Journal: Circ Arrhythm Electrophysiol

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Abstract

Preventive Effect of Berberine on Postoperative Atrial Fibrillation.

Zhang J, Wang Y, Jiang H, Tao D, ... Jin Y, Wang H
Background
Postoperative atrial fibrillation (POAF) is one of the most common complications of cardiac surgery, but the underlying factors governing POAF are not well understood. The aim of this study was to investigate the efficacy of berberine administration on POAF.
Methods
We conducted a randomized, double-blind, placebo-controlled trial with patients who underwent isolated coronary artery bypass grafting in China to study the impact of oral berberine on the incidence of POAF. A total of 200 patients who underwent coronary artery bypass grafting were randomized into the berberine group (n=100) and the placebo group (n=100). All patients underwent 7-day continuous telemetry and Holter monitoring.
Results
The primary outcome was the incidence of POAF at 7 days. Secondary outcomes included clinical outcomes, POAF burden, intestinal endotoxin, and serum inflammatory biomarker levels. The POAF incidence was reduced from 35% to 20% under berberine treatment (hazard ratio, 0.5 [95% CI, 0.29-0.78]; P=0.0143). Perioperative mortality and morbidity did not differ between the 2 groups. POAF burden and the dose of amiodarone were significantly reduced in the berberine group. Oral berberine significantly decreased lipopolysaccharide, CRP (C-reactive protein), and IL (interleukin)-6 levels. Elevated lipopolysaccharide after surgery has been associated with POAF.
Conclusions
Our results showed that administration of berberine may be effective for reducing the occurrence of POAF after coronary artery bypass grafting.
Registration
URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2000028839.



Circ Arrhythm Electrophysiol: 30 Sep 2022:101161CIRCEP122011160; epub ahead of print
Zhang J, Wang Y, Jiang H, Tao D, ... Jin Y, Wang H
Circ Arrhythm Electrophysiol: 30 Sep 2022:101161CIRCEP122011160; epub ahead of print | PMID: 36178742
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Abstract

Parametric Study of Pulsed Field Ablation With Biphasic Waveforms in an In Vivo Heart Model: The Role of Frequency.

García-Sánchez T, Amorós-Figueras G, Jorge E, Campos MC, ... Guerra JM, Ivorra A
Background
Pulsed field ablation (PFA) is a novel nonthermal cardiac ablation technology based on irreversible electroporation. Unfortunately, the characteristics of the electric field waveforms used in clinical and experimental PFA are not typically reported. This study examines the effect of the frequency of biphasic waveforms and compares biphasic to monophasic waveforms.
Methods
A total of 29 Sprague-Dawley rats were treated with PFA using an epicardial monopolar electrode. Biphasic waveforms with three different frequencies, 90, 260, and 450 kHz (10 bursts of 100 µs duration at 500 V or 800 V) and monophasic waveforms (10 pulses of 100 µs duration at 500 V) were studied. Collateral neuromuscular stimulation and temperature increase in the point of application were directly measured. Lesion formation was assessed 3 weeks after treatment by histopathologic analysis. Computer simulations were used to estimate the electric field lethal threshold for each condition. A previous in vitro study was performed to draw a complete characterization of the studied dependencies.
Results
Morphometric analysis demonstrated a significant association between chronic lesion size and waveform characteristics. For the same voltage level, monophasic waveforms yielded the largest lesions compared with any of the biphasic protocols (P<0.05). Increasing PFA frequency was associated with reduced neuromuscular stimulation but also with reduced ablation efficacy. Maximum absolute temperature increase recorded along a complete treatment was 3 °C. Vascular structures inside the lesions were preserved for all conditions. Computer simulation-based analysis showed that waveform frequency had a graded effect on the lethal electric field threshold, with threshold of 600 V/cm for monophasic waveforms versus 2000 V/cm for biphasic waveforms with a frequency of 450 kHz.
Conclusions
Frequency is a major determinant of efficacy in biphasic PFA. Our results highlight the critical need of disclosing waveform characteristics when reporting the results of different PFA systems.



