Journal: Circ Arrhythm Electrophysiol

Sorted by: date / impact
Abstract

Hybrid Convergent Procedure for the Treatment of Persistent and Long Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial.

DeLurgio DB, Crossen KJ, Gill J, Blauth C, ... Gilligan DM, Calkins H

- The limited effectiveness of endocardial catheter ablation (CA) for persistent and long-standing persistent atrial fibrillation (Ps/LSP-AF) treatment led to the development of a minimally-invasive epicardial/endocardial ablation approach (Hybrid Convergent) to achieve a more comprehensive lesion set with durable transmural lesions. The multi-center randomized controlled CONVERGE trial (NCT01984346) evaluated the safety of Hybrid Convergent and compared its effectiveness to CA for Ps/LSP-AF treatment.- One-hundred fifty-three patients were randomized 2:1 to Hybrid Convergent vs. CA. Primary effectiveness was freedom from AF/AFL/AT absent new/increased dosage of previously failed/intolerant class I/III anti-arrhythmic drugs (AADs) through 12-months. Primary safety was major adverse events through 30 days. CONVERGE permitted left atrium size up to 6cm and imposed no limits on AF duration, making it the only ablation trial to substantially include LSP-AF i.e. 42% patients with LSP-AF.- Of 149 evaluable patients at 12 months, primary effectiveness was achieved in 67.7% (67/99) patients with Hybrid Convergent and 50.0% (25/50) with CA (p=0.036) on/off previously failed AADs and in 53.5% (53/99) versus 32.0% (16/50) (p=0.0128) respectively off AADs. At 18-months using 7-day Holter, 74.0% (53/72) Hybrid Convergent and 55% (23/42) CA patients experienced ≥90% AF burden reduction. A total of 2.9% (3/102) patients had primary safety events within 7 days, and 4.9% (5/102) between 8-30 days post-procedure. No deaths, cardiac perforations or atrioesophageal fistulas occurred. All but one primary safety event resolved.- The Hybrid Convergent procedure has superior effectiveness compared to the CA for the treatment of Ps/LSP-AF.



Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print
DeLurgio DB, Crossen KJ, Gill J, Blauth C, ... Gilligan DM, Calkins H
Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print | PMID: 33185144
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Artificial Intelligence-Electrocardiography to Predict Incident Atrial Fibrillation: A Population-Based Study.

Christopoulos G, Graff-Radford J, Lopez CL, Yao X, ... Friedman PA, Noseworthy PA

- An artificial intelligence (AI) algorithm applied to electrocardiography (ECG) during sinus rhythm (SR) has recently been shown to detect concurrent episodic atrial fibrillation (AF). We sought to characterize the value of AI-ECG as a predictor of future AF and assess its performance compared to the CHARGE-AF score in a population-based sample.- We calculated the probability of AF using AI-ECG, among participants in the population-based Mayo Clinic Study of Aging who had no history of AF at the time of the baseline study visit. Cox proportional hazards models were fit to assess the independent prognostic value and interaction between AI-ECG AF model output and CHARGE-AF score. Concordance (C) statistics were calculated for AI-ECG AF model output, CHARGE-AF score and combined AI-ECG and CHARGE-AF score.- A total of 1,936 participants with median age 75.8 (interquartile range [IQR] 70.4, 81.8) years and median CHARGE-AF score 14.0 (IQR 13.2, 14.7) were included in the analysis. Participants with AI-ECG AF model output of >0.5 at the baseline visit had cumulative incidence of AF 21.5% at 2 years and 52.2% at 10 years. When included in the same model, both AI-ECG AF model output (hazard ratio [HR] 1.76 per standard deviation (SD) after logit transformation, 95% confidence interval [CI] 1.51, 2.04) and CHARGE-AF score (HR 1.90 per SD, 95% CI 1.58, 2.28) independently predicted future AF without significant interaction (p=0.54). C statistics were 0.69 (95% CI 0.66, 0.72) for AI-ECG AF model output, 0.69 (95% CI 0.66, 0.71) for CHARGE-AF and 0.72 (95% CI 0.69, 0.75) for combined AI-ECG and CHARGE-AF score.- In the present study, both the AI-ECG AF model output and CHARGE-AF score independently predicted incident AF. The AI-ECG may offer a means to assess risk with a single test and without requiring manual or automated clinical data abstraction.



Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print
Christopoulos G, Graff-Radford J, Lopez CL, Yao X, ... Friedman PA, Noseworthy PA
Circ Arrhythm Electrophysiol: 12 Nov 2020; epub ahead of print | PMID: 33185118
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Characterization of Lesions Created by a Heated, Saline Irrigated Needle-Tip Catheter in the Normal and Infarcted Canine Heart.

Dickow J, Suzuki A, Henz BD, Madhavan M, ... Curley MG, Packer DL

- Inability to eliminate intramural arrhythmogenic substrate may lead to recurrent ventricular tachycardia after catheter ablation. The aim of the present study was to evaluate intramural and full thickness lesion formation using a heated saline-enhanced radiofrequency (SERF) needle-tip catheter, compared to a conventional ablation catheter in normal and infarcted myocardium.- Twenty-two adult mongrel dogs (30-40 kg, 15 normal and 7 myocardial infarct group) were studied. Lesions were created using the SERF catheter (40W/50°C) or a standard contact force (CF) catheter in both groups.- Comparing SERF to CF ablation, the SERF catheter produced larger lesion volumes than the standard CF catheter - even with >20 g of CF - in both normal (983.1 ± 905.8 mm3 vs. 461.9 ± 178.3 mm3; p=0.023) and infarcted left ventricular myocardium (1052.3 ± 543.0 mm3 vs. 340.3 ± 160.5 mm3; p=0.001). SERF catheter lesions were more often transmural than standard CF lesions with >20 g of CF in both groups (59.1% vs. 7.7%; p<0.001 and 60.0% vs. 12.5%; p=0.017, respectively). Using the SERF catheter, mean depth of ablated lesions reached 90% of the left ventricular wall in both normal and infarcted myocardium.- The SERF catheter created more transmural and larger ablative lesions in both normal and infarcted canine myocardium. SERF ablation is a promising new approach for endocardial intramural and full thickness ablation of ventricular tachycardia substrate that is not accessible with current techniques.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Dickow J, Suzuki A, Henz BD, Madhavan M, ... Curley MG, Packer DL
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198498
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The Pros and Cons of Left Bundle Branch Pacing: A Single Center Experience.

