufficient length of post-procedural follow-up.

Conclusions

CNA is an effective and safe method, which is not only an alternative to the pacemaker implant but can also be used in patients with functional bradyarrhythmias, and previously implanted pacemakers who experience significant adverse events associated with the pacing system.
Income and education are associated with incidence of sudden cardiac death in a general population cohort
Authors: Warming PE , Aagesen FN , Lynge TH , Prescott E , Banner J , Jabbari R , Tfelt-Hansen J
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381

Introduction

Socioeconomic status is associated to all-cause mortality and common cardiac risk factors. The association between socioeconomic status and sudden cardiac death (SCD) taking prevalence of other risk factors into account has not been fully established.

Objective

The aim of this study was to investigate the association between income and education level and incidence of SCD.

Methods

All participants in the third wave of the Copenhagen City Heart Study were followed from 1993 to 2016 and all deaths were adjudicated using high quality death certificates, autopsy reports, and national registry data. Medical history and social demographics were self-reported. Hazard ratios (HR) were calculated using Cox proportional hazards regression and adjusted cumulative incidences were predicted using cause specific cox models.

Results

The study enrolled 10099 participants who were alive at start of follow up (median age at entry (IQR): 61 (48-72) years, 56% female). During 24 years of follow up, there were 5575 deaths of which 834 were classified as SCD. Compared with lowest income group and adjusted for age, sex, job, and education, higher income was associated with lower HR of SCD: middle income HR 0.82 (95% CI: 0.69-0.98) and high income HR 0.62 (0.47-0.81). This effect was attenuated, but still present, when adjusting for common cardiac risk factors (smoking, alcohol, BMI, physical activity, AMI, diabetes, hypertension, hypercholesterolemia). Compared with no education, increasing length of education was associated with lower HR of SCD: apprenticeship HR 0.82 (0.68-0.98), short education HR 0.80 (0.67-0.96), bachelor’s degree HR 0.56 (0.41-0.76), master’s degree HR 0.41 (0.28-0.59). This effect was also attenuated when adjusting for risk factors, job, and income. Adjusted cumulative incidences of SCD during the first 10 years of follow up according to income and education are shown in the figures.

Conclusions

In this study we found an association between lower income and shorter education and increased risk of SCD, an association not fully explained by prevalence of common cardiac risk factors, calling for further research into competing causes of SCD.
Clinical characteristics, therapy and long-term outcome of short-coupled idiopathic ventricular fibrillation. A systematic review of published case reports with new extended long-term follow-up
Authors: Tovia Brodie O , Belhassen B
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Short-coupled idiopathic ventricular fibrillation (SC-IVF) is a rare, potentially lethal arrhythmia, initiated by SC-PVCs. Only small series have been published.

Purpose

To assess the clinical characteristics, therapies and long-term outcomes of patients (pts) with SC-IVF.

Methods

Data from all published case reports on SC-IVF/Polymorphic VT were collected. Inclusion criteria were normal cardiac work-up including during follow-up (FU), and documented SC-PVC-VF available for our analysis and ruling out early repolarization syndromes and CPVT at VF onset. Updated information was provided by 82% of authors contacted, with 22 additional ECG tracings provided.

Results

A total of 100 pts’ cases were identified, including 82 who met inclusion criteria. Mean FU increased from 2.75+3.6 years in the original publications to 10.5+7.9 years (p<0.0001). There were 42 (51%) males, aged 39.6+13.5 years at the time of SC-IVF diagnosis. Pts presented with syncope (40%), aborted cardiac arrest (ACA) (16%), ACA + arrhythmic storm (13%), arrhythmic storm (10%), ICD shocks (8%) or palpitations (1%). Prior history included syncope in 32 (39%) pts. Mean coupling interval of the SC-PVC was 293.6+50.7ms. Presumed sites of PVC origin were the RV, LV and RVOT in 54%, 21% and 5% of pts, respectively. A total of 69 (84%) pts had an ICD implanted before or after SC-IVF documentation. During long-term treatment with quinidine (n=11) or verapamil (n=32), SC-IVF did not recur in 82% and 50% of pts, respectively (p=0.08). Ablation was performed in 43 (92%) of the 47 pts in whom it was attempted. Ablation sites were the Purkinje RV (43%) or LV (23%), and the non-Purkinje RV (19%) or LV (2%). Acute and late success rates after a first ablation were 83% and 61.7%, respectively. A second ablation in 7 pts yielded a 74.5% total success rate. No difference was found in the success rate of quinidine compared with ablation procedures (p=0.6). During FU, 4 pts died including 2 from sudden cardiac death; both pts were treated with verapamil and refused ICD implantation or replacement.