Circ Arrhythm Electrophysiol: 30 Sep 2022:101161CIRCEP122010992; epub ahead of print
García-Sánchez T, Amorós-Figueras G, Jorge E, Campos MC, ... Guerra JM, Ivorra A
Circ Arrhythm Electrophysiol: 30 Sep 2022:101161CIRCEP122010992; epub ahead of print | PMID: 36178752
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Abstract

A Mechanistic Clinical Trial Using ()- Versus )-Propafenone to Test RyR2 (Ryanodine Receptor) Inhibition for the Prevention of Atrial Fibrillation Induction.

Shoemaker MB, Yoneda ZT, Crawford DM, Akers WS, ... Ellis CR, Knollmann BC
Background
Experimental data suggest ryanodine receptor-mediated intracellular calcium leak is a mechanism for atrial fibrillation (AF), but evidence in humans is still needed. Propafenone is composed of two enantiomers that are equally potent sodium-channel blockers; however, (R)-propafenone is an ryanodine receptor inhibitor whereas (S)-propafenone is not. This study tested the hypothesis that ryanodine receptor inhibition with (R)-propafenone prevents induction of AF compared to (S)-propafenone or placebo in patients referred for AF ablation.
Methods
Participants were randomized 4:4:1 to a one-time intravenous dose of (R)-propafenone, (S)-propafenone, or placebo. The study drug was given at the start of the procedure and an AF induction protocol using rapid atrial pacing was performed before ablation. The primary endpoint was 30 s of AF or atrial flutter.
Results
A total of 193 participants were enrolled and 165 (85%) completed the study protocol (median age: 63 years, 58% male, 95% paroxysmal AF). Sustained AF and/or atrial flutter was induced in 60 participants (84.5%) receiving (R)-propafenone, 60 (80.0%) receiving (S)-propafenone group, and 12 (63.2%) receiving placebo. Atrial flutter occurred significantly more often in the (R)-propafenone (N=23, 32.4%) and (S)-propafenone (N=26, 34.7%) groups compared to placebo (N=1, 5.3%, P=0.029). There was no significant difference between (R)-propafenone and (S)-propafenone for the primary outcome of AF and/or atrial flutter induction in univariable (P=0.522) or multivariable analysis (P=0.199, adjusted for age and serum drug level).
Conclusions
There is no difference in AF inducibility between (R)-propafenone and (S)-propafenone at clinically relevant concentrations. These results are confounded by a high rate of inducible atrial flutter due to sodium-channel blockade.
Registration
https://clinicaltrials.gov; Unique Identifier: NCT02710669.



Circ Arrhythm Electrophysiol: 27 Sep 2022:101161CIRCEP121010713; epub ahead of print
Shoemaker MB, Yoneda ZT, Crawford DM, Akers WS, ... Ellis CR, Knollmann BC
Circ Arrhythm Electrophysiol: 27 Sep 2022:101161CIRCEP121010713; epub ahead of print | PMID: 36166682
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Abstract

Left Bundle Branch Pacing Postatrioventricular Junction Ablation for Atrial Fibrillation: Propensity Score Matching With His Bundle Pacing.

Cai M, Wu S, Wang S, Zheng R, ... Su L, Huang W
Background
Left bundle branch pacing (LBBP) has emerged as a promising pacing modality to preserve physiological left ventricular activation; however, prospective data evaluating its long-term safety and efficacy in pacemaker-dependent patients following atrioventricular junction (AVJ) ablation are lacking. This study aimed to examine the feasibility, safety, and efficacy of LBBP in patients with atrial fibrillation and heart failure (HF) after AVJ ablation and compare LBBP with His bundle pacing (HBP) through a propensity score (PS) matching analysis.
Methods
We prospectively enrolled patients with atrial fibrillation and HF referred for AVJ ablation and LBBP between July 2017 and December 2019. The control group was patients selected from HBP implants performed from 2012 to 2019 using PS matching with a 1:1 ratio.
Results
A total of 99 patients were enrolled in the study. The LBBP implant success rate was 100%. Left ventricular ejection fraction improved from baseline 30.3±4.9 to 1-year 47.3±14.5 in HF patients with reduced ejection fraction and from baseline 56.3±12.1 to 1-year 62.3±9.1 in HF patients with preserved ejection fraction (both P<0.001), and left ventricular ejection fraction in both groups remained stable for up to 3 years of follow-up. A threshold increase >2 V at 0.5 ms occurred in only one patient. Of 176 (81.9%) of 215 patients who received permanent HBP post-AVJ ablation, 86 were matched to the LBBP group by 1:1 PS (propensity score matched His bundle pacing, N=86; propensity score matched left bundle branch pacing, N=86). No significant differences in echocardiographic or clinical outcomes were observed between the 2 groups (P>0.05), whereas lower thresholds, greater sensed R-wave amplitudes, and fewer complications were observed in the propensity score matched left bundle branch pacing group (P<0.05).
Conclusions
LBBP is feasible, safe, and effective in patients with atrial fibrillation and HF post-AVJ ablation and has similar clinical benefits, a higher implant success rate, better pacing parameters, and fewer complications compared with HBP.



