bluuebunny/crossref_metadata_2025 huggingface dataset:
Late potentials assessment - an useful tool for Brugada Syndrome risk stratification
Authors: Brito J , Silverio Antonio P , Nunes Ferreira A , Lima Da Silva G , Ricardo I , Neves I , Cortez-Dias N , J Pinto F , Sousa J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Brugada syndrome (BrS) is a channelopathy confining an increased risk of sudden cardiac death (SCD). Asymptomatic patients (pts) management remains challenging enhancing the necessity for additionally stratification tools.

Purpose

To evaluate the role of the non-invasive assessment of late potentials (LP) based on SA-ECG as stratification tools in a BrS cohort.

Methods

Prospective, observational single-center study of pts with BrS with the following criteria (1) Type 1 Brugada ECG pattern, either spontaneous or drug induced; (2) SA-ECG performed before anti-arrhythmic treatment; (3) minimum follow up duration of 12 months. LPs were evaluated by SA-ECG with determination of the total filtered QRS duration (fQRS); root mean square voltage of the 40ms terminal portion of the QRS (RMS40) and duration of the low amplitude electric potential component of the terminal portion of the QRS (LAS40) in conventional and modified right precordial leads. Malignant arrhythmic events (MAEs) were defined as a composite event of SCD or appropriate ICD shocks. Association of relevant risk factors and MAE was conducted with Univariate Cox regression analysis, as well as SA-ECG evaluated as a continuous and categorical divided on standard cut-offs (fQRS >114ms, RMS40<20µV, LAS40>38ms). A risk score for predicting MAE was computed incorporating the significant LPs variables.

Results

A total of 106 pts fulfilled the inclusion criteria (mean age: 48 ± 12 years, 67.9% male), 52 (49.1%) with type 1 spontaneous pattern. The majority were asymptomatic at baseline (81.1%) while 13 presented with syncope and 3 with polymorphic VT/cardiac arrest. A total of 10 (7.1%) pts MAEs were documented during a mean 4.7 years - 4 with SCD and 6 with appropriate ICD shocks. Clinical presentation with a polymorphic VT/cardiac arrest (p <0.001) and LP evaluated on SA-ECG were significant predictors of MAE on univariate analysis, except for RMS40 on conventional leads. Neither of the common risk factors (male gender, spontaneous type 1 pattern at baseline, previous syncope or the presence of a pathogenic SCN5A mutation) were predictors of MAE during follow-up– figure 1. Positive LPs defined by standard cut-offs, in all variables and leads, were significantly associated with an increased risk of MAE during follow-up – figure 2. A LP score was computed incorporating the standard cut-offs on conventional leads. The presence of 2 and 3 positive LP represented an additionally 4.7-fold increased risk of MAE during follow-up (HR 4.693, 95% CI 1.506-14.624, p = 0.008) – figure 2.

Conclusion

LPs based on noninvasive assessment SAECG represent an useful prognostic stratification tool in BrS. A LP score based on standard cut-offs identified a subset of pts at a higher risk of events and who may deserve individualized preventive strategies.
Sex-specific differences in infranodal conduction properties in patients undergoing transcatheter aortic valve replacement
Authors: Serban T , Knecht S , Mannhart M , Nestelberger T , Kaiser C , Leibundgut G , Bischof M , Sticherling C , Kuehne M , Badertscher P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Electrophysiological (EP) testing has been proposed for risk stratification of patients with left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR). A uniform cut-off of 70ms for the His-Ventricular (HV) interval has been proposed to trigger pacemaker implantation. However, sex-specific periprocedural data regarding infranodal conduction properties are lacking.

Purpose

We aimed to compare the HV interval in men and women undergoing TAVR.

Methods

We analyzed consecutive prospectively included patients undergoing TAVR between June 2020 and June 2021 at a tertiary referral center. EP testing was performed in all patients pre- and post-valve deployment and in the case of LBBB additionally for a third time the following day.

Results

127 patients were included (81 ± 7 years, 46% female). Median HV interval pre-valve deployment was 43 [37-50] ms vs 46 [42-53] ms in women and men, respectively (p=0.016). Nine patients underwent peri-procedural pacemaker (PM) implantation for third-degree AV-block. The median HV interval post-valve deployment was 54 [42-59] ms in women and 56 [51-61] ms in men (p=0.038). The median HV interval the day following TAVR in patients with LBBB was 45 [41-49] ms in women and 50 [48-62] ms in men (p=0.048). An HV interval ≥ 55 ms and ≥70 ms was present the day following TAVR in seven patients (24%, two females) and three patients (10%, one female). (Figure)

Conclusion

Women have shorter HV intervals pre-and post-valve-deployment as well as the day following TAVR compared to men. Further studies evaluating sex-specific cut-offs for the HV interval are warranted.
Pitfalls and limitations in the assessment of the HV interval in a transcatheter aortic valve replacement population. A prospective analysis
Authors: Teres C , Haddad C , Pagnoni M , Le Bloa M , Herrera-Siklody C , Domenichini G , Porretta A , Pruvot E , Pascale P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

identification of patients with new-onset conduction disturbances at risk of AV-block remains a major unmet challenge in Transcatheter Aortic Valve Replacement (TAVR). His-Ventricular interval (HVI) measurement has been proposed in patients at risk. However, the HVI assessment is often overlooked, performed as a single assessment without active mapping, and even single-catheter assessment is sometimes performed.