Ravi V, Hanifin JL, Larsen T, Huang HD, Trohman RG, Sharma PS

- Left Bundle Branch Pacing (LBBP) has recently emerged as a promising alternative modality for conduction system pacing. However, limited real-world data exists on the advantages and complications associated with LBBP. We analyzed the Rush conduction system pacing registry on LBBP to assess the success rates and complications associated with LBBP.- All patients with an indication for pacing (PPM) or cardiac resynchronization therapy (CRT) that underwent LBBP for various reasons from 06/2018 to 04/2020 were included in the analysis.- A total of 57 of 59 patients underwent successful LBBP (success rate 97%). The average follow-up duration was 6.2 ± 5 months. The implanted devices included 38 dual-chamber pacemakers, 17 CRT defibrillators, and 2 CRT pacing systems. The most common reason for performing LBBP was a high His Bundle Pacing threshold (n = 23) at implant. The mean LBBP capture threshold at implant was 0.62 ± 0.21 V @ 0.4 ms which remained stable during follow up at 0.65 ± 0.68 V @ 0.4ms. In 21 patients with cardiomyopathy, there was a significant improvement in LVEF from 30 ± 11% to 42 ± 15%. A total of 7 lead-related complications (12.3%) were noted in the follow-up period. Three patients (5.3%) required lead revision during the follow-up period. Interventricular septal (IVS) perforation occurred (as late sequela) after 2 weeks in one patient.- LBBP can be achieved with a high success rate and low capture thresholds. Left ventricular dysfunction improved significantly during follow-up. Lead-related complications were relatively common occurring in 12.3% of initially successful implants. Lead revision was required in 3 (5%) of patients.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Ravi V, Hanifin JL, Larsen T, Huang HD, Trohman RG, Sharma PS
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198496
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Left Cardiac Sympathetic Denervation Monotherapy in Patients with Congenital Long QT Syndrome.

Niaz T, Bos JM, Sorensen KB, Moir C, Ackerman MJ

- Videoscopic left cardiac sympathetic denervation (LCSD) is an effective anti-fibrillatory, minimally invasive therapy for patients with potentially life-threatening arrhythmia syndromes like long QT syndrome (LQTS). Although initially used primarily for treatment intensification following documented LQTS-associated breakthrough cardiac events (BCEs) while on beta-blockers, LCSD as one-time monotherapy for certain patients with LQTS requires further evaluation. We are presenting our early experience with LCSD-monotherapy for carefully selected patients with LQTS.- Among the 1400 patients evaluated and treated for LQTS, a retrospective review was performed on the 204 patients with LQTS who underwent LCSD at our institution since 2005 to identify the patients where the LCSD served as stand-alone, monotherapy. Clinical data on symptomatic status prior to diagnosis, clinical and genetic diagnosis, and BCEs after diagnosis were analyzed to determine efficacy of LCSD-monotherapy.- Overall, 64 of 204 patients (31%) were treated with LCSD alone [37 (58%) female, mean QTc 466 ± 30 ms, 16 (25%) patients were symptomatic prior to diagnosis with a mean age at diagnosis 17.3 ± 11.8 years, 5 had (8%) ≥ 1 BCE after diagnosis, and mean age at LCSD was 21.1 ± 11.4 years]. The primary motivation for LCSD-monotherapy was an unacceptable quality of life stemming from beta-blocker related side effects (i.e. beta-blocker intolerance) in 56/64 patients (88%). The underlying LQTS genotype was LQT1 in 36 (56%) and LQT2 in 20 (31%). There were no significant LCSD-related surgical complications. With a mean follow-up of 2.7 ± 2.4 years so far, only 3 patients have experienced a non-lethal, post-LCSD BCE in 180 patient-years.- LCSD may be a safe and effective stand-alone therapy for select patients who do not tolerate beta-blockers. However, LCSD is not curative and patient selection will be critical when potentially considering LCSD as monotherapy.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Niaz T, Bos JM, Sorensen KB, Moir C, Ackerman MJ
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198487
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-Term Evaluation of the Vagal Denervation by Cardioneuroablation using Holter and Heart Rate Variability.

Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, ... Silva RF, Osorio TG

- Several disorders present reflex or persistent increase in vagal tone that may cause refractory symptoms even in a normal heart patient. Cardioneuroablation (CNA), the vagal denervation by RF ablation of the neuromyocardial interface, was developed to treat these conditions without pacemaker implantation. A theoretical limitation could be the reinnervation, that naturally grows in the first year, that could recover the vagal hyperactivity. This study aims to verify the vagal denervation degree in the chronic phase after CNA. Additionally, it intends to investigate the arrhythmias behavior after CNA.- prospective longitudinal study with intra-patient comparison of 83 very symptomatic cases without significant cardiopathy, submitted to CNA, 49(59%) male, 47.3±17 years-old, having vagal paroxysmal atrial fibrillation 58(70%) or neurocardiogenic syncope 25(30%), NYHA Class < II and absence of significant comorbidities. CNA was performed in both atria by interatrial septum puncture, with irrigated conventional catheter and electroanatomic reconstruction. Ablation targeted the neuromiocardial interface by fragmentation mapping (AF-Nests) using the Velocity Fractionation software, conventional recording and anatomical localization of the ganglionated plexi. There were compared the time and frequency domain of the heart rate variability (HRV) and arrhythmias in 24h Holter pre-, 1-year-post- and 2-year-post-CNA. Clinical outpatient follow-up and serial Holter showed 80% asymptomatic cases at 40 months.- Time and frequency domain HRV demonstrated significant decrease in all autonomic parameters, showing an important parasympathetic and sympathetic activity reduction at 2 years-post-CNA (p<0.001). There was no difference in HRV between the 1-year- and 2-post-CNA (p>0.05) suggesting that the reinnervation has halted. There was also an important reduction in all brady- and tachyarrhythmias pre- vs. post-CNA, (p <0.01).- There is an important and significant vagal and sympathetic denervation after 2 years of CNA with a significant reduction in brady and tachyarrhythmia in the whole group. There were no complications.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, ... Silva RF, Osorio TG
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198486
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Personalized Digital-heart Technology for Ventricular Tachycardia Ablation Targeting in Hearts with Infiltrating Adiposity.

Sung E, Prakosa A, Aronis KN, Zhou S, ... Chrispin J, Trayanova NA

- Infiltrating adipose tissue (inFAT) is a newly recognized pro-arrhythmic substrate for post-infarct ventricular tachycardias (VT) identifiable on contrast-enhanced computed tomography (CE-CT). This study presents novel digital-heart technology that incorporates inFAT from CE-CT to non-invasively predict VT ablation targets and assesses the capability of the technology by comparing its predictions with VT ablation procedure data from patients with ischemic cardiomyopathy (ICM).- Digital-heart models reflecting patient-specific inFAT distributions were reconstructed from CE-CTs. The Digital-heart Identification of Fat-based Ablation Targeting (DIFAT) technology evaluated the rapid-pacing-induced VTs in each personalized inFAT-based substrate. DIFAT targets that render the inFAT substrate non-inducible to VT, including VTs that arise post-ablation, were determined. DIFAT predictions were compared to corresponding clinical ablations to assess the capabilities of the technology.- DIFAT was developed and applied retrospectively to 29 ICM patients with CE-CTs. DIFAT ablation volumes were significantly less than the estimated clinical ablation volumes (1.87±0.35 cm vs. 7.05±0.88 cm, p<0.0005). DIFAT targets overlapped with clinical ablations in 79% of patients, mostly in the apex (72%) and inferior/inferolateral (74%). In 3 patients, DIFAT targets co-localized with redo ablations delivered years after the index procedure.- DIFAT is a novel digital-heart technology for individualized VT ablation guidance designed to eliminate VT inducibility following initial ablation. DIFAT predictions co-localized well with clinical ablation locations but provided significantly smaller lesions. DIFAT also predicted VTs targeted in redo procedures years later. As DIFAT uses widely accessible CT, its integration into clinical workflows may augment therapeutic precision and reduce redo procedures.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Sung E, Prakosa A, Aronis KN, Zhou S, ... Chrispin J, Trayanova NA
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33198484
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope.