Circ Arrhythm Electrophysiol: 27 Sep 2022:101161CIRCEP122010926; epub ahead of print
Cai M, Wu S, Wang S, Zheng R, ... Su L, Huang W
Circ Arrhythm Electrophysiol: 27 Sep 2022:101161CIRCEP122010926; epub ahead of print | PMID: 36166683
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Abstract

Effects of Electrode-Tissue Proximity on Cardiac Lesion Formation Using Pulsed Field Ablation.

Howard B, Verma A, Tzou WS, Mattison L, ... Stewart MT, Sigg DC
Background
Pulsed field ablation (PFA) is a novel energy modality for treatment of cardiac arrhythmias. The impact of electrode-tissue proximity on lesion formation by PFA has not been conclusively assessed. The objective of this investigation was to evaluate the effects of electrode-tissue proximity on cardiac lesion formation with a biphasic, bipolar PFA system.
Methods
PFA was delivered on the ventricular epicardial surface in an isolated porcine heart model (n=8) via a 4-electrode prototype catheter. An offset tool was designed to control the distance between electrodes and target tissue; deliveries were placed 0 mm (0 mm offset), 2 mm (2 mm offset), and 4 mm away from the tissue (4 mm offset). Lesions were assessed using tetrazolium chloride staining. Numerical models for the experimental setup with and without the offset tool validated and supported results.
Results
Cardiac lesion dimensions decreased proportional to the distance between epicardial surface and electrodes. Lesion depth-averaged 4.3±0.4 mm, 2.7±0.4 mm, and 1.3±0.4 mm for the 0, 2, and 4 mm and lesion width averaged 9.4±1.1 mm, 7.5±0.8 mm and 5.8±1.4 mm for the 0, 2, and 4 mm offset distances, respectively. Numerical modeling matched ex vivo results well and predicted lesion creation with and without the offset tool.
Conclusions
Using a biphasic, bipolar PFA system resulted in cardiac lesions even in the 0 mm offset distance case. The relationship between lesion depth and offset distance was linear, and the deepest lesions were created with 0 mm offset distance, that is, with electrodes in contact with tissue. Therefore, close electrode-tissue proximity increases the likelihood of achieving transmural lesions by maximizing the electric field penetration into the target tissue.



Circ Arrhythm Electrophysiol: 27 Sep 2022:101161CIRCEP122011110; epub ahead of print
Howard B, Verma A, Tzou WS, Mattison L, ... Stewart MT, Sigg DC
Circ Arrhythm Electrophysiol: 27 Sep 2022:101161CIRCEP122011110; epub ahead of print | PMID: 36166690
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Abstract

Substrate Characterization and Outcomes of Catheter Ablation of Ventricular Arrhythmias in Patients With Mitral Annular Disjunction.

