bluuebunny/crossref_metadata_2025 huggingface dataset:
Left atrium substrate and wave speed mapping using Omnipolar technology in patients undergoing paroxysmal atrial fibrillation catheter ablation
Authors: Casella M , Compagnucci P , Conti S , Cipolletta L , Parisi Q , Majocchi B , Quinto L , Bulian F , Volpato G , Valeri Y , Mantovan R , China P , Sgarito G , Tondo C , Dello Russo A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The new Ensite X Cardiac Mapping (Abbott) system, with the introduction of Omnipolar technology (OT), provides three-dimensional information on voltage, direction of activation and conduction velocity of endocardial potentials, regardless of catheter orientation. OT thus enables the creation of more defined voltage maps and a wave speed map, a color map encoded by the numerical value of conduction velocity.

Purpose

We aimed to evaluate the feasibility and reliability of left atrium (LA) substrate and wave speed mapsperformed with OT in patients undergoing pulmonary vein isolation of paroxysmal atrial fibrillation (AF).

Methods

We included 39 patients undergoing catheter ablation for paroxysmal AF with the new Ensite X Cardiac Mapping System at five Italian Institution. In all patients the left atrium (LA) was mapped with the Advisor HD Grid catheter (Abbott). A sinus rhythm high-density voltage map and wave speed map were obtained and analyzed to compare low-voltage areas and to identify high conduction velocity areas.

Results

Thirty-nine pts were included in this analysis (61±10 years, 64% male, 68% with paroxysmal AF, CHA2DS2-VASc = 1.6±1.1, left atrial diameter = 46±9 mm, left ventricle ejection fraction 63±4%). The voltage maps were obtained by acquiring and, after point validation, analyzing significantly more points in the OT analysis than in the bipolar analysis (11455±8833 vs 8186±5826 and 2611±1728 vs 1753±1324, respectively; p < 0.001). Low-voltage area (< 0.05 mV) was significantly less extensive using OT (low-voltage OT area 8.9 cm2 [5.8; 24.2] vs low-voltage bipolar area 10.8 [6.4; 31.4]; p < 0.05), Fig 1. Considering wave speed maps, the pulmonary veins showed significantly higher values than the atrial values (LSPV: 2.89 ms/s ± 1.99; LIPV 2.86 ms/s ± 1.78; RSPV 3.31 ms/s ± 2.07; RIPV 2.86 ms/s ± 1.96; LA 1.67 ms/s ± 0.80; p< 0.001) while, in the atrium, the area of greatest speed was located on the roof (2.35 ms/s ± 1.53; p 0.02) almost drawing a bundle from the RSPV to the LA appendage that could coincide with the anatomical Bachmann’s bundle location, Fig 2.

Conclusion

OT makes it possible to obtain voltage maps by analyzing a larger number of points and providing a better substrate definition. Wave speed mapping is a promising new map type, allowing characterization and identification of high velocity areas. Further studies are needed to assess the impact of this new technology on procedural workflow and clinical outcome.
Impact of catheter ablation on atrial fibrillation burden and symptoms in patients with hypertrophic cardiomyopathy
Authors: Ahluwalia N , Honarbakhsh S , Assadi R , Martin S , Monkhouse C , Mohiddin S , Sporton S , Schilling R J , Dhinoja M , Lambiase P , Hunter R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial Fibrillation (AF) is more common in patients with hypertrophic cardiomyopathy (HCM) and is often very symptomatic in this cohort. The impact of catheter ablation (CA) in this context is controversial with low success rates using the guideline mandated end-point of freedom from arrhythmia.

Purpose

To determine whether CA of AF in patients with HCM would be associated with a significant reduction in AF burden and symptoms.

Methods

Patients diagnosed with HCM undergoing CA of AF between February 2017 and June 2021 were identified from a prospective, single-centre registry. Patients with CIED in situ were selected. Patients were followed up for objective evaluation of symptom severity. Interval device interrogation and remote CIED monitoring was used to determine first AF/AT recurrence and percentage AF/AT burden on continuous rhythm monitoring 12-months before and after CA.

Results

Of 257 HCM patients undergoing CA of AF, 33 had CIEDs and were followed up for 32±15 months. The mean age was 56.4±10.2 years and 22 (67%) were male. The maximal wall thickness on echocardiography was 1.7±0.3cm and LA diameter was 4.8±0.9. The left ventricular ejection fraction was 50±15%. 17 (52%) patients had paroxysmal AF and 16 (48%) had persistent AF of which 6 (18%) were longstanding persistent AF. Mean AF burden prior to CA was 36.9±26.5% and 24 (73%) reported EHRA III-IV symptom severity.

AF recurred in 27 (82%) patients with a median time to first recurrence of 8 (3-17) months. AF burden significantly reduced after index AF CA (27% (7,59) to 2% (0, 41)) (Z=-2.2, p= 0.03)) and reduced further when allowing for repeat procedures in 10 (30%) patients to 0% (0-30%). This represented a >50% relative reduction in 22 (67%) patients and >95% relative reduction in 16 (48%) patients.

This correlated with a reduction in symptom score with 20 (60.6%) patients reporting a change of ≥1 EHRA class, and 20 (60.6%) patients reporting EHRA class I-IIa status at 12 months. A positive relationship was seen on regression analysis, with a 16.4% absolute reduction in AF burden associated with a reduction of one EHRA class. (R2= 0.206, F=7.5, p=0.01). Amongst the 24 (72%) patients who had an AF/AT recurrence after the final procedure who would conventionally be called failures by guideline definitions, 11 (45.8%) patients improved by ≥ 1 EHRA class and 11 (45.8%) were class I-IIa.