Zheng L, Sun W, Liu S, Liang E, ... Asirvatham SJ, Yao Y

- Increased parasympathetic activity is thought to play important roles in syncope events of vasovagal syncope (VVS) patients. However, direct measurements of the vagal control are difficult. The novel deceleration capacity (DC) of heart rate measure has been used to characterize the vagal modulation. This study aimed to assess vagal control in VVS patients and evaluate the diagnostic value of the DC in VVS.- Altogether 161 consecutive VVS patients (43 ± 15 years; 62 males) were enrolled. Tilt table test (TTT) was positive in 101 and negative in 60 patients. Sixty-five healthy subjects were enrolled as controls. DC and heart rate variability (HRV) in 24-hour electrocardiogram, echocardiogram, and biochemical examinations were compared between the syncope and control groups.- DC was significantly higher in the syncope group than in the control group (9.6 ± 3.3 ms vs. 6.5 ± 2.0 ms, 0.001). DC was similarly increased in VVS patients with a positive and negative TTT (9.7±3.5 ms and 9.4±2.9 ms, =0.614). In multivariable logistic regression analyses, DC was independently associated with syncope (=1.518, 95%1.301-1.770,=0.0001). For the prediction of syncope, the area under curve (AUC) analysis showed similar values when comparing single DC and combined DC with other risk factors (=0.1147). From the receiver operator characteristic (ROC) curves for syncope discrimination, the optimal cut-off value for the DC was 7.12 ms.- DC > 7.5 ms may serve as a good tool to monitor cardiac vagal activity and discriminate VVS, particularly in those with negative TTT.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Zheng L, Sun W, Liu S, Liang E, ... Asirvatham SJ, Yao Y
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33197331
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Characteristics of Patients with Arrhythmogenic Left Ventricular Cardiomyopathy: Combining Genetic and Histopathologic Findings.

Casella M, Gasperetti A, Sicuso R, Conte E, ... Dello Russo A, Tondo C

- Arrhythmogenic left ventricular cardiomyopathy (ALVC) is an under-characterized phenotype of arrhythmogenic cardiomyopathy involving the LV ab initio. ALVC was not included in the 2010 International Task Force Criteria (ITFC) for arrhythmogenic right ventricular cardiomyopathy diagnosis and data regarding this phenotype are scarce.- clinical characteristics were reported from all consecutive patients diagnosed with ALVC, defined as a LV isolated late gadolinium enhancement (LGE) and fibro-fatty replacement (FFR) at cardiac magnetic resonance (CMR) plus genetic variants associated with ARVC and/or of an endomyocardial biopsy (EMB) showing FFR complying with the 2010 ITFC in the LV.- twenty-five ALVC patients (53 [48-59] years, 60% male) were enrolled. T-wave inversion in infero-lateral and left precordial leads were the most common ECG abnormalities. Overall arrhythmic burden at study inclusion was 56%. CMR showed LV LGE in the LV lateral and/or posterior basal segments in all patients. In 72% of the patients an invasive evaluation was performed, in which electroanatomical voltage mapping (EVM) and EVM-guided EMB showed low endocardial voltages and FFR in areas of LGE presence. Genetic variants in desmosomal genes (desmoplakin and desmoglein-2) were identified in 12/25 of the cohort presenting pathogenic/likely-pathogenic variants. A definite/borderline 2010 ITFC ARVC diagnosis was reached only in 11/25 patients.- ALVC presents with a preferential involvement of the lateral and/or postero-lateral basal LV and is associated mostly with variants in desmoplakin and desmoglein-2 genes. An amendment to the current ITFC is reasonable to better diagnose ALVC patients.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Casella M, Gasperetti A, Sicuso R, Conte E, ... Dello Russo A, Tondo C
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33197325
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Impact of Vein of Marshall Ethanol Infusion on Mitral Isthmus Block: Efficacy and Durability.

Nakashima T, Pambrun T, Vlachos K, Goujeau C, ... Jaïs P, Derval N

- Achieving bidirectional mitral isthmus (MI) block using radiofrequency catheter ablation (RFCA) alone is challenging, and MI reconnection is common. Adjunctive vein of Marshall (VOM) ethanol infusion (VOM-Et) can facilitate acute MI block. However, little is known regarding its long-term success. This study sought to evaluate the impact of adjunctive VOM-Et on MI block achievement and durability compared to RFCA alone.- Patients undergoing a first attempt of posterior MI ablation were grouped according to their MI block index strategy: adjunctive VOM-Et and RFCA alone. Rates of acute MI block and MI reconnection observed during repeat procedures were compared between the two groups.- The VOM-Et group consisted of 152 patients (63.8 ± 9.4 years) undergoing adjunctive VOM-Et for MI block. The RFCA group consisted of 110 patients (60.9 ± 9.2 years) undergoing MI ablation using RFCA alone. Acute MI block was more frequently achieved in the VOM-Et group (98.7% [150/152] vs. 63.6% [70/110]; p < 0.001) with shorter RFCA duration (5.00 [3.00-7.00] vs. 19.0 [13.6-22.0] mins; p < 0.001). Of the 220 patients with MI block achieved during the index procedure, 81 underwent a repeat procedure during follow-up (VOM-Et group: 23.3% [35/150] vs. RFCA group: 65.7% [46/70], respectively; p < 0.001). A significantly greater number of patients exhibited durable MI block in the VOM-Et group (62.9% [22/35] vs. 32.6% [15/46], respectively; p = 0.008).- Beyond facilitating acute MI block, VOM-Et is associated with greater lesion durability as evidenced by higher rates of MI block during repeat procedures.



Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print
Nakashima T, Pambrun T, Vlachos K, Goujeau C, ... Jaïs P, Derval N
Circ Arrhythm Electrophysiol: 15 Nov 2020; epub ahead of print | PMID: 33197321
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiac Inflammation Impedes Response to Cardiac Resynchronization Therapy in Patients With Idiopathic Dilated Cardiomyopathy.

Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, ... Heymans SRB, Hazebroek MR
Background
Cardiac resynchronization therapy (CRT) is an established therapy in patients with dilated cardiomyopathy (DCM) and conduction disorders. Still, one-third of the patients with DCM do not respond to CRT. This study aims to depict the underlying cardiac pathophysiological processes of nonresponse to CRT in patients with DCM using endomyocardial biopsies.
Methods
Within the Maastricht and Innsbruck registries of patients with DCM, 99 patients underwent endomyocardial biopsies before CRT implantation, with histological quantification of fibrosis and inflammation, where inflammation was defined as >14 infiltrating cells/mm. Echocardiographic left ventricular end-systolic volume reduction ≥15% after 6 months was defined as response to CRT. RNA was isolated from cardiac biopsies of a representative subset of responders and nonresponders.
Results
Sixty-seven patients responded (68%), whereas 32 (32%) did not respond to CRT. Cardiac inflammation before implantation was negatively associated with response to CRT (25% of responders, 47% of nonresponders; odds ratio 0.3 [0.12-0.76]; =0.01). Endomyocardial biopsies fibrosis did not relate to CRT response. Cardiac inflammation improved the robustness of prediction beyond well-known clinical predictors of CRT response (likelihood ratio test <0.001). Cardiac transcriptomic profiling of endomyocardial biopsies reveals a strong proinflammatory and profibrotic signature in the hearts of nonresponders compared with responders. In particular, , andwere significantly higher expressed in the hearts of nonresponders.
Conclusions
Cardiac inflammation along with a transcriptomic profile of high expression of combined proinflammatory and profibrotic genes are associated with a poor response to CRT in patients with DCM.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008727
Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, ... Heymans SRB, Hazebroek MR
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008727 | PMID: 32997547
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Superior-Type Fast-Slow Atrioventricular Nodal Reentrant Tachycardia Phenotype Mimicking the Slow-Fast Type.