Purpose

To systematically evaluate HVI measurements in a post TAVR population, in search of methodological pitfalls as related to outcomes

Methods

Consecutive patients who underwent HVI assessment post-TAVR between June 2014 and December 2021. HV interval was classified as normal (<55), intermediate (55-70) and abnormal (>70 ms). Incremental atrial pacing was performed whenever possible. All tracings were reviewed by two blinded operators. Pitfalls in the assessment of atrioventricular conduction were categorized into types 1 to 5, as reported in Table 1. In sinus rhythm, only proximal HVI were considered defined as the concomitant recording of a near-field atrial signal.

Results

90 cases were analyzed; median age 81 years1 [76 – 86] years; 37 (41%) male. The median HV interval was 54 [50 – 65] ms. An abnormal HV interval, exceeding the 55 and 70ms cut-off values, was found in 41 (45.9%) and 13 (14.8%) patients, respectively. At least one pitfall was found in 15 patients (16%). Short-term AV block occurred in 3 patients in sinus rhythm in whom no incremental pacing was performed, and in 2 patients with AF despite normal or borderline HVI in both groups.

Conclusions

Pitfalls in the assessment of the HVI are often observed after TAVR. Identification of infra- and especially intra-His disorders requires careful mapping and must be an active process on behalf of the operator. Our results call into question the value of the HV assessment using a single catheter or in patients with atrial fibrillation, considering the value of incremental atrial pacing and the inherent limitations in AF to assess the most proximal His or intraHis block.
Association between different catheter designs for the characterization of the left atrial substrate
Authors: Knecht S , Schlageter V , Badertscher P , Krisai P , Schaer B , Jousset F , Spies F , Osswald S , Sticherling C , Kuhne M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The study was supported by an investigator sponsored grant (Boston Scientific).

Background

Bipolar voltage electrograms (BVE) for left atrial (LA) substrate characterization strongly depend on the catheter design and electrode configuration.

Purpose

The aim of the study was to compare bipolar voltage electrograms (BVE) obtained from the left atrium using four different established mapping catheters and to deduce the individual catheter-specific cut-offs for scar and healthy myocardial tissue.

Methods

We prospectively included 25 consecutive patients referred for catheter ablation for atrial fibrillation recurrence after index PVI. The pipeline of the analysis leading to the individual cut-off for every catheter based on a reference catheter value is shown in the figure. In detail, consecutive high-resolution electroanatomic mapping was performed using a multipolar catheter (Orion), a duo-decapolar variable circular mapping catheter (Lasso), an irrigated ablation catheter with micro electrodes (MIFI) and a 4.5 mm tip-size irrigated ablation catheter (Nav). BVEs for the four catheters were compared in voxels with a size of 3x3x3mm^3 (Figure, top left). Total least squares regression was performed for every patient to investigate the logarithmic relationship between the BVE measured by two different catheter types (Figure, top right). The mean equivalent BVE cut-off over all patients for every catheter was calculated for the reference cut-offs of 0.1 mV, 0.2 mV, 0.5 mV, 1.0 mV, and 1.5 mV (Figure, bottom left).

Results

Correlation between the four different BVE maps for the 25 patients showed a slight individual variation between the patients. Compared to the BVE cut-offs from the standard Nav catheter with a 4.5 mm tip, the scar cut-off using the Orion catheter must be lowered to 0.034 mV for a 0.1 mV cut-off, to 0.09 mV for a 0.2 mV cut-off, and to 0.35 mV for the 0.5 mV cut-off (Figure). Similar values hold true for a Lasso map as comparator (Figure). For healthy tissue above 1 mV, similar cut-offs to the reference values might be advisable.

Conclusion

In contrast to the established Nav or Lasso catheter, the scar voltage cut-off for the Orion catheter needs to be lowered to 0.1 mV instead of the 0.2 mV cut-off and approx. 0.35 mV for a 0.5 mV cut-off. At lower voltages the difference between the catheters increases. The presented connective table enables to transfer the studies of left atrial substrate characterizations using different catheter types.
Role of the implantable loop recorder in clinical practice: insights on indications, diagnostic yield and therapeutic implications from a single, high volume, tertiary care centre experience
Authors: Castagno D , Ferraris F , Anselmino M , Millesimo M , Saglietto A , Matta M , Verna D , Donadoni M , Ruffini S , Giustetto C , De Ferrari G M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Besides the established class I indication for the evaluation of patients with recurrent syncope of uncertain origin, implantable loop recorders (ILRs) have been increasingly used for other diagnostic purposes (e.g. detection of atrial fibrillation (AF) following cryptogenic stroke).

Purpose

To describe the main indications to ILR and to investigate procedural parameters, outcomes and diagnostic yield of ILR in a single, high-volume tertiary care centre.

Methods

All patients undergoing ILR implantation between November 2007 and April 2022 were consecutively enrolled in this study. Clinical characteristics of patients, procedural data and outcomes were collected. The indications to ILR implantation were divided into four categories: 1) AF detection in patients with recent cryptogenic stroke or peripheral thromboembolism [CRYSP], 2) recurrent syncope of uncertain origin [RSUO], 3) monitoring of ventricular arrhythmic events [VAE] in patients with predisposing cardiomyopathy/channelopathy, 4) monitoring of AF burden or relapse [AFB]. The main endpoint of the study was the diagnostic yield (number of definitive diagnoses made) and the time to diagnosis following ILR implantation. The occurrence of acute or subacute complications was used as a secondary safety endpoint.