Ezzeddine FM, Siontis KC, Giudicessi J, Ackerman MJ, ... Asirvatham SJ, Del-Carpio Munoz F
Background
Mitral annular disjunction (MAD) has recently been recognized as an arrhythmogenic entity. Data on the electrophysiological substrate as well as the outcomes of catheter ablation of ventricular arrhythmias in patients with MAD is limited.
Methods
Forty patients with MAD (mean age 47±15 years; 70% female) underwent catheter ablation for ventricular arrhythmias. Detailed clinical, electrocardiographic, cardiac imaging, and procedural data were collected. Clinical outcomes were compared between patients who had substrate modification in the MAD area and those who did not.
Results
Twenty-three (57.5%) patients had ablation for premature ventricular contractions, 10 (25%) patients for sustained ventricular tachycardia, and 7 (17.5%) patients for premature ventricular contraction-triggered ventricular fibrillation ablation. Mean end-systolic MAD length was 10.58±3.49 mm on transthoracic echocardiography. Seventeen (42.5%) patients had preprocedural cardiac magnetic resonance imaging, and 5 (29%) patients had late gadolinium enhancement. Among the 18 (45%) patients who had abnormal local electrograms (low voltage, long-duration, fractionated, isolated mid-diastolic potentials) during electroanatomical mapping, 10 (25%) patients had abnormal electrograms in the anterolateral mitral annulus or MAD area. Substrate modification was performed in 10 (25%) patients. Catheter ablation was acutely successful in 36 (90%) patients (elimination of premature ventricular contraction or noninducibility of ventricular tachycardia). After a median follow-up duration of 54.08 (interquartile range, 10.67-89.79) months, premature ventricular contraction burden decreased from a median of 9.75% (interquartile range, 3.25-14) before the ablation to a median of 4% (interquartile range, 1-7.75) after the ablation (P=0.03 [95% CI, 0.055-6.5]). Eight (20.5%) patients had repeat ablation for ventricular arrhythmias. Substrate modification of the MAD was associated with a trend toward lower rates of repeat ablation (0% versus 26.7%; P=0.16).
Conclusions
Patients with MAD have a complex arrhythmogenic substrate, and catheter ablation is effective in reducing recurrence of ventricular arrhythmias. Substrate mapping and ablation may be considered in these patients.



Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122011088; epub ahead of print
Ezzeddine FM, Siontis KC, Giudicessi J, Ackerman MJ, ... Asirvatham SJ, Del-Carpio Munoz F
Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122011088; epub ahead of print | PMID: 36074649
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Abstract

Pulsed Field Ablation of the Porcine Ventricle Using a Focal Lattice-Tip Catheter.

Kawamura I, Reddy VY, Wang BJ, Dukkipati S, ... Santos-Gallego CG, Koruth JS
Background
Our understanding of catheter-based pulsed field ablation (PFA) of the ventricular myocardium is limited. We conducted a series of exploratory evaluations of ventricular PFA in swine ventricles.
Methods
A focal lattice-tip catheter was used to deliver proprietary biphasic monopolar PFA applications to swine ventricles under general anesthesia, with guidance from electroanatomical mapping, fluoroscopy, and intracardiac echocardiography. We conducted experiments to assess the impact of (1) delivery repetition (2×, 3×, or 4×) at each location, (2) epicardial PFA delivery, and (3) confluent areas of shallow healed endocardial scar created by prior PFA (4 weeks earlier) on subsequent endocardial PFA. Additional assessments included PFA optimized for the ventricle, lesion visualization by intracardiac echocardiography imaging, and immunohistochemical insights.
Results
Experiment no. 1: lesions (n=49) were larger with delivery repetition of either 4× or 3× versus 2×: length 17.6±3.9 or 14.2±2.0 versus 12.7±2.0 mm (P<0.01, P=0.22), width 13.4±1.8 or 10.6±1.3 versus 10.5±1.1 mm (P<0.01, P=1.00), and depth 6.1±2.1 or 5.1±1.3 versus 4.2±1.0 mm (P<0.01, P=0.21). Experiment no. 2: epicardial lesions (n=18) were reliably created and comparable to endocardial lesions: length 24.6±9.7 mm (n=5), width 15.6±4.6 mm, and depth 4.5±3.7 mm. Experiment no. 3: PFA (n=16) was able to penetrate to a depth of 4.8 (interquartile range, 4.5-5.4) mm in healthy myocardium versus 5.6 (interquartile range, 3.6-6.6) mm in adjacent healed endocardial scar (P=0.79), suggesting that superficial scar does not significantly impair PFA. Finally, we demonstrate, PFA optimized for the ventricle yielded adequate lesion dimensions, can result in myocardial activation, can be visualized by intracardiac echocardiography, and have unique immunohistochemical characteristics.
Conclusions
This in vivo evaluation offers insights into the behavior of endocardial or epicardial PFA delivered using the lattice-tip catheter to normal or scarred porcine ventricular myocardium, thereby setting the stage for future clinical studies.



Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122011120; epub ahead of print
Kawamura I, Reddy VY, Wang BJ, Dukkipati S, ... Santos-Gallego CG, Koruth JS
Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122011120; epub ahead of print | PMID: 36074657
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Abstract

Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm.

Ninni S, Gallot-Lavallée T, Klein C, Longère B, ... Klug D, Mirabel X
Background
Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES.
Methods
This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock.
Results
Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5-17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (-91% [95% CI, 78-103]), P<0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year.
Conclusions
SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.



Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122010955; epub ahead of print
Ninni S, Gallot-Lavallée T, Klein C, Longère B, ... Klug D, Mirabel X
Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122010955; epub ahead of print | PMID: 36074658
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Abstract

Catheter Ablation for Atrial Fibrillation in Adult Congenital Heart Disease: An International Multicenter Registry Study.

Griffiths JR, Nussinovitch U, Liang JJ, Sims R, ... Ernst S, Nguyen DT
Background
Data on atrial fibrillation (AF) ablation and outcomes are limited in patients with congenital heart disease (CHD). We aimed to investigate the characteristics of patients with CHD presenting for AF ablation and their outcomes.
Methods
A multicenter, retrospective analysis was performed of patients with CHD undergoing AF ablation between 2004 and 2020 at 13 participating centers. The severity of CHD was classified using 2014 PACES/HRS guidelines. Clinical data were collected. One-year complete procedural success was defined as freedom from atrial tachycardia or AF in the absence of antiarrhythmic drugs or including previously failed antiarrhythmic drugs (partial success).
Results
Of 240 patients, 127 (53.4%) had persistent AF, 62.5% were male, and mean age was 55.2±0.9 years. CHD complexity categories included 147 (61.3%) simple, 69 (28.8%) intermediate, and 25 (10.4%) severe. The most common CHD type was atrial septal defect (n=78). More complex CHD conditions included transposition of the great arteries (n=14), anomalous pulmonary veins (n=13), tetralogy of Fallot (n=8), cor triatriatum (n=7), single ventricle physiology (n=2), among others. The majority (71.3%) of patients had trialed at least one antiarrhythmic drug. Forty-six patients (22.1%) had reduced systemic ventricular ejection fraction <50%, and mean left atrial diameter was 44.1±0.7 mm. Pulmonary vein isolation was performed in 227 patients (94.6%); additional ablation included left atrial linear ablations (25.4%), complex fractionated atrial electrogram (19.2%), and cavotricuspid isthmus ablation (40.8%). One-year complete and partial success rates were 45.0% and 20.5%, respectively, with no significant difference in the rate of complete success between complexity groups. Overall, 38 patients (15.8%) required more than one ablation procedure. There were 3 (1.3%) major and 13 (5.4%) minor procedural complications.
Conclusions
AF ablation in CHD was safe and resulted in AF control in a majority of patients, regardless of complexity. Future work should address the most appropriate ablation targets in this challenging population.



Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122010954; epub ahead of print
Griffiths JR, Nussinovitch U, Liang JJ, Sims R, ... Ernst S, Nguyen DT
Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP122010954; epub ahead of print | PMID: 36074954
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Abstract

Sinus Tachycardia: a Multidisciplinary Expert Focused Review.

Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, ... Stewart J, Olshansky B
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.



Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP121007960; epub ahead of print
Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, ... Stewart J, Olshansky B
Circ Arrhythm Electrophysiol: 08 Sep 2022:101161CIRCEP121007960; epub ahead of print | PMID: 36074973
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Abstract

Forward-Solution Noninvasive Computational Arrhythmia Mapping: The VMAP Study.