Kaneko Y, Nakajima T, Tamura S, Hasegawa H, ... Iizuka T, Kurabayashi M
Background
Superior-type fast-slow (sup-F/S-) atrioventricular nodal reentrant tachycardia (AVNRT) is a rare AVNRT variant using a superior slow pathway (SP) as the retrograde limb. Its intracardiac appearance, characterized by a short atrio-His (AH) interval and the earliest site of atrial activation in the His-bundle, is an initial indicator for making a diagnosis.
Methods
Among 22 consecutive patients with sup-F/S-AVNRT, 3 (age, 68-81 years) patients had an apparent slow-fast (S/F-) AVNRT characterized by a long AH interval and the earliest site of atrial activation in or superior to the His-bundle region (tachy-long-AH).
Results
The diagnosis of sup-F/S-AVNRT was based on the standard criteria in 2 patients and on the occurrence of Wenckebach-type atrioventricular block during tachycardia, which was attributable to a block at the lower common pathway (LCP) below the circuit of the AVNRT, detected owing to the lower common pathway potentials, in one patient. As with the typical S/F-AVNRT, tachy-long-AH was induced after a jump in the AH interval. In contrast to typical S/F-AVNRT, fluctuation in the ventriculoatrial interval was observed during the tachy-long-AH. Ventricular overdrive pacing was unable to entrain or terminate the tachy-long-AH. Moreover, the tachy-long-AH reciprocally transited to/from sup-F/S-AVNRT spontaneously or was triggered by ventricular contractions while the atrial cycle length and earliest site of atrial activation remained unchanged. Both tachycardias were cured by ablation at a single site in the right-side para-Hisian region of 2 patients and the noncoronary aortic cusp of one patient. Collectively, the essential circuit of both tachycardias was identical, and the tachy-long-AH was diagnosed as another phenotype of sup-F/S-AVNRT accompanied by sustained antegrade conduction via another bystander slow pathway breaking through the His-bundle owing to the repetitive antegrade block at the lower common pathway, thus representing a long AH interval during the ongoing sup-F/S-AVNRT.
Conclusions
An unknown sup-F/S-AVNRT phenotype exists that apparently mimics the typical S/F-AVNRT and is also an unknown subtype of apparent S/F-AVNRT.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008732
Kaneko Y, Nakajima T, Tamura S, Hasegawa H, ... Iizuka T, Kurabayashi M
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008732 | PMID: 33000970
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-Term Outcomes of Left Atrial Appendage Electrical Isolation in Patients With Nonparoxysmal Atrial Fibrillation: A Propensity Score-Matched Analysis.

Romero J, Di Biase L, Mohanty S, Trivedi C, ... Lakkireddy D, Natale A
Background
Left atrial appendage electrical isolation (LAAEI) has been proposed for the treatment of nonparoxysmal atrial fibrillation (AF). The long-term clinical outcomes of this approach remain unclear. The objective of our study was to investigate the incremental benefit and safety of LAAEI in patients undergoing catheter ablation for nonparoxysmal AF.
Methods
Propensity score-matched analysis was performed using a prospective registry database from 2010 to 2014. All patients in the LAAEI group were matched based on baseline characteristics, echocardiographic parameters, and procedural ablation techniques.
Results
We identified 1842 patients who underwent catheter ablation for nonparoxysmal AF. Propensity score matching yielded 1092 patients, 546 patients with LAAEI, and 546 patients without LAAEI. At 5-year follow-up, overall freedom from all-atrial arrhythmia recurrence, off-antiarrhythmic drugs, in patients who underwent LAAEI was 68.9% versus 50.2% in those who underwent standard ablation alone (<0.001). Acute complication rates were similar between groups (LAAEI 1.3% versus non-LAAEI 0.73%, =0.36). At 5-year follow-up, 382 (70%) patients in the LAAEI group remained on oral anticoagulation versus 217 (39.7%) in the non-LAAEI group. At 5-year follow-up, thromboembolic events occurred in 15/546 (2.75%) in the LAAEI group and 4/546 (0.73%) in the non-LAAEI group (=0.01). No thromboembolic events occurred in either group on-oral anticoagulation. In patients who were off-oral anticoagulation, at 5-year follow-up, thromboembolic events occurred in 15/164 (9.1%) in the LAAEI group and 4/329 (1.2%) in the non-LAAEI group (<0.001).
Conclusions
At 5-year follow-up, LAAEI was associated with significantly higher freedom from all-atrial arrhythmia recurrence in patients with persistent and long-standing persistent AF without increasing acute procedural complication rate. In patients off-oral anticoagulation, there appears to be a higher risk of thromboembolic events in the LAAEI group.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008390
Romero J, Di Biase L, Mohanty S, Trivedi C, ... Lakkireddy D, Natale A
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008390 | PMID: 32998529
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-Term Outcome of the Randomized DAPA Trial.

Haanschoten DM, Elvan A, Ramdat Misier AR, Delnoy PPHM, ... Ottervanger JP,
Background
The randomized DAPA trial (Defibrillator After Primary Angioplasty) aimed to evaluate the survival benefit of prophylactic implantable cardioverter defibrillator (ICD) implantation in early selected high-risk patients after primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction.
Methods
A randomized, multicenter, controlled trial compared ICD versus conventional medical therapy in high-risk patients with primary percutaneous coronary intervention, based on one of the following factors: left ventricular ejection fraction <30% within 4 days after ST-segment-elevation myocardial infarction, primary ventricular fibrillation, Killip class ≥2 or TIMI (Thrombolysis in Myocardial Infarction) flow <3 after percutaneous coronary intervention. ICD was implanted 30 to 60 days after MI. Primary end point was all-cause mortality at 3 years follow-up. The trial prematurely ended after inclusion of 266 patients (38% of the calculated sample size). Additional survival assessment was performed in February 2019 for the primary end point.
Results
A total of 266 patients, 78.2% males, with a mean age of 60.8±11.3 years, were enrolled. One hundred thirty-one patients were randomized to the ICD arm and 135 patients to the control arm. All-cause mortality was significant lower in the ICD group (5% versus 13%, hazard ratio, 0.37 [95% CI, 0.15-0.95]) after 3 years follow-up. Appropriate ICD therapy occurred in 9 patients at 3 years follow-up (5 within the first 8 months after implantation). After a median long-term follow-up of 9 years (interquartile range, 3-11), total mortality (18% versus 38%; hazard ratio, 0.58 [95% CI, 0.37-0.91]), and cardiac mortality (hazard ratio, 0.52 [95% CI, 0.28-0.99]) was significant lower in the ICD group. Noncardiac death was not significantly different between groups. Left ventricular ejection fraction increased ≥10% in 46.5% of the patients during follow-up, and the extent of improvement was similar in both study groups.
Conclusions
In this prematurely terminated and thus underpowered randomized trial, early prophylactic ICD implantation demonstrated lower total and cardiac mortality in patients with high-risk ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention. Registration: URL: https://www.trialregister.nl; Unique identifier: Trial NL74 (NTR105).