Results

Overall, 1442 patients underwent ILR implantation (mean age 65 years, 43% female). The two main indications to ILR were AF detection following CRYSP and RSUO (42% and 34% of all implantations respectively, table 1). The commonest site of implantation was the left parasternal position (902 patients, 63%), median procedural time was 20 minutes (IQR 15-25). During a median follow-up of 397 days (134-1094), infections requiring ILR extraction or pocket revision occurred in 13 patients (0.9%). A definitive diagnosis was achieved in 500 (35%) patients after a median time of 206 days (IQR 60-533) [table 1 shows details and action taken following diagnosis for each indication subgroup]. At multivariable analysis, age and PR interval duration were significantly associated with the need for PM/ICD implantation among patients receiving ILR for RSUO whilst age was associated with AF detection among those with CRYSP (table 2).

Conclusions

In this cohort of patients use of ILR was associated with a good diagnostic yield regardless of the initial indication, triggered timely therapeutic actions and was overall safe.
Invasive risk stratification and implantable loop recorders in brugada syndrome: a single centre experience
Authors: Abela M , Meilak S , Sammut M A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Risk stratification in Brugada syndrome (BrS) is challenging. Cardiogenic syncope, family history of sudden cardiac death and ECG markers are useful variables in determining patient risk. Invasive risk stratification is sometimes needed in those with an intermediate risk phenotype. Implantable loop recorders (ILR) may be considered in those patients with no inducible ventricular arrythmias during programmed ventricular stimulation (PVS).

Objective

The aim of this study was to retrospectively evaluate the outcome of BrS patients referred for PVS and ILR implantation.

Methodology

Demographic, clinical and follow-up data of BrS patients seen in clinic were retrospectively analysed from hospital databases. A p vale of <0.05 was considered significant.

Results

129 patients have been diagnosed with BrS since launching the inherited arrhythmia clinic service (53.5% males). 15 (high risk patients) had an ICD (n=13, 10.1%) or PM (n=2, 1.6%) implanted because of a hospital cardiac arrest, ventricular arrhythmias, high grade AV Block or cardiogenic syncope.

26 (20.2%) were placed in the intermediate risk category, (65.4% males). Patients were offered an electrophysiology study (EPS/PVS) or an ILR depending on the clinical indication (Figure 1). Most were male (65.4%), with a mean age of 41.8±17.7 years at the time of risk stratification. 6 had a likely or definite pathogenic mutation (n=5 19.2% SCN5A, n=1 3.8% MYBPC3). This group had a median Shanghai score of 4.0±0.9. Gender (p=0.429), age (p=0.246), genotype (p=0.273) and shanghai score (p=0.746) did not differ between strategies.

Most (n=12, 9.3%) were offered an EPS/PVS from the offset. Ventricular arrhythmias were induced in 1 (8.3%), an ICD was then implanted. The rest were implanted with an ILR on the day.

Patients not offered an EPS (n=14, 10.9%) were initially implanted with an ILR because of insufficient grounds to proceed with an EP study.

Patients with an ILR (n=25, 19.4%) were followed up for a median 39 ± 21 months. ILR monitoring identified actionable events in 3 (12.0%) patients. One (4.0%) needed a pacemaker for sick sinus syndrome. Two (8.0%) recorded non-sustained ventricular arrhythmias. Both were subjected to an EPS/PVS, one needed an ICD. None of the patients who had an EPS initially had any significant events during follow up.

Conclusion

ILR implantation has a role in risk stratifying intermediate risk patients who do not fulfil criteria for EPS referral. This may also be considered in intermediate risk patients who are not keen on an invasive risk assessment with EPS.
Management of modifiable risk factors and comorbidities in atrial fibrillation: suggestions for improvement from a patient perspective
Authors: Klaveback S , Svennberg E , Braunschwig F , Lidin M
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): SLL Region Stockholm Innovation

SLL Region Stockholm Klinisk Forskare.

Background

In patients with atrial fibrillation (AF), improved management of modifiable risk factors, unhealthy lifestyle and concomitant diseases is highly recommended by guidelines, in particular if rhythm control is desired. Yet, many AF patients have suboptimal management of risk factors and comorbidities. There is a lack of understanding how patients can be better aided to achieve these goals in clinical practice. Digital health solutions may offer support in this matter.

Purpose

To identify what patients with atrial fibrillation would find important in a digital tool aimed at optimization of modifiable risk factors and comorbidities.

Methods

This is a qualitative, descriptive study based on semi-structured interviews that were analyzed by manifest content analysis. 16 AF patients with recent in- or outpatient encounters were included (age 68 (52-78) years; 43% female; BMI 29.5 (20.4-35.8) kg/m2; paroxysmal/persistent AF (50%/50%); AF duration 7 (0-22) years). Four semi-structured focus-group interviews were conducted. Study results were intended to inform the development of a digital tool aimed to support risk factor and comorbidity optimization in patients scheduled for rhythm control interventions.

Results

Relevant comorbidities were hypertension (88%), heart failure (25%), diabetes mellitus type 2 (19%) and ischemic heart disease (13%). Only 19% stated that they were satisfied with their current level of physical activity and 19% were satisfied with their current eating habits. The participants’ suggestions were summarized into three main categories. First, person-centered information is essential, meaning that information should be customized, conveyed in an appropriate tone and include practical tips. Second, there is an unmet need for help with managing lifestyle habits in a way that is easily applicable in everyday life, and patients desire help with creating habits. Third, regular communication is necessary including inspirational reminders and motivational feedback.