Conclusion

SC-IVF mainly presents following syncope. Quinidine and ablation procedures have comparable long-term high efficacy in arrhythmia control. The commonest sites of successful ablation are the RV and LV Purkinje fibers.
EGM characteristics of intramural outflow tract ventricular arrhythmias
Authors: Yalin K , Ikitimur B , Onder E , Soysal AU , Yalman H , Atici A , Aksu T
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Successful ablation of outflow ventricular premature contractions (VPC) depends on the identification of earliest activation. Annotation of bipolar (bi) EGMs can be challenging for especially multicomponent EGMs. Universally, annotation of earliest depolarization which depends on maximum dV/dt of unipolar (uni) EGMs and uni-QS morphology identify site of origin for VPC. However, identification of uni-QS morphology has limitations due to low spatial resolution. Additionally, time difference between bi- and uni-EGM can be observed and may be associated with deeper origin. Aim of this study is to compare EGM characteristics at successful ablation site in RVOT and RVOT+LVOT VPC ablation cases.

Methods

In this retrospective study, 40 patients who underwent successful RFA for RVOT and RVOT+LVOT VPCs were included. Local activation time (LAT), duration and voltage data of each bi- and uni-EGM at the successful ablation sites from RVOT and RVOT+LVOT cases were analyzed.

Results

28/40 (70%) of patients were ablated from RVOT and in 12/40 (30%) required both side ablation. All patients had acute PVC suppression. Bi-EGM-QRS onset was earlier (36.2±13.8 ms vs 28.8±7.3 ms, p=0.03), duration of bi-EGM was shorter (58.2±19.6 ms vs 83.8±22.3 ms, p=0.003) and Bi-voltage amplitude was higher (3.1±2.4 mV vs 1.2 ±0.9 mV, p=0.01) for patients with RVOT only ablation. Mean Bi-Uni EGM difference was 5.6±5.1ms in the RVOT group vs 13.5±5.4 ms in RVOT+LVOT group (p<0.001). Uni-QS morphology was recorded in 3.6±4.5 vs 3.3±1.9 cm2 in RVOT and RVOT+LVOT group respectively (P=0.80). In 11/40 (28%) of patients uni-QS was not identified at successful ablation site.

Conclusion

QS in uni-EGM was not a perfect predictor for successful ablation sites. Analysis of bipolar voltage amplitude and duration with Bi-uni EGM time difference may identify deeper source.
Electroanatomic visualization of coronary arteries: a case series to elicit safety, feasibility and diagnostic value in complex ablation procedures
Authors: Fries B , Johnson V , Schneider N , Fraebel C , Doerr O , Mathew S , Hamm CW , Schmitt J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Although three dimensional (3D) electroanatomic mapping systems allow detailed assessment of anatomy and substrates, ablation still carries substantial risk when close proximity to coronary arteries is suspected. 3D integration of coronary anatomy in mapping systems is still cumbersome, highlighting the need for an option of ad hoc acquirement of coronary artery anatomy. The goal of this case series was to evaluate the feasibility of a wire-based approach to the live visualization of coronary arteries and to assess its diagnostic information regarding procedure guiding.

Methods

For this single center case series, we included procedures in which close proximity of an ablation site to an epicardial vessel had to be suspected. An uninsulated-tip wire was then introduced into the relevant coronaries via diagnostic catheters after exclusion of critical stenosis by coronary angiography. The wire was connected to an impedance based 3D mapping system using a clamp and standard pin connection. Integrating this setup in the mapping system allows for live visualization of the wire tip, as well as the assessment of local electrograms within the respective vessel.

Results

We included a total of 9 procedures (4 ventricular tachycardia (VT) ablation procedures and 5 procedures for the ablation of premature ventricular contractions (PVCs)). The left coronary arteries were mapped in 8 cases, the right coronary artery was mapped in one case. In the majority of cases, the arrhythmogenic substrate was found in the left ventricle (5/9) or left ventricular summit area and the distal coronary sinus respectively (3/9). In two cases, epicardial mapping was performed combined with visualization of the right or left coronary arteries, respectively. There were no complications attributed to coronary wiring and mapping in this case series.

In two cases, the diagnostic information from mapping of the coronary arteries could be used to rule out an epicardial origin of arrhythmia. In the majority of cases, coronary visualization was used to ascertain a proper distance between the ablation site and the vessel.

Discussion

In this case series, we could demonstrate the feasibility and safety of coronary artery visualization and its integration in a 3D mapping system. The data obtained was used for diagnostic, as well as safety aspects. The electrograms from the wire were used to quickly assess relative timing of arrhythmias, thus allowing for an estimation of possible epicardial origin.