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008484
Haanschoten DM, Elvan A, Ramdat Misier AR, Delnoy PPHM, ... Ottervanger JP,
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008484 | PMID: 33003972
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Risk Factors for Early Recurrence Following Ablation for Accessory Pathways: The Role of Consolidation Lesions.

Dionne A, Gauvreau K, O\'Leary E, Mah DY, ... Triedman JK, Walsh EP
Background
Atrioventricular reentrant tachycardia is common in children. Catheter ablation is increasingly used as a first-line therapy with a high acute success rate, but recurrence during follow-up remains a concern. The aim of this study was to identify risk factors for recurrence after accessory pathway (AP) ablation.
Methods
Retrospective cohort study including patients who underwent AP ablation between 2013 and 2018. Cox proportional hazards model was used to examine the association between patient and procedural characteristics and recurrence during follow-up.
Results
From 558 AP ablation procedure, 542 (97%) were acutely successful. During a median follow-up of 0.4 (interquartile range, 0.1-1.4) years, there were 42 (8%) patients with documented recurrence. On univariate analysis, early recurrence was associated with younger age, congenital heart disease, multiple AP, AP location (right sided and posteroseptal versus left sided), cryoablation (versus radiofrequency), empirical ablation, the lack of full power radiofrequency lesions (<50 W), radiofrequency consolidation time <90 seconds and the use of fluoroscopy without a 3-dimensional electroanatomic mapping system. On multivariable analysis, only multiple AP (hazard ratio, 2.78 [95% CI, 1.063-4.74]) and radiofrequency consolidation time < 90 seconds (hazard ratio, 4.38 [95% CI, 1.92-9.51]) remained significantly associated with early recurrence; this association remained true when analyzed in subgroups by pathway location for right and left free wall AP.
Conclusions
In our institutional experience, radiofrequency consolidation time <90 seconds after ablation of AP was associated with an increased risk of early recurrence.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008848
Dionne A, Gauvreau K, O'Leary E, Mah DY, ... Triedman JK, Walsh EP
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008848 | PMID: 33017181
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Three-Dimensional Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Predicts Inducibility of Ventricular Tachycardia in Adults With Repaired Tetralogy of Fallot.

Ghonim S, Ernst S, Keegan J, Giannakidis A, ... Gatzoulis MA, Babu-Narayan SV
Background
Adults with repaired tetralogy of Fallot die prematurely from ventricular tachycardia (VT) and sudden cardiac death. Inducible VT predicts mortality. Ventricular scar, the key substrate for VT, can be noninvasively defined with late gadolinium enhancement (LGE) cardiovascular magnetic resonance but whether this relates to inducible VT is unknown.
Methods
Sixty-nine consecutive repaired tetralogy of Fallot patients (43 male, mean 40±15 years) clinically scheduled for invasive programmed VT-stimulation were prospectively recruited for prior 3-dimensional LGE cardiovascular magnetic resonance. Ventricular LGE was segmented and merged with reconstructed cardiac chambers and LGE volume measured.
Results
VT was induced in 22 (31%) patients. Univariable predictors of inducible VT included increased RV LGE (odds ratio [OR], 1.15; =0.001 per cm), increased nonapical vent LV LGE (OR, 1.09; =0.008 per cm), older age (OR, 1.6; =0.01 per decile), QRS duration ≥180 ms (OR, 3.5; =0.02), history of nonsustained VT (OR, 3.5; =0.02), and previous clinical sustained VT (OR, 12.8; =0.003); only prior sustained VT (OR, 8.02; =0.02) remained independent in bivariable analyses after controlling for RV LGE volume (OR, 1.14; =0.003). An RV LGE volume of 25 cm had 72% sensitivity and 81% specificity for predicting inducible VT (area under the curve, 0.81; <0.001). At the extreme cutoffs for ruling-out and ruling-in inducible VT, RV LGE >10 cm was 100% sensitive and >36 cm was 100% specific for predicting inducible VT.
Conclusions
Three-dimensional LGE cardiovascular magnetic resonance-defined scar burden is independently associated with inducible VT and may help refine patient selection for programmed VT-stimulation when applied to an at least intermediate clinical risk cohort.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008321
Ghonim S, Ernst S, Keegan J, Giannakidis A, ... Gatzoulis MA, Babu-Narayan SV
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008321 | PMID: 33022183
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Digital Health and the Care of the Patient With Arrhythmia: What Every Electrophysiologist Needs to Know.

Tarakji KG, Silva J, Chen LY, Turakhia MP, ... Wan EY, Chung M

The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and health care apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e007953
Tarakji KG, Silva J, Chen LY, Turakhia MP, ... Wan EY, Chung M
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e007953 | PMID: 33021815
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The Clinical Application of the Deep Learning Technique for Predicting Trigger Origins in Patients With Paroxysmal Atrial Fibrillation With Catheter Ablation.

Liu CM, Chang SL, Chen HH, Chen WS, ... Lu HH, Chen SA
Background
Non-pulmonary vein (NPV) trigger has been reported as an important predictor of recurrence post-atrial fibrillation ablation. Elimination of NPV triggers can reduce the recurrence of postablation atrial fibrillation. Deep learning was applied to preablation pulmonary vein computed tomography geometric slices to create a prediction model for NPV triggers in patients with paroxysmal atrial fibrillation.
Methods
We retrospectively analyzed 521 patients with paroxysmal atrial fibrillation who underwent catheter ablation of paroxysmal atrial fibrillation. Among them, pulmonary vein computed tomography geometric slices from 358 patients with nonrecurrent atrial fibrillation (1-3 mm interspace per slice, 20-200 slices for each patient, ranging from the upper border of the left atrium to the bottom of the heart, for a total of 23 683 images of slices) were used in the deep learning process, the ResNet34 of the neural network, to create the prediction model of the NPV trigger. There were 298 (83.2%) patients with only pulmonary vein triggers and 60 (16.8%) patients with NPV triggers±pulmonary vein triggers. The patients were randomly assigned to either training, validation, or test groups, and their data were allocated according to those sets. The image datasets were split into training (n=17 340), validation (n=3491), and testing (n=2852) groups, which had completely independent sets of patients.
Results
The accuracy of prediction in each pulmonary vein computed tomography image for NPV trigger was up to 82.4±2.0%. The sensitivity and specificity were 64.3±5.4% and 88.4±1.9%, respectively. For each patient, the accuracy of prediction for a NPV trigger was 88.6±2.3%. The sensitivity and specificity were 75.0±5.8% and 95.7±1.8%, respectively. The area under the curve for each image and patient were 0.82±0.01 and 0.88±0.07, respectively.
Conclusions
The deep learning model using preablation pulmonary vein computed tomography can be applied to predict the trigger origins in patients with paroxysmal atrial fibrillation receiving catheter ablation. The application of this model may identify patients with a high risk of NPV trigger before ablation.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008518
Liu CM, Chang SL, Chen HH, Chen WS, ... Lu HH, Chen SA
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008518 | PMID: 33021404
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Magnetic Resonance Imaging-Guided Fibrosis Ablation for the Treatment of Atrial Fibrillation: The ALICIA Trial.