Conclusions

From a patient perspective, person-centered information, practical help with managing lifestyle habits, and regular communication are considered essential in helping to optimize treatment of comorbidities and associates risk factors associated to lifestyle. This can, at least in part, be done digitally and should be implemented more in standard care to improve outcomes and reduce cost.
Accelerometer-derived physical activity and the risk of death, heart failure, and stroke in atrial fibrillation patients: A prospective study from UK Biobank
Authors: Ahn H J , Rhee T M , Kwon S , Lee S R , Choi E K , Oh S , Gregory L I P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Data on the risk of cardiovascular outcomes according to the objectively measured physical activity (PA) in atrial fibrillation (AF) is scarce.

Purpose

We aimed to explore the association between accelerometer-derived PA and the risk of death, heart failure, and stroke in patients with AF.

Methods

From the UK Biobank prospective cohort, 2324 AF patients with valid wrist-accelerometer data recruited between 2013 and 2015 were included. Wrist accelerometers were used to define the intensity and duration of light, moderate, and vigorous PA. The primary outcomes were all-cause mortality, cardiovascular disease (CVD) mortality, heart failure (HF), and stroke. Restricted cubic splines were used to evaluate the dose-response associations between moderate to vigorous physical activity (MVPA) duration and the primary outcomes. We analyzed the adjusted hazard ratio (aHR) of primary outcomes in AF patients who adhere to the PA guideline of the World Health Organization (MVPA≥150 min/week) compared to the patients with low PA.

Results

The mean age was 61.1±6.2 years and 64.9% were male. During a median of 6.9 years, 184 all-cause deaths, 62 cardiovascular deaths, 225 heart failure, and 92 stroke events were observed. There was a linear inverse dose-response relationship between MVPA time (≥108 min/week) and all-cause mortality. A certain range of MPVA time (105 to 590 min/week) was associated with a lower risk of HF. The risk of stroke and CVD mortality had no significant relationships with MVPA time. AF patients with guideline-adherent PA levels have lower risks of all-cause mortality and heart failure: aHRs (95% CIs) were 0.70 (0.50-0.98), p=0.04 for all-cause mortality and 0.67 (0.49-0.93), p=0.02 for heart failure.

Conclusion

In this study of objectively measured PA data, AF patients with higher PA showed lower risks of all-cause mortality and heart failure. AF patients adhere to PA guideline (MVPA≥150 min/week) might have a lower risk trend of CVD mortality and stroke. Exercise should be strongly encouraged for AF patients as in the general population.
The outcomes of cryoballoon, high-power short-duration, and conventional radiofrequency atrial fibrillation catheter ablation: a propensity score weighted study
Authors: Park H , Park J W , Kim D H , Yu H T , Kim T H , Uhm J S , Joung B Y , Lee M H , Hwang C , Pak H N
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Purpose

We compared the efficacy, safety, and heart rate variability (HRV) after cryo-balloon (Cryo-PVI), high-power short-duration (HPSD-PVI) or conventional radiofrequency pulmonary vein isolation (conventional-PVI) in patients with atrial fibrillation (AF).

Methods

In this retrospective analysis of single-center cohort, we included 2,975 patients who underwent AF catheter ablation (74.1% male, median 60 years old, 74.1% paroxysmal AF). We compared the procedural factors, rhythm outcomes, complication rates, and post-procedural heart rate variability (HRV) between the Cryo-PVI (n=493), HPSD-PVI (n=638), and conventional-PVI (n=1,844).

Results

In spite of significantly shorter procedural time in the Cryo-PVI group (73 min for Cryo-PVI vs 110 min for HPSD-PVI vs 153 min for conventional-PVI, p<0.001), major complication (2.8% for Cryo-PVI vs 2.4% for HPSD-PVI vs 2.5% for conventional-PVI, p=0.875) or freedom from late recurrence (log-rank, p=0.357) did not differ among the three ablation groups. Cryo-PVI showed significantly lower risk for AF recurrence in patients with paroxysmal AF (weighted hazard ratio [WHR] 0.62, 95% confidence interval [CI] 0.41-0.93), but worse rhythm outcome in those with non-paroxysmal AF (WHR 1.47, 95% CI 1.06-2.05, p for interaction=0.002) as compared with conventional-PVI. In the subgroup analysis for HRV (n=1,429), Cryo-PVI group showed significantly higher low-frequency to high-frequency ratio at post-procedure 3 month (p<0.001), 1-year (p<0.001), and 2-year (p=0.023).

Conclusion

Cryo-PVI showed better rhythm outcome in patients with paroxysmal AF, but worse outcome in those with non-paroxysmal AF with higher long-term post-procedural sympathetic nervous activity as compared with conventional-PVI.
Early recurrences predict late therapy failure after pulsed field ablation of atrial fibrillation: midterm clinical outcome from a high-volume center
Authors: Plank K , Bordignon S , Schmidt B , Urbanek L , Chen S , Schaack D , Tohoku S , Chun K R J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

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. Data regarding midterm outcome are sparse.

Purpose

The aim of this single-center study was to report midterm clinical outcomes following PFA-based pulmonary vein isolation (PVI).