Krummen DE, Villongco CT, Ho G, Schricker AA, ... McCulloch AD, Han FT
Background
The accuracy of noninvasive arrhythmia source localization using a forward-solution computational mapping system has not yet been evaluated in blinded, multicenter analysis. This study tested the hypothesis that a computational mapping system incorporating a comprehensive arrhythmia simulation library would provide accurate localization of the site-of-origin for atrial and ventricular arrhythmias and pacing using 12-lead ECG data when compared with the gold standard of invasive electrophysiology study and ablation.
Methods
The VMAP study (Vectorcardiographic Mapping of Arrhythmogenic Probability) was a blinded, multicenter evaluation with final data analysis performed by an independent core laboratory. Eligible episodes included atrial and ventricular: tachycardia, fibrillation, pacing, premature atrial and ventricular complexes, and orthodromic atrioventricular reentrant tachycardia. Mapping system results were compared with the gold standard site of successful ablation or pacing during electrophysiology study and ablation. Mapping time was assessed from time-stamped logs. Prespecified performance goals were used for statistical comparisons.
Results
A total of 255 episodes from 225 patients were enrolled from 4 centers. Regional accuracy for ventricular tachycardia and premature ventricular complexes in patients without significant structural heart disease (n=75, primary end point) was 98.7% (95% CI, 96.0%-100%; P<0.001 to reject predefined H0 <0.80). Regional accuracy for all episodes (secondary end point 1) was 96.9% (95% CI, 94.7%-99.0%; P<0.001 to reject predefined H0 <0.75). Accuracy for the exact or neighboring segment for all episodes (secondary end point 2) was 97.3% (95% CI, 95.2%-99.3%; P<0.001 to reject predefined H0 <0.70). Median spatial accuracy was 15 mm (n=255, interquartile range, 7-25 mm). The mapping process was completed in a median of 0.8 minutes (interquartile range, 0.4-1.4 minutes).
Conclusions
Computational ECG mapping using a forward-solution approach exceeded prespecified accuracy goals for arrhythmia and pacing localization. Spatial accuracy analysis demonstrated clinically actionable results. This rapid, noninvasive mapping technology may facilitate catheter-based and noninvasive targeted arrhythmia therapies.
Registration
URL: https://www.
Clinicaltrials
gov; Unique identifier: NCT04559061.



Circ Arrhythm Electrophysiol: 07 Sep 2022:101161CIRCEP122010857; epub ahead of print
Krummen DE, Villongco CT, Ho G, Schricker AA, ... McCulloch AD, Han FT
Circ Arrhythm Electrophysiol: 07 Sep 2022:101161CIRCEP122010857; epub ahead of print | PMID: 36069189
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Abstract

Short- and Long-Term Risk of Lead Dislodgement Events: Real-World Experience From Product Surveillance Registry.

Qin D, Filippaios A, Murphy J, Berg M, ... Noone M, Mela T
Background
Lead dislodgement (LD) has been one of the most common early complications after cardiovascular implantable electronic device implant. However, limited data are available on the clinical characteristics and long-term outcomes of LD events. The aim of this study was to examine the risk factors, clinical significance, and management strategies of LD events after cardiovascular implantable electronic device implant.
Methods
This study was a retrospective cohort analysis of 20 683 patients who underwent cardiovascular implantable electronic device implant between January 1, 2010 and January 31, 2020 in Medtronic\'s Product Surveillance Registry, with a mean follow-up time of 3.3±2.5 SD years. The study population was divided into 2 groups: group A with LD events (N=350) and group B without LD events (N=20 333).
Results
During this period, 350 patients (1.69%) had LD events involving 371 leads (0.95%), among a total of 39 060 leads implanted. Passive fixation type (right atrium pacing lead, P=0.041), lower sensing amplitude (right ventricle defibrillating lead, P=0.020), and lower lead impedance at implant (right atrium pacing lead, P=0.009) were associated with increased LD risk. Multivariate analysis showed female sex (hazard ratio, 1.520, P=0.008) and higher body mass index (hazard ratio, 1.012, P=0.001) were independently associated with increased risk of LD events. LD events were not associated with significant changes in the long-term risks of cardiac and overall mortality. In group A, repositioning the dislodged leads increased the risk of a second LD event compared with implanting new leads (P=0.012).
Conclusions
Female sex and higher body mass index were associated with higher risk of LD events in the Product Surveillance Registry. Among patients with dislodged leads, implanting new leads was associated with lower risk of future LD events. Further studies on how to reduce LD risk and to improve management of these events are needed.
Registration
URL: https://www.
Clinicaltrials
gov; Unique identifier: NCT01524276.