Bisbal F, Benito E, Teis A, Alarcón F, ... Bayés-Genís A, Mont L
Background
Myocardial fibrosis is key for atrial fibrillation maintenance. We aimed to test the efficacy of ablating cardiac magnetic resonance (CMR)-detected atrial fibrosis plus pulmonary vein isolation (PVI).
Methods
This was an open-label, parallel-group, randomized, controlled trial. Patients with symptomatic drug-refractory atrial fibrillation (paroxysmal and persistent) undergoing first or repeat ablation were randomized in a 1:1 basis to receive PVI plus CMR-guided fibrosis ablation (CMR group) or PVI alone (PVI-alone group). The primary end point was the rate of recurrence (>30 seconds) at 12 months of follow-up using a 12-lead ECG and Holter monitoring at 3, 6, and 12 months. The analysis was conducted by intention-to-treat.
Results
In total, 155 patients (71% male, age 59±10, CHADS-VASc 1.3±1.1, 54% paroxysmal atrial fibrillation) were allocated to the PVI-alone group (N=76) or CMR group (N=79). First ablation was performed in 80% and 71% of patients in the PVI-alone and CMR groups, respectively. The mean atrial fibrosis burden was 12% (only ≈50% of patients had fibrosis outside the pulmonary vein area). One hundred percent and 99% of patients received the assigned intervention in the PVI-alone and CMR group, respectively. The primary outcome was achieved in 21 patients (27.6%) in the PVI-alone group and 22 patients (27.8%) in the CMR group (odds ratio: 1.01 [95% CI, 0.50-2.04]; =0.976). There were no differences in the rate of adverse events (3 in the CMR group and 2 in the PVI-alone group; =0.68).
Conclusions
A pragmatic ablation approach targeting CMR-detected atrial fibrosis plus PVI was not more effective than PVI alone in an unselected population undergoing atrial fibrillation ablation with low fibrosis burden. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02698631.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008707
Bisbal F, Benito E, Teis A, Alarcón F, ... Bayés-Genís A, Mont L
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008707 | PMID: 33031713
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cross-Center Virtual Education Fellowship Program for Early-Career Researchers in Atrial Fibrillation.

Ajayi TB, Remein CD, Stafford RS, Fagerlin A, ... Childs E, Benjamin EJ
Background
It is estimated that over 46 million individuals have atrial fibrillation (AF) worldwide, and the incidence and prevalence of AF are increasing globally. There is an urgent need to accelerate the academic development of scientists possessing the skills to conduct innovative, collaborative AF research.
Methods
We designed and implemented a virtual AF Strategically Focused Research Network Cross-Center Fellowship program to enhance the competencies of early-stage AF basic, clinical, and population health researchers through experiential education and mentorship. The pedagogical model involves significant cross-center collaboration to produce a curriculum focused on enhancing AF scientific competencies, fostering career/professional development, and cultivating grant writing skills. Outcomes for success involve clear expectations for fellows to produce manuscripts, presentations, and-for those at the appropriate career stage-grant applications. We evaluated the effectiveness of the fellowship model via mixed methods formative and summative surveys.
Results
In 2 years of the fellowship, fellows generally achieved the productivity metrics sought by our pedagogical model, with outcomes for the 12 fellows including 50 AF-related manuscripts, 7 publications, 28 presentations, and 3 grant awards applications. Participant evaluations reported that the fellowship effectively met its educational objectives. All fellows reported medium to high satisfaction with the overall fellowship, webinar content and facilitation, staff communication and support, and program organization.
Conclusions
The fellowship model represents an innovative educational strategy by providing a virtual AF training and mentoring curriculum for early-career basic, clinical, and population health scientists working across multiple institutions, which is particularly valuable in the pandemic era.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008552
Ajayi TB, Remein CD, Stafford RS, Fagerlin A, ... Childs E, Benjamin EJ
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008552 | PMID: 33031707
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Histopathologic and Ultrastructural Findings in Human Myocardium After Stereotactic Body Radiation Therapy for Recalcitrant Ventricular Tachycardia.

Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS
Background
Stereotactic body radiation therapy (SBRT) is a novel treatment for refractory ventricular tachycardia (VT). While outcomes have been described in small studies, histological findings after SBRT for VT are unknown.
Methods
We identified 4 explanted hearts in the context of transplant that received prior SBRT as part of an 11-patient compassionate use series at our institution. Clinical VTs and computed tomography-defined target volume areas of SBRT were correlated to the anatomic specimens. Gross pathological, histological, and ultrastructural examination of tissue in the target area of SBRT was performed.
Results
All 4 patients had nonischemic cardiomyopathy, and 3 had left ventricular assist devices. In all cases, patients had recurrent sustained VT and had failed multiple antiarrhythmics and radiofrequency ablations. Four patients underwent 5 total SBRT therapy sessions with 25-Gy single-fraction dose delivered to the area of culprit scar. The time from SBRT to explant ranged from 12 to 250 days. Histopathologic features following radiation were comparable in all patients and were characterized by areas of subendocardial necrosis surrounded by a rim of fibrosis. In 1 patient, the surrounding myocardium showed cytoplasmic vacuolization in myocytes and in another patchy interstitial fibrosis. Vascular changes consisted of myointimal thickening with prominence of endothelial cells. Electron microscopy of myocardium showed irregular, convoluted intercalated disc regions, loss of contractile elements with disrupted and haphazardly arranged myofibrils, and edematous mitochondria with loss of cisternae.
Conclusions
Here, we report the first series of findings in human tissue in 4 patients after SBRT. Histopathologic features were consistent across all 4 patients and were indicative of cell injury, death, and to a lesser extent, fibrosis. Electron microscopy demonstrated features consistent with acute injury. These specimens provide radiobiological mechanisms of acute cellular injury during SBRT for VT, which may have an antiarrhythmic effect before the onset of fibrosis.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008753
Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008753 | PMID: 33031001
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Social Media Influence Does Not Reflect Scholarly or Clinical Activity in Real Life.