Methods

Consecutive patients with symptomatic AF were enrolled to undergo PFA-PVI based on the "5S Study" ablation strategy. Procedures were done between March 2021 and January 2022. A dedicated catheter with five splines delivering bipolar energy with a voltage of 1.8-2.0 kV was used. Arrhythmia recurrence was defined as documented AF/atrial tachycardia (AT) lasting more than 30 seconds after a 90 days blanking period (BP). Procedural and demographic data were analysed.

Results

231 patients (42% female, age 69±12, 55% paroxysmal atrial fibrillation [PAF]) were included in this preliminary analysis. 901 pulmonary veins (PV) were identified, and all PVs could be isolated using solely the PFA device. 895 (99.3 %) PVs were isolated with the first application. 32±4 applications per patient were delivered. The overall complication rate was 3.5% (vascular access complication: 2.2%, stroke: 0.9%, tamponade: 0.4%). Median follow-up time was 323 days. 22% of patients experienced a recurrence during the BP after a median of 23 days. Kaplan Meier estimated freedom of AF/AT out of the BP was 75% at one year, 83% for PAF and 64% for persistent atrial fibrillation (persAF, p< 0.0036). In a multivariate analysis blanking recurrence (p<0.001) and female sex (p=0.002) were the only independent predictors for late recurrence.

Conclusions

This study indicates high acute efficacy of PFA based PVI. 75% of patients are free of AF at one year. Blanking recurrence is an independent predictor for late recurrence after PFA-PVI: further studies are required to better define the duration of the BP after PFA PVI.
Very high power- short duration radiofrequency ablation in patients with congenital heart disease and atrial fibrillation: safety and outcome
Authors: Lengauer S , Telishevska M , Krafft K , Bahlke B , Englert E , Lennerz L , Popa P , Reents R , Deisenhofer D , Hessing H
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

It has been shown recently that ablation of paroxysmal and persistent atrial fibrillation (AF) using very high-power-short duration (vHPSD) ablation protocol is safe and effective. Data for vHPSD ablation protocol in adult patients with congenital heart disease (ACHD) are lacking. We searched our database for ACHD patients undergoing AF ablation using vHPSD ablation regarding periprocedural safety and outcome.

Methods

The data of 62 consecutive ACHD patients with mild (n=43; 69.4%), moderate (n=15; 24.2%) or complex (n= 4; 6.4%) CHD were analysed (Table 1 ). Mean age was 60,43 ± 12,7 years ( 46% male) with a Cha2ds2-VASc2 Score median of 2. Patients were diagnosed with paroxysmal AF (n= 24; 38%) or persistent AF (n= 38; 61%). In 6 patients (9,6 %), a previous conventional pulmonary vein isolation (PVI) had been performed.

Settings used for vHPSD ablation were 70 W/5-7 s or 60 W/7-10 s using irrigated-tip catheters. Circumferential PVI was performed in all 62 patients; in 30 patients (48%) additional substrate ablation was performed. The 30-day incidence of adverse events was analyzed and patients followed-up in regular visits at our outpatient clinic using repetitive 7 days Holter ECGs every 3 months.

Results

No adverse events such as cardiac tamponade, pericardial effusion >10mm, transient ischemic attack/stroke, atrio-esophageal fistula, cardiac arrest or death occurred. Vascular access complications were detected in 7/62 patients (11%), including 4 patients with a need of intervention (surgical n=2, thrombin injection n=2).

Complete PVI was performed in all patients (mean procedure time 129 ± 42min, mean fluoroscopy time 9,09 ± 5.44 min. Radiofrequency (RF) time was 127.27 ± 7,25 min (111,43 ± 27,83 min PVI only, 148,76 ± 46,07 min PVI + substrate ablation).

After a mean follow up of 249 days, freedom of any atrial arrhythmia off antiarrhythmic drugs (AAD) after a single ablation procedure was present in 26/47 patients (55.3%). Success rate was significantly higher in patients with paroxysmal AF (n=16/18; 88%) compared to patients with persistent AF (n=10/29; 34.5%; p< 0.001; Figure 1) Conclusion: In this first study using vHPSD in ACHD patients of variable complexity with paroxysmal or persistent AF, the technique was safe and effective. Major periprocedural complications were rare and limited to vascular access problems. No vHPSD ablation modality-related complications occurred. vHPSD was fast in all patintes regardless of CHD complexity. Results in the paroxysmal CHD group were excellent and encouraging for persistent AF.
New insight in epicardial ablations: 3D-printed additive manufacturing as intra-procedural diagnostic and operative tool
Authors: Monaco C , Pannone L , Della Rocca D G , Talevi G , Cappello I A , Ramark R , Candelari M , Terryn H , Baert K , Laha P , Bori E , Gharaviri A , La Meir M , Innocenti B , De Asmundis C
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The feasibility of additive manufacturings (AMs) as peri-procedural tools has already been established. In order to extend their use to intra-procedural tools for surgical, interventional, or electrophysiology procedures, AMs must be able to convey specific data from cardiac imaging and to come into contact with both biological tissue and energy sources.

Methods

A resin (MED625FLX) and a urethane thermoplastic elastomer (TPU) were chosen as materials for AMs, printed in a variety of thicknesses and configurations. Geometry test was conducted to compare the properties of materials before and after sterilization. In-vitro test was carried out in a wet lab to validate the safety related to propagation of energy underneath the material during application of power sources; three different sources (cryothermal, bipolar radiofrequency, unipolar radiofrequency) were tested. The release of debris derived from the AM on the biological tissue was verified both with electron microscopy and Raman spectroscopy.