Conclusion

Although AF recurrence is common after CA in HCM patients, there is a significant reduction in AF burden and symptoms in a majority of patients. A more comprehensive evaluation of AF burden, symptoms, quality of life and impact on hard end-points is needed to determine the utility of CA in this context.
Interim analysis of a prospective randomized comparison of pulsed field ablation vs. radiofrequency ablation for longstanding persistent atrial fibrillation
Authors: Fiala M , Cernosek M , Bulkova V , Lehar F , Funasako M , Bahnik J , Rybka L , Manousek J , Toman O , Kala P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Benefits of pulsed field ablation (PFA) compared to radiofrequency ablation (RFA) are not known in patients with longstanding persistent atrial fibrillation (LSPAF).

Purpose

To present interim procedural and short-term clinical results of an ongoing prospective randomized comparison of PFA vs. RFA in patients with LSPAF.

Methods

In 9/2021-10/2022, 125 patients underwent catheter ablation for LSPAF using PFA (n=64, 69±8 years, 11 F, continuous AF 32±20 months) vs. RFA (n=61, 68±8 years, 17 F, continuous AF 29±23 months). PFA included pulmonary vein isolation (PVI) and extra-PV left atrial (LA) ablation. RFA included stepwise PVI, electrogram-guided LA ablation, CS isolation, and electrogram-guided right atrial ablation. Intermediate endpoints were PVI, mitral isthmus, LA roof and CTI blocks); sinus rhythm (SR) restoration by ablation was the desired procedural endpoint. Follow-up included 7-day ECG monitoring every 3 months during the first year, and every 6 months afterwards.

Results

In groups PFA vs. RFA, procedure and fluoroscopy times were 116±32 vs. 204±44 minutes, and 17±5 vs. 8±2 minutes, respectively (both p<0.001). AF termination (into intermediate AT or directly into SR) and SR restoration by ablation were achieved in 30 (47%) vs. 42 (69%) patients (p=0,19), and in 23 (36%) vs. 35 (57%) patients (p=0,15). Of those 48 vs. 50 patients with follow-up ≥3 months (≥6 months in 37 vs. 39 patients), freedom from any AF/AT (>30 s) was achieved in 38 (79%) vs. 23 (46%) patients.

Conclusion

Interim results of ongoing comparison suggest procedure time reduction and improved AF/AT free survival after PFA as compared to RFA in patients with LSPAF.
Visualizable vs. non-visualizable steerable sheaths for AF procedures: randomized tiral
Authors: Kupo P , Janosa B , Debreceni D , Bocz B , Simor T , Janosi K F
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ÚNKP-22-4 New National Excellence Program of the Ministry for Culture and Innovation from the source of the National Research, Development and Innovation Fund.

Steerable sheaths (SSs) are frequently used to improve catheter stability during atrial fibrillation (AF) procedures. A new type of visualizable (by electroanatomical mapping system) SS has become available in clinical treatment.

Purpose

We aimed to compare procedural and follow up data of visualizable vs. non-visualizable SS assisted pulmonary vein isolation procedures in patients with AF.

Methods

In this single-centre randomized study, we enrolled a total of 100 consecutive patients who underwent PVI due to AF.

Results

100 consecutive patients were enrolled and randomized into 2 groups (visualizable SS group: 50; non-visualizable SS group: 50). With the use of visualizable SS, left atrial (LA) procedure time (53.1 [41.3; 73.1] min vs. 59.5 [47.6; 74.1] min.; p = 0.04), LA fluoroscopy time (0 [0; 0] s vs. 17.5 [5.5; 69.25] s; p < 0.01) and LA fluoroscopy dose (0 [0; 0.27] mGy vs. 0.74 [0.16; 2.34] mGy; p < 0.01) was significantly less, however, there was no difference in the total procedural time (90 ± 35.2 min vs. 99.5 ± 31.8 min; p = 0.13), total fluoroscopy time (184 ± 89 s vs. 193 ± 44 s; p = 0.79), and total fluoroscopy dose (9.12 ± 1.98 mGy vs. 9.97 ± 2.27 mGy; p = 0.76). Compared to standard SS group total ablation time was reduced (1049 sec. [853; 1175] vs. 1265 sec. [1085; 1441]; p < 0.01) using visualizable SS, and the number of radiofrequency ablations was fewer (69 [58; 80] vs. 79 [73; 86); p < 0.01) in this group. There was no difference between the groups regarding acute ablation success (both group 100%) and first pass isolation rate (92% vs. 89%; p = 0.88). No major complications occurred in either group. During the 6 months follow up period there was no difference either in blanking period (visulaizable SS: 3/50, standard SS: 4/50; p=0.70) or at 6 months after the ablation (visulaizable SS: 3/50, standard SS: 5/50; p=0.46).

Conclusion

Visualizable SS significantly can reduce the left atrial procedure time, total ablation time and fluoroscopy exposure without compromising its safety or mid-term success in patients undergoing PVI procedures for AF.
Statin use improves the outcomes in patients with atrial fibrillation: A population-based study
Authors: Huang J , Wu M Z , Ren Q W , Tse H F , Lip G Y H , Yiu K H Y
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Sanmin project, Shenzhen, China

Background

There is inconclusive evidence regarding the impact of statins on the risk of atrial fibrillation (AF) related outcomes. The current study investigated whether statin use would improve outcomes among patients with non-valvular AF.