Zenger B, Swink JM, Turner JL, Bunch TJ, ... Piccini JP, Steinberg BA
Background
Social media has become a major source of communication in medicine. We aimed to understand the relationship between physicians\' social media influence and their scholarly and clinical activity.
Methods
We identified attending US electrophysiologists on Twitter. We compared physician Twitter activity to (1) scholarly publication record (h-index) and (2) clinical volume according to Centers for Medicare and Medicaid Services. The ratio of observed versus expected (obs/exp) Twitter followers was calculated based on each scholarly (K-index) and clinical activity.
Results
We identified 284 physicians, with mean Twitter age of 5.0 (SD, 3.1) years and median 568 followers (25th, 75th: 195, 1146). They had a median 34.5 peer-reviewed articles (25th, 75th: 14, 105), 401 citations (25th, 75th: 102, 1677), and h-index 9 (25th, 75th: 4, 19.8). The median K-index was 0.4 (25th, 75th: 0.15, 1.0), ranging from 0.0008 to 29.2. The median number of electrophysiology procedures was 77 (25th, 75th: 0, 160) and evaluation and management visits 264 (25th, 75th: 59, 516) in 2017. The top 1% electrophysiologists for followers accounted for 20% of all followers, 17% of status updates, had a mean h-index of 6 (versus 15 for others, =0.3), and accounted for 1% of procedural and evaluation and management volumes. They had a mean K-index of 21 (versus 0.77 for others, <0.0001) and clinical obs/exp follower ratio of 17.9 and 18.1 for procedures and evaluation and management (<0.001 each, versus others [0.81 for each]).
Conclusions
Electrophysiologists are active on Twitter, with modest influence often representative of scholarly and clinical activity. However, the most influential physicians appear to have relatively modest scholarly and clinical activity.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008847
Zenger B, Swink JM, Turner JL, Bunch TJ, ... Piccini JP, Steinberg BA
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008847 | PMID: 33030380
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Left Ventricular Enlargement, Cardiac Resynchronization Therapy Efficacy, and Impact of MultiPoint Pacing.

Varma N, Baker J, Tomassoni G, Love CJ, ... Lee K, Corbisiero R
Background
Left ventricular (LV) epicardial pacing results in slowly propagating paced wavefronts. We postulated that this effect might limit cardiac resynchronization therapy efficacy in patients with LV enlargement using conventional biventricular pacing with single-site LV pacing, but be mitigated by LV stimulation from 2 widely spaced sites using MultiPoint pacing with wide anatomic separation (MPP-AS: ≥30 mm). We tested this hypothesis in the multicenter randomized MPP investigational device exemption trial.
Methods
Following implant, quadripolar biventricular single-site pacing was activated in all patients (n=506). From 3 to 9 months postimplant, among patients with available baseline LV end-diastolic volume (LVEDV) measures, 188 received biventricular single-site pacing and 43 received MPP-AS. Patients were dichotomized by median baseline LVEDV indexed to height (LVEDVI). Outcomes were measured by the clinical composite score (primary efficacy end point), quality of life, LV structural remodeling (↑EF >5% and ↓ESV 10%) and heart failure event/cardiovascular death.
Results
LVEDVI was 1.1 mL/cm. Baseline characteristics differed in patients with LVEDVI versus LVEDVI. Among patients with LVEDVI, biventricular single-site pacing was less efficacious compared to patients with LVEDVI (clinical composite score, 65% versus 79%). In contrast, MPP-AS programming generated greater clinical composite score response (92% versus 65%, =0.023) and improved quality of life (-31.0±29.7 versus -15.7±22.1, =0.038) versus biventricular single-site pacing in patients with LVEDVI. Reverse remodeling trended better with MPP-AS programming. In patients with LVEDVI, heart failure event rate increased following the 3-month randomization point with biventricular single-site pacing (0.0150±0.1725 in LVEDVI -0.0190±0.0808 in LVEDVI , =0.012), but no heart failure event occurred in patients with MPP-AS programming between 3 and 9 months in LVEDVI. All measured outcomes did not differ in patients receiving MPP-AS and biventricular single-site pacing with LVEDVI.
Conclusions
Conventional biventricular single-site pacing, even with a quadripolar lead, has reduced efficacy in patients with LV enlargement. However, the greatest response rate in patients with larger hearts was observed when programmed to MPP-AS pacing.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008680
Varma N, Baker J, Tomassoni G, Love CJ, ... Lee K, Corbisiero R
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008680 | PMID: 33028082
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Novel Neuromodulation Approach to Improve Left Ventricular Contractility in Heart Failure: A First-in-Human Proof-of-Concept Study.

Y Reddy V, Petrů J, Málek F, Stylos L, Goedeke S, Neužil P
Background
Morbidity and mortality outcomes for patients admitted for acute decompensated heart failure are poor and have not significantly changed in decades. Current therapies are focused on symptom relief by addressing signs and symptoms of congestion. The objective of this study was to test a novel neuromodulation therapy of stimulation of epicardial cardiac nerves passing along the posterior surface of the right pulmonary artery.
Methods
Fifteen subjects admitted for defibrillator implantation and ejection fraction ≤35% on standard heart failure medications were enrolled. Through femoral arterial access, high fidelity pressure catheters were placed in the left ventricle and aortic root. After electro anatomic rendering of the pulmonary artery and branches, either a circular or basket electrophysiology catheter was placed in the right pulmonary artery to allow electrical intravascular stimulation at 20 Hz, 4 ms pulse width, and ≤20 mA. Changes in maximum positive dP/dt (dP/dt) indicated changes in ventricular contractility.
Results
Of 15 enrolled subjects, 5 were not studied due to equipment failure or abnormal pulmonary arterial anatomy. In the remaining subjects, dP/dt increased significantly by 22.6%. There was also a significant increase in maximum negative dP/dt (dP/dt), mean arterial pressure, systolic pressure, diastolic pressure, and left ventricular systolic pressure. There was no significant change in heart rate or left ventricular diastolic pressure.
Conclusions
In this first-in-human study, we demonstrated that in humans with stable heart failure, left ventricular contractility could be accentuated without an increase in heart rate or left ventricular filling pressures. This benign increase in contractility may benefit patients admitted for acute decompensated heart failure.



Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008407
Y Reddy V, Petrů J, Málek F, Stylos L, Goedeke S, Neužil P
Circ Arrhythm Electrophysiol: 30 Oct 2020; 13:e008407 | PMID: 32991220
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiac Emerinopathy: A Nonsyndromic Nuclear Envelopathy With Increased Risk of Thromboembolic Stroke Due to Progressive Atrial Standstill and Left Ventricular Noncompaction.

Ishikawa T, Mishima H, Barc J, Takahashi MP, ... Schott JJ, Makita N
Background
Mutations in the nuclear envelope genes encodingandare responsible for Emery-Dreifuss muscular dystrophy. However,mutations often manifest dilated cardiomyopathy with conduction disturbance without obvious skeletal myopathic complications. On the contrary, the phenotypic spectrums ofmutations are less clear. Our aims were to determine the prevalence of nonsyndromic forms of emerinopathy, which may underlie genetically undefined isolated cardiac conduction disturbance, and the etiology of thromboembolic complications associated withmutations.
Methods
Targeted exon sequencing was performed in 87 probands with familial sick sinus syndrome (n=36) and a progressive cardiac conduction defect (n=51).
Results
We identified 3 X-linked recessivemutations (start-loss, splicing, missense) in families with cardiac conduction disease. All 3 probands shared a common clinical phenotype of progressive atrial arrhythmias that ultimately resulted in atrial standstill associated with left ventricular noncompaction (LVNC), but they lacked early contractures and progressive muscle wasting and weakness characteristic of Emery-Dreifuss muscular dystrophy. Because the association of LVNC withhas never been reported, we further genetically screened 102 LVNC patients and found a frameshiftmutation in a boy with progressive atrial standstill and LVNC without complications of muscular dystrophy. All 6 malemutation carriers of 4 families underwent pacemaker or defibrillator implantation, whereas 2 female carriers were asymptomatic. Notably, a strong family history of stroke observed in these families was probably due to the increased risk of thromboembolism attributable to both atrial standstill and LVNC.
Conclusions
Cardiac emerinopathy is a novel nonsyndromic X-linked progressive atrial standstill associated with LVNC and increased risk of thromboembolism.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008712
Ishikawa T, Mishima H, Barc J, Takahashi MP, ... Schott JJ, Makita N
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008712 | PMID: 32755394
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Impact of Left Ventricular Function and Heart Failure Symptoms on Outcomes Post Ablation of Atrial Fibrillation in Heart Failure: CASTLE-AF Trial.