Results

Geometries below 1 mm and above 2.5 mm did not pass the test after sterilization for both materials. A total of 100 energy applications were delivered during in-vitro testing. Temperature was kept constant. The type of material used for the AM, the energy-type delivered and the factorial combination of distance/material and distance/energy-type had a significant p-value for temperature changes on the tissue underneath the AM (Temperature*Material p=0,003; Temperature*Energy p<0,001; Temperature*Material*Position p=0,02; Temperature*Position*Energy p<0,001). Post-hoc test using Dunn's procedure showed significant p-values for distance (Temperature*Position p<.001) and energy-type erogated (Temperature*Energy*Cryo-biRF p<.001; Temperature*Energy*Cryo-uniRF p<.001; Temperature*Energy*biRF-uniRF p<.001), while there were no significant differences of temperature in relation to AM thickness and material. Raman spectroscopy on biological tissues revealed that no AM particles >1μm were released.

Conclusions

The use of AMs in intra-operative cardiac procedures may be feasible and safe, and it can be employed as a reliable integration of cardiological imaging into tangible localisation of certain specific structures or pathological substrates.
Determinants of left atrial local impedance: relationships with contact force, atrial fibrosis and rhythm
Authors: Bates A , Paisey J R , Yue A , Banks P , Roberts P R , Ullah W
Published: May 2023

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Boston Scientific

Background

The relationships between baseline tissue local impedance (LI), contact force (CF), atrial fibrosis and atrial rhythm are uninvestigated in a clinical setting.

Objectives

To compare the relationship of LI and CF between atrial fibrillation (AF) and sinus rhythm (SR). Establish the effects of atrial fibrosis as assessed by bipolar voltage and LI.

Methods

Patients undergoing persistent AF ablation were recruited. The ablation catheter was placed against the left atrial wall and CF levels varied from 1-40g. LI was recorded concurrent to changes in CF at these locations, with data collected at the same locations in AF and SR following DC cardioversion. LI values were referenced to patient blood pool, (LIr).

Results

20 patients were recruited. 109 locations were sampled obtaining 1903 datapoints (SR: 966, AF: 937). CF correlated strongly with LI (repeated measures correlation = 0.64). The relationship between CF and LIr was logarithmic. Rhythm and CF had a significant main (both p < 0.0005) and interaction effect (p = 0.022) on tissue LI: AF demonstrated higher LIr values than SR for similar CF (Figure 1). Furthermore, AF modelled a more predictable relationship between CF and LI than SR (R2 = 0.21 vs 0.13).

Bipolar voltage had no effect on the relationship of CF to LIr in either rhythm when using conventional cut-offs to determine scar (0.05mV and 0.5mV). Cut-offs for assessing scar using LIr used values of 0.5Ω and 10.5Ω based on concurrent work. Through assessing fibrosis using these values, LIr showed an interaction effect with CF for LIr in SR and AF, (SR: p <0.0005, AF: p = 0.01), with more fibrosis demonstrating shallower CF-LIr curves than healthier tissue, (Figure 2).

Conclusions

CF and rhythm significantly affect the measured LIr of LA myocardium. Optimal catheter-tissue coupling may be better achieved with higher levels of CF and in AF rather than SR. Atrial fibrosis as assessed by bipolar voltage did not affect the CF-LI relationship, but was when assessed by LIr.
Cardioneuroablation for the treatment of vasovagal syncope, functional sinus node dysfunction and functional atrioventricular block: initial experience in one center
Authors: Minguito Carazo C , Rodriguez Manero M , Martinez Sande J L , Garcia Seara J , Gonzalez Melchor L , Fernandez Lopez X A , Gonzalez Ferrero T , Gonzalez Juanatey J R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background and purpose

Cardioneuroablation (CNA) or ablation of the ganglionated plexi (GP) is an emergent procedure that has been used in the treatment of vasovagal syncope (VVS), functional sinus node dysfunction (SND) and functional atrioventricular block (AVB). The aim of the present study was to describe our initial experience with this technique.

Methods

Prospective, unicentric, observational study of consecutive patients which were referred to our institution for VVS, functional SND or functional AVB. Prior the procedure, all the patients underwent atropine test.

Results

A total of 19 patients were included in the study (51.5 ± 12.7 years, 68.4% males). 15 patients (78.9%) had prior syncope with a median of 1.6 ± 3.8 episodes per month. 8 patients (42.1%) underwent the procedure due to recurrent VVS, 6 patients (31.6%) due to SND and 5 patients (26.3%) due to AVB. Prior the procedure there was an increase of 39 ± 8% of the heart rate (HR) with the atropine test. Extracardiac vagal stimulation, was attempted in 11 patients (59.7%) and from them, only 63.6% had vagal responses. We used an anatomic approach in 79% of the patients. The right superior GP was ablated with a bi-atrial approach in 100% of the patients. At the end of the procedure all the patients had a negative atropine test with an increase in the HR significantly lower than prior the procedure (39 ± 8% vs 5 ± 5%; p=0.002). After a median follow-up of 8.5 (3.9-17.7) months, freedom from syncope was 93.3% and the incidence decrease from 1.6 ± 3.8 to 0.02 ± 0.11 episodes per month. Freedom from pacemaker implantation was 88.8%. There was a significant reduction in the patients who experience presyncope after the procedure (94.7% vs 21.1%; p=0.002) (Figure 1). No complications were observed related to the procedure.