Purpose

To assess the association between statin use and AF-related outcomes among patients with AF.

Methods

Patients newly diagnosed with AF (n = 51,472) between 2010-2018 were divided into statin users (n =11,866) and statin nonusers (n =39,606), according to whether they received statin therapy after their first diagnosis of AF. The primary outcomes included ischaemic stroke (IS) and systemic embolism (SE), haemorrhagic stroke (HS), and transient ischaemic attack (TIA). An inverse probability of treatment weighting was used to balance baseline covariates between the two groups. The Fine and Grey competing risks model was applied, with death defined as the competing event.

Results

The median age of the cohort was 74.9 years, and 47.7% were female. During the median follow-up of 5.1 years, previous statin use was significantly associated with a lower risk of IS/SE compared with statin nonusers (subdistribution hazard ratio [SHR] = 0.83, 95%CI: 0.78-0.89). Similar patterns were found in the association between previous statin use and HS (SHR = 0.93, 95%CI: 0.89-0.98) and TIA (SHR = 0.85, 95%CI: 0.80-0.90, P <0.01). Moreover, ≥6 years of statin use predicted a lower risk of IS/SE, HS and TIA (IS/SE: SHR = 0.57, 95%CI: 0.54-0.61; HS: SHR = 0.56, 95%CI: 0.53-0.60; TIA: SHR = 0.58, 95%CI: 0.52-0.64) compared to those with short-term (3 months to <2 years) statin use. Stratified analyses demonstrated that the lower risk of IS associated with statin use was consistent.

Conclusion

Statin use was associated with a lower risk of incident IS/SE, HS and TIA in a duration-dependent manner among AF patients.
How good is time-in-therapeutic-range defined warfarin treatment compared to standard dose direct oral anticoagulants? Incidence of stroke in atrial fibrillation in a nationwide registry study
Authors: Lehto M , Luojus A , Halminen O , Haukka J , Aro A L , Putaala J , Linna M , Mustonen P , Kinnunen J , Niemi M , Hartikainen J , Airaksinen K E J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): The Finnish Foundation for Cardiovascular Research, and Helsinki and Uusimaa Hospital District research fund.

Background and aims

Direct oral anticoagulants (DOACs) have largely replaced warfarin in patients with atrial fibrillation (AF) to reduce risk of stroke. However, it is not known whether DOACs are more efficacious in preventing stroke or safer than good-quality warfarin treatment with high time in therapeutic range (TTR).

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a nationwide study of AF patients that combines data from several Finnish health care registers. We analyzed all new-onset AF patients in Finland from January 2011 to December 2018 with laboratory data available.

Comorbidities, concomitant medications and CHA2DS2-VASc -scores were recorded until date of AF diagnosis. OAC purchases from diagnosis of AF to the end of study were analyzed. ICD-10 diagnoses for stroke (ischemic or hemorrhagic) or transient ischemic attack during OAC use were analyzed until maximum follow-up of 730 days. Confounding factors by baseline characteristics as well as medications were taken in account by use of an inverse probability of treatment weighted analysis.

For warfarin users, time in therapeutic range (TTR) was calculated and patient quartiles by TTR were assigned. Rate of stroke in different TTR quartiles for warfarin users were compared to standard dose dabigatran (150 mg bd.), apixaban (5mg bd.) and rivaroxaban (20mg od.).

Results

Altogether, 74 008 new-onset AF patients with OAC therapy (50.4 % male, mean age 73.0 years, 43 549 on warfarin, with mean TTR 66% and median TTR 72%) were followed for 109 143 patient years (py). Rate of stroke among patients with standard dose direct oral anticoagulants was 6.0/100 py for dabigatran (n=4545), 6.2/100 py for apixaban (n=12 426) and 4.0/100 py for rivaroxaban (n=12 950). In the TTR quartiles of patients on warfarin, rates of stroke were 9.3, 7.2, 5.5 and 4.3/100 py from the lowest (mean TTR 32%) to the highest quartile (mean TTR 90%), respectively.

The weighted rates of stroke were 6.3, 6.1 and 4.5/100 py for dabigatran, apixaban and rivaroxaban, respectively, and for warfarin from the lowest to the highest quartile: 8.8, 7.0, 5.5 and 4.2/100 py, respectively. The Figure provides survival probabilities (crude rates) of stroke with confidence intervals of the analysed OAC groups.

Conclusion

Rates of stroke were evidently the highest among patients on warfarin in the two lowest TTR quartiles, while the differences between high TTR groups and standard dose DOACs were only modest.
3D intracardiac echocardiography for left atrial appendage sizing and percutaneous occlusion guidance
Authors: Della Rocca D , Magnocavallo M , Gianni C , Mohanty S , Vetta G , Lavalle C , Santangeli P , De Asmundis C , Chierchia G B , Burkhardt J D , Di Biase L , Lakkireddy D J , Al-Ahmad A , Horton R P , Natale A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time.

Purpose

To report procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing.

Methods

Among 274 patients undergoing LAAO, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel 3D-ICE one (54 patients; Fig.1).

Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks≥3mm at follow-up TEE.

Results

3D-ICE measurements of maximum landing zone correlated highly with preprocedural TEE reference values [Pearson’s: 0.94; p<0.001; bias: -0.06 (-2.39, 2.27)] (Fig.2).