Conclusion

Applying the same caveats as for any other wiring of coronary arteries, their electroanatomic visualization is achieved in a safe and straightforward manner, with minimal technical requirements. Mapping of the coronary arteries adds critical diagnostic information and their real-time visualization is feasible without exceeding costs or risks
Stereotactic body radiotherapy for refractory ventricular tachycardia: the overall czech experience
Authors: Peichl P , Haskova J , Wichterle D , Neuwirth R , Jiravsky O , Cvek J , Knybel L , Sramko M , Kautzner J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation (CA) is a well-established treatment strategy for the management of drug-refractory ventricular tachycardia (VT) in patients with structural heart disease. Stereotactic body radiotherapy (SBRT) was proposed recently as a treatment option for cases of failed CA.

Purpose

This study reports overall experience with the SBRT from two Czech centers.

Methods

Since 2014, we enrolled consecutive patients who underwent at least one prior CA for recurrent scar-related VT and had subsequent VT recurrences due to inaccessible substrate. Single-session SBRT for VT was performed without the use of general anesthesia or sedation. A dose of 25 Gy was delivered.

Results

The study investigated 33 patients (3 women) with a mean age of 66 ± 9 years. Underlying heart disease was ischemic (58%) and nonischemic (39%) cardiomyopathy; one patient had large cardiac fibroma. The mean left ventricular ejection fraction was 31 ± 8%. Seventy-six percent of patients were on amiodarone. Before SBRT, they underwent a median of 2 (IQR: 1-3; range: 1-5) CA that included epicardial access in 42% of patients.

Following SBRT with a planned target volume of 42.6 ± 22.8 ml, the immediate effect was not observed in any patient, VT burden gradually decreased over weeks or months.

Seventeen (52%) patients died (2 of them suddenly) during the mean follow up of 29 ± 23 months mainly due to the progression of heart failure (Figure 1). One patient died due to bleeding associated with esophagopericardial fistula that developed 9 months after SBRT.

Overall, the number of DC shocks after a single procedure decreased significantly from 0.9 ± 1.9 per month in the period of 6 months before SBRT to 0.1 ± 0.3 per month in the period of 6-12 months after SBRT (P=0.008, Figure 2). However, 14 patients (42%) had to undergo additional CA due to VT recurrences at a mean interval of 13 ± 14 months after SBRT. Three patients underwent repeated SBRT (after 3, 29, and 38 months), which was successful in 2 of them.

Conclusions

SBRT in patients with refractory VT is feasible but the long-term mortality after the procedure is high and reflects mainly the severity of the underlying disease. The treatment effect of SBRT is delayed and additional CA is often necessary for VT suppression. At present, SBRT should be offered as only a bailout procedure for otherwise intractable VT.
Pacing electrodes to ablate, not to pace: what settings to use to create lesions even deep in the septum
Authors: Nedios S , Seewoester T , Darma A , Dinov B , Hildert S , Lucas J , Doering M , Dagres N , Arya A , Hindricks G , Bollmann A , Richter S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Intramural septal ventricular arrhythmia remains challenging, requiring emergent technologies and experimental approaches. Although conduction system pacing (CSP) has allowed us to reach deep in the septum, ablation though pacing electrodes has not been examined yet.

Purpose

To evaluate lesion creation by radiofrequency ablation (RFA) through pacing electrodes.

Methods

A custom ex vivo swine model in a saline bath with an indifferent electrode was used to apply RFA with an 8 mm non-irrigated catheter (SJM, MN, USA) on the proximal end of pacing (CapSureFix 5086) or CSP-electrodes (SelectSecure 3830, Medtronic, MN, USA), screwed in perpendicularly to the slab. A generator (Ampere, SJM, MN, USA) applied RFA at varying settings (1-10 W, 1-20 sec). Lesion depth (D), width (W) and volume (V=3,14*W2*D/4) were assessed and analyzed (SPSS 23).

Results

A total of 80 lesions were used for analysis. Median RFA with 3 W over 6 sec resulted in an impedance drop from 200 to 140 Ω and a lesion of 2x3 mm or 9.4 mm3 (Figure 1). Higher energy settings caused impedance rise with abort (n=3, 4%) or charring (n=3, 4%). Compared to conventional electrodes, lesions with CSP-electrodes had similar volume (9.3±7 vs. 10.8±9 mm3, p=0.45) and width (2±0.8 vs. 2±0.7, p=0.58), but more depth (2.6±0.5 vs. 3±0.6, p=0.0.01). Regression analysis showed final-impedance (FI), power and duration (WS=W*Sec) as independent predictors of lesion volume (V=4.7WS-4.1WS2+4.5FI-4, p<0.001).