Conclusions

In our initial experience CNA could be a reasonable option for young patients with recurrent VVS, and functional SND or AVB, which could even be an alternative to pacemaker implantation. However more prospective and randomized studies are needed to support these conclusions.
Cardiac Troponin I kinetic after pulmonary vein isolation for atrial fibrillation ablation with pulsed-field ablation and cryo-energy
Authors: Majocchi B , Moltrasio M , Fassini G , Tundo F , Riva S , Vettor G , Sicuso R , Bianchini L , Malacrida M , Tondo C
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Previous studies have demonstrated that cardiac biomarkers elevate after both cryoballoon (CB) and radiofrequency atrial fibrillation (AF) ablation, depending on the amount of energy delivered and the site of ablation. To date no comparison has been made between these thermal energy source and a novel non-thermal pulsed-field ablation (PFA) technology based on cells electroporation.

Purpose

Our analysis aims to compare acute myocardial injury through cardiac troponin I variation after pulmonary vein isolation (PVI) performed with different technologies (PFA vs CB).

Methods

All consecutive patients undergoing paroxysmal AF ablation with CB and PFA at our center from July to November 2022 were included. Protocol-directed cryoablation (CBA) was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. A standard PFA protocol-directed PVI was applied using 2kV with eight applications per vein (four applications each in the basket and flower poses). The ablation endpoint was PVI as assessed by entrance and exit block. Pre- and post-procedure samples of cardiac troponin I (CTpI) were collected before CBA/PFA and at 24h after ablation. Only patients with normal baseline values for myocardial injury were included.

Results

A total of 71 patients met inclusion criteria and were included in this analysis. The CBA group consists of 50 (70%) patients and the PFA group comprises 21 (30%) patients. The number of CBA applications to reach PVI was 5.0±1.4 and the number of PFA applications to achieve PVI was 32±4. All (100%) patients were in sinus rhythm at the time of the procedure. Evaluating the kinetic of CTpI, baseline values were homogeneous between CBA and PFA groups (p=0.979) whereas CTpI values significantly rose from baseline (7±2 ng/L) to 24h (8979±3691 ng/L, p<0.0001) and were significantly different between groups after CBA/PFA (8148±3311 ng/L for CBA vs 11900±7143 ng/L for PFA, p=0.0056). PVI was achieved in all patients (100%) using only CB or PFA. No major procedure-related adverse events were reported.

Conclusion

Our preliminary results showed that cardiac troponin I enzyme level increased after PVI by means of both cryoballoon and pulsed-field ablation and were higher after cellular electroporation by PFA than cryoablation.
Preinterventional quantification of dense scar or borderline zone in patients undergoing ventricular tachycardia ablation
Authors: Oebel S R , Jahnke C , Paetsch I , Dagres N , Hindricks G , Dinov B , Arya A , Ter Bekke R , Vernooy K , Darma A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

This study sought to examine the prognostic role of quantifying areas of interest in preinterventional cardiac magnetic resonance (CMR) in patients with structural heart disease (SHD) referred for ablation of ventricular tachycardia (VT).

Background

The role of preinterventional CMR for the identification of scar areas, borderline zones and reentry channels in the ventricles has been well established. Whether the burden of dense scar or borderline tissue has a prognostic impact on the acute and the long-term ablation outcome in SHD patients is disputed.

Methods and results

We investigated 185 patients with SHD undergoing preinterventional CMR prior to VT-ablation. 38 patients were excluded because of poor imaging quality, leaving a cohort of 147 patients with positive late enhancement (LGE) imaging (mean age 62 years, 47% non-ischemic cardiomyopathy, mean left ventricle ejection fraction 38%, 96% with implanted ICD). The cohort was divided in ischemic (ICM) and non-ischemic (NICM) cardiomyopathy group and the results regarding burden of overall scar tissue, dense scar, borderline zone, as well as clinical and procedural characteristics, acute and long-term results of the two groups were compared. The ICM patients had more advanced NYHA stadium (p = 0.046), reduced left ventricular ejection fraction (LV-EF, p <0.001) and higher left ventricular enddiastolic volume (LVEDV, p <0.001). The NICM patients were more often under antiarrhythmic therapy (p = 0.005) and underwent more frequently epicardial ablation (p <0.001). Although the overall scar burden war higher in ICM patients (p <0.001), the groups showed no significant difference in borderline zone burden (p = 0.580). Furthermore, the two groups had similar results in number of inducible VTs (p = 0.054) and VT inducibility at the end of the procedure (p = 0.121). Nevertheless, the NICM group underwent overall more ablation procedures during the 19-month follow up (p = 0.023). Both groups showed similar results regarding assist device implantation, heart transplantation or death until the end of the follow up (p = 0.192).

Conclusion

While quantification of the scar tissue and the borderline zone is feasible in ICD patients with SHD, the scar or the borderline zone burden were not predictive of the VT ablation outcome.
Beat-to-beat variation of P-wave morphology immediately after ablation of persistent atrial fibrillation correlates with long-term clinical outcome
Authors: Luca A , Coudray E , Vesin J M , Le Bloa M , Teres C , Herrera C , Roten L , Kuehne M , Spies F , Knecht S , Sticherling C , Pascale P , Pruvot E
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

P-wave morphology on surface ECG reflects the atrial electrical remodelling, and is regarded as a predictor of ablation outcome for atrial fibrillation (AF).