The agreement between 3D-ICE-based device selection and final device size was 96.3% versus 79.1% with 2D-ICE (p=0.005).

The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (p=0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs 44.5%; p=0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients versus 45.9% of 2D-ICE ones (p=0.065).

Conclusions

ICE-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for device size selection and may provide better guidance during device deployment.
Size matters - body size and acute device-implantation failure after LAAC
Authors: Zweiker D , Sieghartsleitner R , Toth G , Stix G , Vock P , Schratter A , Fiedler L , Martinek M , Steinwender C , Binder R K , Adukauskaide A , Ablasser K , Verheyen N , Zirlik A , Scherr D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patient-device mismatch in patients undergoing left atrial appendage closure (LAAC) may lead to failure to implant, dislocation, and cardiac tamponade. There is limited data about patient cohorts that are especially susceptible to these complications.

Objective

To analyse the association between body height, weight and acute complications due to probable device mismatch.

Methods

A retrospective analysis from a multicentre registry including consecutive patients undergoing LAAC was performed. Device related complications were defined as dislocation, failure to implant or cardiac tamponade requiring intervention.

Results

A total of 431 patients from 9 centres were included. Median age was 75 (interquartile range, IQR 70-79) years and 35.7% were female. Mean±SD body height was 171.3±8.8 cm and median weight was 80 (IQR 70-90) kg. Median CHADS-VASc score was 5 (IQR 3-5) and HAS-BLED score was 3 (IQR 3-4). Indications were bleeding (66.6%), stroke (9.7%) and other (23.6%). Acute device-related complications after LAAC occurred in 5.6% of cases (24/431): Failure to implant (3.0%), cardiac tamponade (2.1%), and dislocation (0.7%). Complications occurred significantly more often in the tercile with lowest body weight and highest body height (23.5% vs. 4.3%, p=0.01, Figure).

Conclusion

Acute device-related complications as sign of patient-device mismatch are most pronounced in patients with lowest body weight and highest body height.
Platelet count as a predictor of thrombotic events following left atrial appendage occlusion: the proof is in the platelet?
Authors: Aarnink E , Della Rocca D G , Cepas-Guillen P L , Benito-Gonzalez T , Polzin A , Branca L , Spoon D , Freixa X , Boersma L V A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Patients undergoing left atrial appendage occlusion (LAAO) often are at increased risk for bleeding or thromboembolic events, but no specific risk score for these events in patients after LAAO exists. Concurrently, biomarkers are of growing importance in risk stratification for AF-patients. Therefore, hemostatic biomarkers may have added value in predicting what patients are prone to develop thrombotic and bleeding events and aid in personalizing antithrombotic treatment strategy following LAAO.

Methods

Six implanting centers retrospectively gathered data on pre-procedural hemostasis markers (i.e. platelet count (PLC), mean platelet volume (MPV), and fibrinogen). Prespecified composite endpoints on thrombotic events (i.e. stroke, transient ischemic attack, systemic embolism and device-related thrombus) and bleeding (major, minor and intracranial hemorrhage) were collected.

Results

In total, 1315 patients were included (74±9 years, 64% male, 72% Watchman 2.5/FLX, 25% Amplatzer Cardiac Plug/AMULET, 4% other device). Patients were at increased risk for thrombotic and bleeding events with a CHA2DS2-VASc score of 4.3±1.5 and a HAS-BLED score of 3.3±1.1. Baseline data on PLC, MPV, and fibrinogen was available in 92%, 50%, and 21%, respectively. Over a total follow-up duration of 2682 patient years, 111 thrombotic events and 140 bleeding events occurred. Univariate Cox regression analysis showed increased thrombotic risk in patient with higher PLC (HR 1.16 [1.03-1.31] per 50*109 increment), while no statistically significant association with MPV was found (Table 1). Fibrinogen tended to be higher both in patients developing a thrombotic event (HR 1.30 [0.94-1.78] per fL increment) and bleeding event (HR 1.23 [0.98-1.54]). No association of MPV or PLC with bleeding was observed. An optimal PLC cut-off point of 200*109 was identified that was able to decently discriminate between patients developing a thrombotic event and those who did not (Figure 1).

Conclusion

PLC may be of added value in thrombotic risk stratification following LAAO. Validation of this biomarker by prospective studies and within multivariate prediction models is warranted.
Outcomes of ischemic stroke in patients with atrial fibrillation
Authors: Marrese A , Meola M , Fonderico C , Salucci A , Comparone G , Pergola V , Faccenda D , Addeo L , Cocchiara L , Ammirati G , Rapacciuolo A , Strisciuglio T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with atrial fibrillation (AF) have higher risk of ischemic stroke.

Purpose

We investigated whether AF patients experiencing an ischemic stroke have worse outcomes.

Methods

AF patients admitted to the stroke unit from 2018 to 2021 were included. The NIHSS and the modified Rankin Scale (mRS) score were calculated at the admission and at discharge. The neurological improvement was calculated as delta NIHSS (NIHSS at admission - NIHSS at discharge =Δdis).