Circ Arrhythm Electrophysiol: 04 Aug 2022:101161CIRCEP122011029; epub ahead of print
Qin D, Filippaios A, Murphy J, Berg M, ... Noone M, Mela T
Circ Arrhythm Electrophysiol: 04 Aug 2022:101161CIRCEP122011029; epub ahead of print | PMID: 35925831
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Abstract

Multielectrode Contact Measurement Can Improve Long-Term Outcome of Pulmonary Vein Isolation Using Circular Single-Pulse Electroporation Ablation.

Groen MHA, van Driel VJHM, Neven K, van Wessel H, ... Loh P, van Es R
Background
Irreversible electroporation (IRE) ablation is generally performed with multielectrode catheters. Electrode-tissue contact is an important predictor for the success of pulmonary vein (PV) isolation; however, contact force is difficult to measure with multielectrode ablation catheters. In a preclinical study, we assessed the feasibility of a multielectrode impedance system (MEIS) as a predictor of long-term success of PV isolation. In addition, we present the first-in-human clinical experience with MEIS.
Methods
In 10 pigs, one PV was ablated based on impedance (MEIS group), and the other PV was solely based on local electrogram information (electrophysiological group). IRE ablations were performed at 200 J. After 3 months, recurrence of conduction was assessed. Subsequently, in 30 patients undergoing PV isolation with IRE, MEIS was evaluated and MEIS contact values were compared to local electrograms.
Results
In the porcine study, 43 IRE applications were delivered in 19 PVs. Acutely, no reconnections were observed in either group. After 3 months, 0 versus 3 (P=0.21) PVs showed conduction recurrence in the MEIS and electrophysiological groups, respectively. Results from the clinical study showed a significant linear relation was found between mean MEIS value and bipolar dV/dt (r2=0.49, P<0.001), with a slope of 20.6 mV/s per Ohm.
Conclusions
Data from the animal study suggest that MEIS values predict effective IRE applications. For the long-term success of electrical PV isolation with circular IRE applications, no significant difference in efficacy was found between ablation based on the measurement of electrode interface impedance and ablation using the classical electrophysiological approach for determining electrode-tissue contact. Experiences of the first clinical use of MEIS were promising and serve as an important basis for future research.



Circ Arrhythm Electrophysiol: 02 Aug 2022:101161CIRCEP121010835; epub ahead of print
Groen MHA, van Driel VJHM, Neven K, van Wessel H, ... Loh P, van Es R
Circ Arrhythm Electrophysiol: 02 Aug 2022:101161CIRCEP121010835; epub ahead of print | PMID: 35917465
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Impact:
Abstract

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias.