Purpose

We sought to investigate whether morphological characteristics of P-waves immediately after a wide circumferential isolation of pulmonary veins (WPVI) in persistent AF (peAF) correlate with long-term maintenance of sinus rhythm (SR).

Methods

33 patients (63±10 y, sustained AF 11±7 months) underwent a de-novo WPVI. A second WPVI was performed in patients with recurrent AF in order to provide complete PV disconnection. We defined "success" as patients who remained in SR after one or two procedures, and "failure" otherwise. The average duration and amplitude of the P-waves, and the coefficient of variation (CoV = standard deviation/mean) of the beat-to-beat similarity between ≥30 successive P-waves per patient were computed on ECG lead II during SR after cardioversion. Panel A shows a group of successive P-waves synchronized with regard to their centers of gravity. The similarity between the shapes of two successive synchronized P-waves was assessed using the dynamic time warping distance. Panel B shows the time-evolution of beat-to-beat distance between the P-waves displayed in Panel A.

Results

Over a mean follow-up of 31±9 months, 21 patients remained free from AF off antiarrhythmics (success group), while 12 patients had AF recurrence after 2 WPVIs (failure group). The clinical characteristics (e.g. age, body mass index, left atrial volume or duration in sustained AF) were similar between groups (p>0.05). The success group displayed significantly lower beat-to-beat variability of P-wave morphology than that of the failure group (p<0.05, Panel C). No significant difference was found in P-wave duration and amplitude between the two groups (p>0.05, Panel D and E).

Conclusion

Low P-wave beat-to-beat morphological variability immediately after WPVI for persistent AF is associated with long-term maintenance of sinus rhythm.
Prevalence and characteristics of arrhythmias during the pregnancy
Authors: Uzakova M , Babajanova G S , Uzokov J K
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmias in pregnancy has been increasing due to the aging of the pregnant women and psychosocial and economic conditions in developing countries. Some of them are benign and do not require special treatment while others will be needed treatment in order to improve subjective feelings. Aim of the study was to evaluate the prevalence and characteristics of cardiac arrhythmias in pregnant women with hypertension and without other cardiac structural pathologies.

Material and Methods

110 pregnant women with hypertension were analyzed during 2018-2021 years. Mean age of the pregnant women were 28.65±11.45 years. Electrocardiogram, echocardiography and if necessary 24 hour Holter monitoring was recorded and analyzed along with other clinical and instrumental data. All statistical analysis were performed using STATA software.

Results

The most frequent type of heart rhythm disorder was supraventricular arrhythmia 34%, followed by premature contractures (24%) and paroxysmal atrial fibrillation (12%). 24% of supraventricular tachycardia was detected in the first trimester, 35% in second trimester and 41% in the last trimester. Among premature contractures only 26% was detected in the first trimester. 29% of premature contractures was detected in the second and 44% in the third trimester of the pregnancy. Regarding the atrial fibrillation, it was detected in 6 (46%) pregnant women in the first trimester, 4 (31%) in the second trimester and 3 (23%) in the third trimester. Pregnant women with supraventricular arrhythmias tended to have higher level of diastolic blood pressure than those without it (88.12±8.2 mmHG vs. 84.25±9.3 mmHg, P=0.034). Pregnant women with premature contractures tended to have higher level of systolic blood pressure than those without it (132.3±11.4 vs. 126.34±12.65 mmHg, P=0.031). Atrial fibrillation was not associated with blood pressure levels.

Conclusion

Supraventricular arrhythmias and premature contractures are common in the third trimester of the pregnancy. High systolic blood pressure is associated with premature contractures whilst high diastolic blood pressure with supraventricular arrhythmias.
Cyclic-di-AMP signalling in lactic acid bacteria
Authors: Turner Mark S , Xiang Yuwei , Liang Zhao-Xun , Marcellin Esteban , Pham Huong Thi
Published: May 2023

Cyclic dimeric adenosine monophosphate (cyclic-di-AMP) is a nucleotide second messenger present in Gram-positive bacteria, Gram-negative bacteria and some Archaea. The intracellular concentration of cyclic-di-AMP is adjusted in response to environmental and cellular cues, primarily through the activities of synthesis and degradation enzymes. It performs its role by binding to protein and riboswitch receptors, many of which contribute to osmoregulation. Imbalances in cyclic-di-AMP can lead to pleiotropic phenotypes, affecting aspects such as growth, biofilm formation, virulence, and resistance to osmotic, acid, and antibiotic stressors. This review focuses on cyclic-di-AMP signalling in lactic acid bacteria (LAB) incorporating recent experimental discoveries and presenting a genomic analysis of signalling components from a variety of LAB, including those found in food, and commensal, probiotic, and pathogenic species. All LAB possess enzymes for the synthesis and degradation of cyclic-di-AMP, but are highly variable with regards to the receptors they possess. Studies in Lactococcus and Streptococcus have revealed a conserved function for cyclic-di-AMP in inhibiting the transport of potassium and glycine betaine, either through direct binding to transporters or to a transcriptional regulator. Structural analysis of several cyclic-di-AMP receptors from LAB has also provided insights into how this nucleotide exerts its influence.