Results

Six-hundred patients (45% men), mean age 69±13 years. Of these 75 had previous history of atrial fibrillation (AF) and 86 had AF during the hospitalization (46 both). Overall 115 had one of the two. Patients with AF had higher NIHSSad (14.5±7 vs 9.6±7; p<0.001) and NIHSS24 (10.4±8 vs 7.2±7; p<0.001) than patients without, however the neurological improvement was greater (Δdis -8.4±8 vs -5.1±6; p=0.004), indeed the NIHSSdis was similar (5.6±7 vs 4.1±6; p=0.1). Patients with AF also had a more impaired mRS before the ischemic event and at discharge (1.34±1.3 vs 0.58±1.1, p<0.001; 2.6±1.7 vs 1.8±1.9, p=0.005). Amongst AF patients with CHADVASC³2 in men and ³3 in women, 36% of them were taking antiplatelet therapy, 35% anticoagulants and 29% didn’t take any therapy. Of interest, no differences in the NIHSSad nor in the NIHSSdis were found between them and neither in the Δdis. As for the treatment of AF patients, patients who underwent to mechanical thrombectomy (MT) had higher NIHSSad (17± 5) compared to patients receiving intravenous thrombolysis (IV) or nothing (11± 7 and 12± 8) (p<0.001). The NIHSSdis was similar between the three groups however the Δdis was significantly higher in patients treated with mechanical thrombectomy (-12.5±6 vs 3.6±4; vs 3.1±8; p=0.003 and p<0.001 respectively).

Conclusions

Patients with AF experience more severe stroke, however the neurological recovery is greater than in patients without the arrhythmia. The treatment with antiplatelets or anticoagulants before the event does not reduce the severity of the stroke and does not influence the improvement of the NIHSS at discharge. The mechanical thrombectomy is more effective in reducing the neurological impairment.
Catheter ablation of left atrial tachyarrhythmia: predictors of recurrence after catheter ablation
Authors: Marazzato J , Zhang X , Lin A , Varrias D , Nagraj S , Saouma S , Chowdhuri N , Chaudhary A , Velasco De La Cuesta A , Della Rocca D G , Santangeli P , Lakkireddy D , Natale A , Zou F , Di Biase L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Differently from catheter ablation (CA) of atrial fibrillation (AF), outcome data on CA of atrial re-entrant arrhythmias are scarce.

Purpose

We sought to evaluate predictors of recurrence at follow up in this setting.

Methods

We analysed consecutive patients undergoing mapping and CA left atrial tachyarrhythmia. Three-dimensional high-density activation and voltage maps were created for each investigated tachycardia by means of CARTO® system. Left atrial (LA) size was measured as the anteroposterior diameter on parasternal long axis view on transthoracic echocardiogram. Severe LA enlargement was defined for LA diameter >47 mm in women and >52 mm in men in accordance with guidelines.

Results

Eighty-eight patients were considered (67 ± 9 years old, 45% males) undergoing 94 CA procedures (1.1 ± 0.3 per patient). Most patient had past medical history of pulmonary vein isolation (57%). In the investigated population, 120 tachycardia morphologies were mapped and ablated. Acute procedural success was achieved in 97% of cases without any major complication. After a mean follow-up of 17 ± 11 months, the overall freedom from atrial arrhythmia was 58% and 65% after single and repeat procedures, respectively. Severe LA enlargement was the only variable associated with arrhythmia recurrence at follow-up and it was consistent after single and repeat procedures (Figure 1 A-B).

Conclusion

CA of complex left atrial tachyarrhythmia is safe and effective, and the mid- and long-term outcome is improved when LA is not severely enlarged. CA of should therefore be considered early in this patient population to achieve better clinical outcome.
Identification of cavotricuspid isthmus conduction block, pitfall of differential pacing maneuver
Authors: Park S , Kim S H , Seung J H , Kim S H , Kim H J , Choi Y , Hwang Y M , Kim T S , Kim J H , Jang S W , Oh Y S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Differential pacing (DP) maneuver was generally used to assess bidirectional block of cavotricuspid isthmus (CTI) after catheter ablation.

Purpose

The purpose of the study is to identify limitation of DP maneuver and suggest continuous sequence (CS) maneuver as a complement of differential pacing.

Methods

Patients who were diagnosed to typical atrial flutter and underwent catheter ablation were enrolled. CTI conduction block was evaluated by two maneuver, DP and CS maneuver. We tried to identify CTI conduction block for each patient with both maneuvers. With CS maneuver, CTI conduction block was assessed with the recorded sequence of diagnostic catheter.

Results

Sixty two patients were investigated. Two maneuvers were performed in all patients. There were 8 cases (8/62, 12.9%) of discrepancy between the result of CS and DP maneuver. One of discrepancy cases, CTI conduction block was identified with CS maneuver, but insufficient conduction block with DP maneuver. The rest of discrepancy (11.2%) cases were the opposite.

Conclusion

DP could not guarantee bidirectional block of CTI because of anatomical complexity and catheter instability. CS maneuver found incomplete block over 10% of conventional maneuver. CS maneuver is simple and can be complement to overcome limitation of DP maneuver.
Are reentrant atrial tachycardias sensitive to adenosine administration?
Authors: Guido Lopez L E , Martinez Cossiani M , Merino D , Martinez Maldonado M E , Castrejon Castrejon S , Jauregui Abularach M , Escobar Cervantes C , Carton Sanchez A J , Ugueto Rodrigo C , Cobarro Galvez L , Contreras Lorenzo C , Severo Sanchez A , Rivero Santana B , Juarez Olmos V , Merino Llorens J L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Adenosine (ADN) infusion may terminate focal atrial tachycardia (AT). However, the effect of ADN on reentrant atrial tachycardia (RAT) is unclear and based on case reports and small series. These latter included mostly patients with cavotricuspid isthmus-dependent atrial flutter and provided conflicting results, with RAT termination found when it involved the septal or the tricuspid/mitral valve regions.