Patel A, Nsahlai M, Flautt T, Da-Warikobo A, ... Dave A, Valderrábano M
Background
Coronary venous ethanol ablation (VEA) can be used as a strategy to treat ventricular arrhythmias arising from the left ventricular summit, but collateral flow and technical challenges cannulating intramural veins in complex venous anatomies can limit its use. Advanced techniques for VEA can capitalize on collateral vessels between target and nontarget sites to improve success.
Methods
Of 55 patients with left ventricular summit ventricular arrhythmia, advanced techniques were used in 15 after initial left ventricular summit intramural vein mapping failed to show suitable targets for single vein, single-balloon VEA. All patients had previous radiofrequency ablation attempts. Techniques included: double-balloon for distal protection to block distal flow and target the proximal portion of a large intramural vein where best signal was proximal (n=6); balloons in 2 different left ventricular summit veins for a cross-fire multivein VEA (n=4); intramural collateral vein-to-vein cannulation to reach of targeted vein via collateral with antegrade ethanol and proximal balloon block (n=2); prolonged ethanol dwell time for vein sclerosis of large intramural vein and subsequent VEA (n=3); and intramural collateral VEA (n=1).
Results
Fifteen (8 females) patients (age 60.6±17.6 years) required advanced techniques. Procedure time was 210±49.9 minutes, fluoroscopy time was 25.3±14.1 minutes, and 113±17.9 cc of contrast was utilized. A median of 7 cc of ethanol was delivered (range, 4-15 cc). Intraprocedural radiofrequency ablation was delivered before ethanol in 9 out of 15 patients but failed. Ethanol achieved acute success in all 15 patients. Ethanol was used as the sole treatment in two patients. At a median follow-up of 194 days, one patient experienced recurrence.
Conclusions
Advanced techniques capitalizing on venous anatomy can enable successful VEA and selective targeting of arrhythmogenic sites, by blocking distal flow, utilization of collaterals between nontarget and target veins and multivein VEA. Understanding individual anatomy is critical for VEA success.



Circ Arrhythm Electrophysiol: 02 Aug 2022:101161CIRCEP122011017; epub ahead of print
Patel A, Nsahlai M, Flautt T, Da-Warikobo A, ... Dave A, Valderrábano M
Circ Arrhythm Electrophysiol: 02 Aug 2022:101161CIRCEP122011017; epub ahead of print | PMID: 35917467
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Impact:
Abstract

Machine Learning-Enabled Multimodal Fusion of Intra-Atrial and Body Surface Signals in Prediction of Atrial Fibrillation Ablation Outcomes.

Tang S, Razeghi O, Kapoor R, Alhusseini MI, ... Narayan SM, Baykaner T
Background
Machine learning is a promising approach to personalize atrial fibrillation management strategies for patients after catheter ablation. Prior atrial fibrillation ablation outcome prediction studies applied classical machine learning methods to hand-crafted clinical scores, and none have leveraged intracardiac electrograms or 12-lead surface electrocardiograms for outcome prediction. We hypothesized that (1) machine learning models trained on electrograms or ECG signals can perform better at predicting patient outcomes after atrial fibrillation ablation than existing clinical scores and (2) multimodal fusion of electrogram, ECG, and clinical features can further improve the prediction of patient outcomes.
Methods
Consecutive patients who underwent catheter ablation between 2015 and 2017 with panoramic left atrial electrogram before ablation and clinical follow-up for at least 1 year following ablation were included. Convolutional neural network and a novel multimodal fusion framework were developed for predicting 1-year atrial fibrillation recurrence after catheter ablation from electrogram, ECG signals, and clinical features. The models were trained and validated using 10-fold cross-validation on patient-level splits.
Results
One hundred fifty-six patients (64.5±10.5 years, 74% male, 42% paroxysmal) were analyzed. Using electrogram signals alone, the convolutional neural network achieved an area under the receiver operating characteristics curve of 0.731, outperforming the existing APPLE scores (area under the receiver operating characteristics curve=0.644) and CHA2DS2-VASc scores (area under the receiver operating characteristics curve=0.650). Similarly using 12-lead ECG alone, the convolutional neural network achieved an AUROC of 0.767. Combining electrogram, ECG, and clinical features, the fusion model achieved an AUROC of 0.859, outperforming single and dual modality models.
Conclusions
Deep neural networks trained on electrogram or ECG signals improved the prediction of catheter ablation outcome compared with existing clinical scores, and fusion of electrogram, ECG, and clinical features further improved the prediction. This suggests the promise of using machine learning to help treatment planning for patients after catheter ablation.



Circ Arrhythm Electrophysiol: 22 Jul 2022:101161CIRCEP122010850; epub ahead of print
Tang S, Razeghi O, Kapoor R, Alhusseini MI, ... Narayan SM, Baykaner T
Circ Arrhythm Electrophysiol: 22 Jul 2022:101161CIRCEP122010850; epub ahead of print | PMID: 35867397
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Impact:

This program is still in alpha version.