Conclusions

Effective ablation through pacing electrodes is possible, but lesion size is limited and low-power settings are necessary. Using CSP-electrodes for effective intramural lesions is possibly a new tool for septal arrhythmias. Further in vivo studies are warranted and bailout use should be considered.
STereotactic Arrhythmia Radioablation in Europe: critical structure contouring benchmark results of the STOPSTORM Consortium
Authors: Balgobind B , Visser J , Grehn M , Knap M , De Ruysscher D , Levis M , Pruvot E , Verhoeff J , Blanck O
Published: May 2022

Funding Acknowledgements

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

Background/Introduction

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

Purpose

The primary goal of the critical structures benchmark study was to harmonize contouring of organs at risk (OAR) for STAR within the STOPSTORM.eu consortium. The results enable to refine protocols and guidelines to ensure treatment harmonization.

Methods

Three well-selected STAR cases [2] were provided for this benchmark and sent to all radiation oncology centres within the consortium. Every case had a contrast-enhanced cardiac-CT which was already deformed to the primary planning-CT to contour the OAR in detail. Every centre was asked to contour 31 OAR’s according to literature-based guidelines. The resulting structure sets were evaluated within VelocityTM 4.1.

Results

Twenty centres participated in the critical structure contouring benchmark.

Contouring of the structures was performed with high accuracy according to the provided guidelines. The contours of common OAR’s in radiotherapy, such as the heart, lungs, stomach, oesophagus, bronchus, great vessels, and spinal canal were correctly contoured by all centres. In the substructures of the heart (chambers, valves, arteries, and nodes), deviations in the contours occurred more frequently, but no large systematic errors were found (see figure 1-2). The centres that already performed STAR treatments had markedly less difficulties with the contouring of the substructures. However, these structures do not have a consensus for treatment planning purposes and late toxicity but need to be contoured correctly for future analysis within the STOPSTORM project.

Conclusion

This large STOPSTORM.eu multi-centre critical structure benchmark study showed a high accuracy regarding standard critical structures. In the case of heart substructures some deviations occurred, which lead to new definitions for contouring these structures within the consortium. In addition, a close collaboration between radiation oncologist and cardiac electrophysiologist is recommended.
Cardiac resynchronization therapy in patients with a history of atrial fibrillation: insights from five major clinical trials
Authors: Dalgaard F , Fudim M , Al-Khatib S , Friedman D , Abraham WT , Cleland JF , Curtis AB , Gold MR , Kutyifa V , Linde C , Young J , Ali-Ahmad F , Olivas-Martinez A , Inoue LYT , Sanders GD
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Heart, Lung, and Blood Institute

Background

Many patients with heart failure who are considered for cardiac resynchronization therapy (CRT) have a history of (h/o) atrial fibrillation (AF) but there are doubts about the efficacy of CRT in patients with AF.

Purpose

To investigate the association of CRT on morbidity and mortality among patients with and without a h/o AF.

Methods

Original, patient-level data from five clinical trials of CRT that permitted enrolment of patients with a h/o AF were included: COMPANION, MADIT-CRT, BLOCK HF, REVERSE, and MIRACLE trial. Patients with permanent or persistent AF were excluded from these trials, and therefore from this analysis. The outcomes of interest were the composite endpoint of time to heart failure hospitalization (HFH) or all-cause mortality or all-cause mortality alone. The association of CRT (versus no CRT) with outcomes for patients with and without a h/o AF was assessed using a Bayesian-Weibull survival regression model with random terms for the trial-specific treatment effects and the trial-specific baseline hazard functions including an interaction between history of paroxysmal AF and CRT. All results are presented as hazard ratios (HRs) with 95% posterior credible intervals (CIs) and posterior probabilities of no association, adjusting for baseline characteristics.

Results

A total of 4062 patients were included, 661 (16.3%) of whom had a h/o AF. Patients with a h/o AF were older (mean [SD] age 68 [10] years versus 64 [11] years) and had a higher proportion of ischemic cardiomyopathy (67% versus 53%, p<0.001), a higher baseline serum creatinine (1.3 mg/dl versus 1.2 mg/dl, p<0.001), and a lower left ventricular ejection fraction (25% versus 26%, p<0.001). The HRs for all outcomes and the interaction term are shown in Table 1. For the overall population, CRT delayed the time to HFH or all-cause mortality (HR: 0.74, 95% CI: 0.62 – 0.87, p=0.005); for patients with a h/o AF, it did not (HR: 0.87, 95% CI: 0.64 to 1.19, p=0.37). In this patient-level meta-analysis, CRT was not associated with a reduction in mortality, overall or by h/o AF. Howevber, the interaction (estimate shown as a ratio of HRs) between those with or without a h/o AF and the effects of CRT was not significant for either outcome (Table 1).