Purpose

The aim of this study was to test the response (termination, transient suppression or no effect) to ADN infusion on RATs and to evaluate differences according to the AT location.

Methods

The effect of ADN was prospectively studied at the time of catheter ablation in consecutive patients with AT. Only patients with RAT were included. This latter mechanism was established by activation and entrainment mapping and confirmed by catheter ablation. A 10 mg adenosine 5'-triphosphate (ATP) bolus was administered in all to evaluate the effects on AT cycle length and termination. Additional ATP bolus of 20 or 30 mg was administered if no AV block for at least 2 secs was obtained with the former ones.

Results

58 patients (67, ±13 years old; 11 female) with 79 RAT were included. 38 RATs were right sided (34 cavotricuspid isthmus-depend atrial flutters, 1 lateral right atrium reentry, 1 upper loop reentry, 1 superior vena cava reentry, and 1 septal reentry around the coronary sinus) and 41 were left sided (21 perimitral reentry, 16 peripulmonary vein reentry and 4 with a small free wall reentry). No RAT was terminated or had a >20 ms cycle length prolongation following ADN administration. There was no transformation of the RAT into other mechanisms of AT or atrial fibrillation by ADN in any case. There were no complications.

Conclusion

RATs are insensitive to ADN infusion, with neither termination nor cycle length prolongation.
Electroanatomical mapping-system guided vs. intracardiac echocardiography-guided slow pathway ablation: a randomized, single-center trial
Authors: Bocz B , Debreceni D , Janosi K , Simor T , Kupo P
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. Procedural outcomes may improve by using electroanatomical mapping systems (EAM), and/or intracardiac echocardiography (ICE).

Purpose

Our aim was to compare EAM-guided vs. ICE-guided approach for SP ablation in patients with AVNRT.

Methods

In our single-center study, 65 patients underwent SP ablation due to AVNRT were randomized to ICE-guided or EAM-guided groups. Procedural outcomes (total procedure time, puncture-to-mapping time, mapping-to-last ablation time), fluoroscopy parameters (total fluoroscopy time, radiation dose) and ablation data (number of RF applications, total ablation time) were analyzed.

Results

ICE guidance reduced puncture-to-mapping time (39.6±7.6 min vs. 32.7±8.2 min; p< 0.001) and total procedure time (68.5 (62.8; 75.3) min vs. 59.5 (56;64) min; p< 0.001). Total fluoroscopy time was shorter (0 (0;0) sec vs. 79 (61; 121.5) sec; p< 0.001), and radiation dose was lower (0 (0;0) mGy vs. 3.1 (2.2; 4.5) mGy; p< 0,001) with the use of EAM. No significant difference was detected regarding mapping-to-last ablation time (6 (2.5;17,0) min vs. 3 (2; 8.3) min; p= 0.13), the number of RF applications (5 (3; 7) vs. 3.5 (3; 5.5); p= 0.30), and total ablation energy (3625 (2513; 5402) J vs. 2676 (1912.5; 5291.5) J; p= 0.10), however total ablation time was shorter in the ICE-guided group (127.5 (86.8; 181) sec. vs. 98.5 (81; 193.5) sec; p= 0.04). No complication occurred. Acute success rate was 100% and there was no recurrence during the follow up.

Conclusions

In our randomized trial enrolled 65 patients underwent SP ablation due to AVNRT, EAM-guided approach reduced fluoroscopy time and fluoroscopy dose, however total procedural, puncture-to-mapping time, as well as total ablation time was longer compared to the ICE-guided group.
A focus on pregnancy course and outcomes in women with complete atrioventricular block: a single center experience
Authors: Abdrakhmanov A , Ainabekova B , Nuralinov O , Smagulova A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

arrhythmias are the most common cardiac complication in pregnant. However, data on pregnancy course and outcomes of women with bradyarrhythmias is limited.

Purpose

we aimed to determine pregnancy course and both maternal and fetal outcomes in women with complete atrioventricular block.

Methods

Out of the 122 pregnant with arrhythmias within the study period of January 2015 to December 2021, 11 patients with complete atrioventricular block were included in this prospective study (study group). All pregnant were without structural pathology of the heart. Clinical signs, treatment as well as outcome data were recorded. Results were compared with the control group (other types of arrhythmias).

Results

The median age was 25.8 (inter-quartile range 3.1) years, the median gestation age was 18.3 (inter-quartile range 2.8) weeks. Unpaced pre-existing congenital heart block were in three cases (27.3%). In eight women atrioventricular block diagnosed for the first time during gestation (72.7%). All patients in study group had varying symptoms of arrhythmia like dizziness, presyncope and syncope. Course of gestation characterized with increased incidences of uterine contractile activity in women with complete atrioventricular block (27.3% vs 2.1%, p<0,001). Implantation of pacemaker was performed in all cases of complete atrioventricular block in pregnant patient. Implantation procedure carried with minimal fluoroscopy with echocardiographic guidance and EnSite NavX mapping system. There were no any procedure related complication and termination of pregnancy. Uterine blood flow violation was numerically lower in study group, although statistically differences not found. In the majority of cases were vaginal delivery at 39,4±1,8 weeks of gestation in both groups (82% vs 85%, p=0.548). All infants were live-born and without malformation. Incidences of placental abruption and preeclampsia were significantly higher in women with complete atrioventricular block (18.2% vs 2.13%, p<0,001). There were no maternal and fetal mortality in both group.

Conclusions

Complete atrioventricular block is rare in pregnant. Despite increased incidence of uterine contractile activity, placental abruption and preeclampsia in women with complete atrioventricular block, neonatal outcome is benign.
Does optimized daytime/nighttime programming reduce insertable cardiac monitor event burden?
Authors: Burke M , Rajan A , Perschbacher D , Mahajan D , Herrmann K
Published: May 2023

Funding Acknowledgements

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

Background

Insertable Cardiac Monitors (ICM) are widely used for long term cardiac arrhythmia monitoring and diagnosis. ICMs can generate episodes (and associated alerts) that are non-actionable from a clinical standpoint leading to alert fatigue. In particular, non-actionable bradycardia and pause events may occur at nighttime due to reduced sympathetic tone during sleep. We have used stored auto-detected events to better understand optimal programming with nighttime settings to eliminate potentially clinically non-actionable episodes and improve clinic workflow.

Objective

Evaluate the reduction in clinic episode review burden in bradycardia (brady) and pause episodes with a new daytime/nighttime programming optimization in LUX-Dx ICM.

Methods

We analyzed data from 2,555 patients implanted with LUX-Dx ICM that included 132,928 detected brady and pause episodes stored remotely. We evaluated optimized settings with separately programmed nocturnal (11p-7a) and nominal daytime (7a-11p) rates and durations as compared to full-time nominal settings (24-hour nominal). Optimized nocturnal programming was set to trigger event storage on a heart rate setting of ≤30 bpm as well as a duration setting of ≥5s for nocturnal brady and pause episodes. The nominal day time and 24-hour settings for brady and pause episodes were HR ≤40bpm and duration ≥3s. The episode burden was analyzed retrospectively using stored episodes comparing optimized versus full-time nominal programming.

Results

A simulation using the optimized settings showed that 98% and 90% of the nocturnal bradycardia (n = 1909) and pause episodes (n = 1198) had a HR >30bpm, and duration <5s respectively. As a result, the optimized settings for nocturnal episodes reduced 75% and 56% of bradycardia and pause episodes, respectively. (See Figure 1). At a patient level, 63% and 25% of patients had a substantial reduction (>=50%) in brady and pause episodes, respectively.

Conclusion

The optimized programming settings, which simply adjusts for nocturnal physiology, may substantially improve clinical workflow by reducing potentially clinically non-actionable episodes and associated alerts detected by the LUX-Dx ICM. More clinical correlative studies are needed to understand patient risk.
Genetic testing in children with Brugada syndrome: results from a large prospective registry
Authors: Pannone L , Osey R , Gauthey A , Sorgente A , Della Rocca D G , Overeinder I , Bala G , Almorad A , Stroker E , Sieira J , La Meir M , Brugada P , Chierchia G B , Van Dooren S , De Asmundis C
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/introduction

A pathogenic/likely pathogenic (P/LP) variant can be found in 20-25% of patients with Brugada syndrome (BrS) and a P/LP variant in SCN5A is associated with a worse prognosis. However, the diagnostic yield and the prognosis of gene testing in pediatric BrS syndrome is unclear.

Purpose

The aim of this study is to define the diagnostic yield of SCN5A gene testing with ACMG standardized variant classification in a large cohort of pediatric BrS. Furthermore, a correlation between the clinical outcomes and the genetic background of children with BrS in comparison with adult BrS is aimed.

Methods

All consecutive patients diagnosed with BrS, between 1992 and 2022 were enrolled in a prospective monocentric registry. Inclusion criteria were: 1) BrS diagnosis; 2) Genetic analysis for SCN5A gene and 3) classification of gene variants following current ACMG guidelines. Pediatric patients were defined if ≤ 12 years of age. The primary endpoint was ventricular arrhythmias (VA) occurrence, defined as documented SCD, aborted SCD, ventricular tachycardia or ventricular fibrillation or appropriate ICD intervention.

Results

A total of 500 BrS patients were included, 41 pediatric patients and 459 adult patients.

Among children with BrS, 19 patients (46.3%) had a P/LP variant (P+) in SCN5A gene. No P/LP variants could be identified in 22 (53.7%) pediatric patients (P-). After a mean follow-up of 140.2 months, 3 children (7.3%) experienced a VA, treated with appropriate ICD shock. Inappropriate shocks occurred in 3 pediatric patients (7.3%). At survival analysis, P- pediatric patients had higher VA free survival during the follow-up, compared with P+ pediatric patients (Log-Rank p=0.021), Figure 1. There was no difference in VA free survival between pediatric and adult BrS patients both without (P-), (Log-Rank p=0.19) and with (P+) a P/LP variant (Log-Rank p=0.91), Figure 2.

Conclusion

In a large BrS cohort, the diagnostic yield for SCN5A P/LP variants in the pediatric population is 46.3%. P+ children with BrS have a worse arrhythmic prognosis.
The V1 transition ratio: electrocardiographic criterion for predicting the success of ablation for outflow tract premature ventricular contractions
Authors: Ohya H
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Several electrocardiographic (ECG) criteria have been proposed for distinguishing left from right ventricular outflow tract premature ventricular contractions (OTPVCs) origins. However, electrocardiographic criteria predicting successful catheter ablation (CA) for OTPVCs are still unknown regardless of right and left ventricular origins.