Conclusion

In the largest post hoc analysis to date, we confirm the benefits of CRT in patients without a h/o AF in reducing HFH or mortality. There was no statistically significant interaction between CRT and h/o AF for any analysed outcome.
A new method for right ventricular lead implantation into the intraventricular septum
Authors: Narumi T , Naruse Y , Kaneko Y , Sano M , Urushida T , Maekawa Y
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Right ventricular (RV) lead placement into the interventricular septum is only accurate in 16–48% of cases under conventional fluoroscopic guidance. A previous report showed the importance of individualized left anterior oblique (LAO) projection to improve the success rate of RV lead placement into the interventricular septum. However, this procedure is complicated. We sought to investigate the preprocedural predictors of individualized LAO projection.

Methods

We assessed the relationship between preoperative electrocardiographic parameters and the angle of the interventricular septum obtained using thoracic computed tomography (CT).

Results

In the retrospective derivation cohort group (n=39), the mean angle of individualized LAO assessed by thoracic CT was 53.1±8.9°, and the preoperative electrocardiogram QRS axis was strongly correlated with the interventricular septum axis detected by thoracic CT (R2 = 0.490). In contrast, the preoperative electrocardiographic transitional zone was not associated with the interventricular septum axis (R2 = 0.041, P = 0.78). Using individual LAO projection derived from the preoperative electrocardiogram QRS axis, it was confirmed that the RV lead was placed in the interventricular septum during the pacemaker procedure in the prospective internal validation group (n=30). The success rate for placing the RV lead into the interventricular septum was significantly improved in the internal validation cohort group (93% vs. 64%, P < 0.05). In addition, the N-terminal pro-brain natriuretic peptide level decreased significantly after surgery in the interventricular septal indwelling group.

Conclusions

Individualized LAO angle derived from the preoperative electrocardiogram QRS axis is a new useful and simple method for RV lead implantation into the interventricular septum.
Predictors of pacemaker dependency after transcatheter aortic valve replacement
Authors: Dias Ferreira Reis JP , Mendonca T , Castelo A , Rodrigues I , Fiarresga A , Ramos R , Cacela D , Oliveira M , Ferreira R
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Conduction disturbances after transcatheter aortic valve replacement (TAVR) are common with a variable risk of long-term pacemaker dependency (PD), being influenced by patient- and procedure-specific factors. As pacemaker (PM) implantation is associated with potential complications, our aim was to assess predictors of PD requirement after TAVR.

Methods

Retrospective analysis of consecutive patients (P) who underwent TAVR with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. Cumulative percentage of ventricular pacing (%Vp) was determined from stored PM data. P with a PM implanted previous to TAVR were excluded. PM implantation post-TAVR was defined as a device implant performed during hospital stay in the context of TAVR or during the first month after discharge. PD was defined as a %Vp > 80% at one-year follow-up. Multivariate analysis for the prediction of PD was done using Cox regression.

Results

A total of 474 P (57% male, age 81.7±6.5 years, left ventricular ejection fraction 51.5±14.6%) were analysed. Mean follow-up was 18.7 months. Mean baseline gradient was 51.7 mmHg with a mean aortic valve area of 0.71 cm2. One hundred and four P (21.9%) required PM implantation after TAVR, with a mean %Vp of 65.3±43.4%, presenting PD in 60% of the cases at one-year follow-up. A glomerular filtration rate > 60 ml/min (OR 0.87, CI 95% 0.74-0.96, p=0.021) and mean aortic annulus perimeter (OR 0.89, CI 95% 0.80-0.98, p=0.029) were independent predictors of a PD < 5%. Arterial hypertension (OR 7.00, CI 95% 1.31-37.40, p=0.023), baseline right bundle branch block (OR 10.2, CI 95% 1.21-18.45, p=0.033), and the EUROSCORE II (OR 1.05, CI 95% 1.01-1.10, p=0.044) were predictors of PD > 80%. Baseline left bundle branch block, implantation depth and aortic valve calcium score were not predictors of PD.

Conclusion

Predictors of PD after TAVR may influence PM implantation, as well as device selection and programming. P with a higher aortic annulus perimeter and preserved kidney function may undergo a more expectant management, as PD rates are low after 1 year follow-up.