Methods

We enrolled 63 patients who underwent CA for OTPVCs from September 2020 to August 2022, except patients with bundle branch block and axis deviation in 12-lead ECG. Radiofrequency catheter ablation (RFCA) was performed using 3D-mapping system and irrigation catheter.

Electrocardiographic parameters of successful and unsuccessful patients were retrospectively analyzed. The transition ratios were calculated by the percentage R-wave during PVC (R/R+S) PVC divided by the percentage R-wave in sinus rhythm (R/R+S) SR . Success of CA for OTPVCs was defined as absence of targeted PVCs during all follow up visits and PVC burden <5% on follow-up period.

Results

54 patients (85.7%) were success and 9 patients (14.3%) were unsuccess. Age, sex, Ejection Fraction (EF) and the burden of PVCs before CA were similar between 2 group. (Age: 50±15 vs 54±12 years, p=0.51, male: 46.3 vs 53.7%, p=0.73, EF: 66(58-73) vs 69(59-74), p=0.52, burden of PVCs: 22(17-29) vs 15(13-33)%, p=0.45). V1 transition ratio of unsuccessful group was significantly higher than successful group. (0.70(0.32-1.49) vs 1.55(1.09-9.37), p=0.013) V2 and V3 transition ratios were not significantly different between the two groups. The best cutoff values of V1 transition ratio were 1.0 (AUC 0.78, 95%CI: 0.61-0.94, sensitivity 0.70, specificity 0.88).

Conclusion

V1 transition ratio>1.0 is more likely to be associated with a higher rate of RFCA failure of OTPVCs.
The long-term outcome of malignant outflow tract ventricular tachycardia in patients without structural heart disease
Authors: Kim Y R , Lee K H , Yoon N S , Park H W , Cho J G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Idiopathic ventricular tachycardia (VT) originating from the outflow tract (OT) is usually considered a benign condition. However, in some rare cases, patients with the malignant OT-VT suffer from syncope or even sudden cardiac death (SCD).

Objectives

The purpose of this study was to clarify the long-term clinical outcome of catheter ablation for malignant OT-VT with no sturctural heart disease (no SHD).

Methods

Fifty two consecutive patients (28 women and 24 men; mean age, 45 years; range, 20-77 years) ablated or implanted cardiac defibrillator (ICD) for malignant OT-VT were followed for median 5 years from 2001 to 2019. Primary end point defined recurrent VT/VF episodes.

Result

All 52 patients underwent electrophysiologic study (EPS). Among these patients, catheter ablation successfully elimiated VT focus in 37 (71.2%), partially suppressed VT in 9 (17.3%), and failed to controll VT in 6 (11.5%) [5 of 6 failed to induce clinical tachcyardia and 1 of 6 failed to ablate VT due to multipe PVC]. There was no acute procedureal complication. ICDs were implanted in 16 patients. 12 of these 16 patients were presented with VF or SCD. One of these 16 patients had recurrent VT in 3 years after ablation and three of 16 patients failed to induce clinical tachcyardia. During a mean follow up 58 months (range, 6-161 months), 19 (36.5%) of 52 patients suffered from recurrent VT/VF episodes. Among the 37 patients with successful ablation, 10 (27.0%) patients reached primary endpoints. More importantly, two patients (with only syncope and no prior VF) experienced SCD, one at 6 years after a successful ablation and the other at 3 years after partially modification of VT focus.

Conclusion

Catheter ablation for the malignant OT-VT in patients with no SHD showed safe and tolerable outcomes. It may consider as an early treatment option for these patients. However, even after the successful ablation, a periodical follow-up is crucial in some patients for preventing sudden cardiac deaths.
Ventricular tachycardia site of origin prediction by a QRS axis-based algorithm confirmed by heterogenous tissue channel localization obtained from artificial-intelligence-powered CMR analysis
Authors: Mazzocchetti L , Parollo M , Sbragi S , Barletta V , Segreti L , Di Cori A , De Lucia R , Grifoni G , Soldati E , Viani S , Branchitta G , Carluccio M , Canu A , Paperini L , Zucchelli G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

A previously validated algorithm allows to accurately identify ventricular tachycardia (VT) exit site in a 17-segments American Heart Association left ventricle model in patients with structural heart disease (SHD). ADAS3D is a novel artificial-intelligence cardiac magnetic resonance (CMR) post-processing software which enables heterogeneous tissue channel (HTC) identification.

Purpose

The aim of this study is to compare inferred VT exit site between QRS-axis based model and HTC identification from CMR post-processing.

Methods

All subjects allocated to a CMR-guided or aided approach from a multicenter randomized clinical trial were analyzed. Patients with available 12-lead ECG of clinical VT obtained before ablation were analyzed in terms of concordance between VT site of origin inferred from a QRS-axis and location of HTCs in a 17-segments model.

Results

10 out of 15 patients had 12-lead ECG of clinical VT (80% male, 60% with ischemic cardiomyopathy, mean age 63,5±16,95 years, mean tachycardia cycle length 373,7±99,55 ms). 7 out of 10 patients (70,00%) had at least one HTC located at VT exit site as predicted by a QRS axis-based algorithm. In all remaining cases (3 out of 10) HTC location was found in a segment adjacent to ECG-derived exit site. All patients underwent CMR-guided or CMR-aided VT ablation with acute clinical success (noninducibility of the clinical VT).

Conclusion

VT site of origin prediction via a QRS axis-based algorithm allows for reasonable prediction of HTC presence at inferred site of origin. Larger studies are needed in order to confirm such findings and their potential clinical implications.