Sohns C, Zintl K, Zhao Y, Dagher L, ... Brachmann J, Marrouche NF
Background
Recent data demonstrate promising effects on left ventricular dysfunction and left ventricular ejection fraction (LVEF) improvement following ablation for atrial fibrillation (AF) in patients with heart failure. We sought to study the relationship between LVEF, New York Heart Association class on presentation, and the end points of mortality and heart failure admissions in the CASTLE-AF study (Catheter Ablation for Atrial Fibrillation With Heart Failure) population. Furthermore, predictors for LVEF improvement were examined.
Methods
The CASTLE-AF patients with coexisting heart failure and AF (n=363) were randomized in a multicenter prospective controlled fashion to ablation (n=179) versus pharmacological therapy (n=184). Left ventricular function and New York Heart Association class were assessed at baseline (after randomization) and at each follow-up visit.
Results
In the ablation arm, a significantly higher number of patients experienced an improvement in their LVEF to >35% at the end of the study (odds ratio, 2.17; <0.001). Compared with the pharmacological therapy arm, both ablation patient groups with severe (<20%) or moderate/severe (≥20% and <35%) baseline LVEF had a significantly lower number of composite end points (hazard ratio [HR], 0.60; =0.006), all-cause mortality (HR, 0.54; =0.019), and cardiovascular hospitalizations (HR, 0.66; =0.017). In the ablation group, New York Heart Association I/II patients at the time of treatment had the strongest improvement in clinical outcomes (primary end point: HR, 0.43; <0.001; mortality: HR, 0.30; =0.001).
Conclusions
Compared with pharmacological treatment, AF ablation was associated with a significant improvement in LVEF, independent from the severity of left ventricular dysfunction. AF ablation should be performed at early stages of the patient\'s heart failure symptoms.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008461
Sohns C, Zintl K, Zhao Y, Dagher L, ... Brachmann J, Marrouche NF
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008461 | PMID: 32903044
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prospective STAR-Guided Ablation in Persistent Atrial Fibrillation Using Sequential Mapping With Multipolar Catheters.

Honarbakhsh S, Schilling RJ, Finlay M, Keating E, Hunter RJ
Background
A novel stochastic trajectory analysis of ranked signals (STAR) mapping approach to guide atrial fibrillation (AF) ablation using basket catheters recently showed high rates of AF termination and subsequent freedom from AF.
Methods
This study aimed to determine whether STAR mapping using sequential recordings from conventional pulmonary vein mapping catheters could achieve similar results. Patients with persistent AF<2 years were included. Following pulmonary vein isolation AF drivers (AFDs) were identified on sequential STAR maps created with PentaRay, IntellaMap Orion, or Advisor HD Grid catheters. Patients had a minimum of 10 multipolar recordings of 30 seconds each. These were processed in real-time and AFDs were targeted with ablation. An ablation response was defined as AF termination or cycle length slowing ≥30 ms.
Results
Thirty patients were included (62.4±7.8 years old, AF duration 14.1±4.3 months) of which 3 had AF terminated on pulmonary vein isolation, leaving 27 patients that underwent STAR-guided AFD ablation. Eighty-three potential AFDs were identified (3.1±1.1 per patient) of which 70 were targeted with ablation (2.6±1.2 per patient). An ablation response was seen at 54 AFDs (77.1% of AFDs; 21 AF termination and 33 cycle length slowing) and occurred in all 27 patients. No complications occurred. At 17.3±10.1 months, 22 out of 27 (81.5%) patients undergoing STAR-guided ablation were free from AF/atrial tachycardia off antiarrhythmic drugs.
Conclusions
STAR-guided AFD ablation through sequential mapping with a multipolar catheter effectively achieved an ablation response in all patients. AF terminated in a majority of patients, with a high freedom from AF/atrial tachycardia off antiarrhythmic drugs at long-term follow-up. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02950844.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008824
Honarbakhsh S, Schilling RJ, Finlay M, Keating E, Hunter RJ
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008824 | PMID: 32903033
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Pulmonary Vein Isolation With Single Pulse Irreversible Electroporation: A First in Human Study in 10 Patients With Atrial Fibrillation.

Loh P, van Es R, Groen MHA, Neven K, ... Wittkampf FHM, Doevendans PA
Background
Irreversible electroporation (IRE) is a promising new nonthermal ablation technology for pulmonary vein (PV) isolation in patients with atrial fibrillation. Experimental data suggest that IRE ablation produces large enough lesions without the risk of PV stenosis, artery, nerve, or esophageal damage. This study aimed to investigate the feasibility and safety of single pulse IRE PV isolation in patients with atrial fibrillation.
Methods
Ten patients with symptomatic paroxysmal or persistent atrial fibrillation underwent single pulse IRE PV isolation under general anesthesia. Three-dimensional reconstruction and electroanatomical voltage mapping (EnSite Precision, Abbott) of left atrium and PVs were performed using a conventional circular mapping catheter. PV isolation was performed by delivering nonarcing, nonbarotraumatic 6 ms, 200 J direct current IRE applications via a custom nondeflectable 14-polar circular IRE ablation catheter with a variable hoop diameter (16-27 mm). A deflectable sheath (Agilis, Abbott) was used to maneuver the ablation catheter. A minimum of 2 IRE applications with slightly different catheter positions were delivered per vein to achieve circular tissue contact, even if PV potentials were abolished after the first application. Bidirectional PV isolation was confirmed with the circular mapping catheter and a post ablation voltage map. After a 30-minute waiting period, adenosine testing (30 mg) was used to reveal dormant PV conduction.
Results
All 40 PVs could be successfully isolated with a mean of 2.4±0.4 IRE applications per PV. Mean delivered peak voltage and peak current were 2154±59 V and 33.9±1.6 A, respectively. No PV reconnections occurred during the waiting period and adenosine testing. No periprocedural complications were observed.
Conclusions
In the 10 patients of this first-in-human study, acute bidirectional electrical PV isolation could be achieved safely by single pulse IRE ablation.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008192
Loh P, van Es R, Groen MHA, Neven K, ... Wittkampf FHM, Doevendans PA
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008192 | PMID: 32898450
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Power, Lesion Size Index and Oesophageal Temperature Alerts During Atrial Fibrillation Ablation: A Randomized Study.

Leo M, Pedersen M, Rajappan K, Ginks MR, ... Bashir Y, Betts TR
Background
Low radiofrequency powers are commonly used on the posterior wall of the left atrium for atrial fibrillation ablation to prevent esophageal damage. Compared with higher powers, they require longer ablation durations to achieve a target lesion size index (LSI). Esophageal heating during ablation is the result of a time-dependent process of conductive heating produced by nearby radiofrequency delivery. This randomized study was conducted to compare risk of esophageal heating and acute procedure success of different LSI-guided ablation protocols combining higher or lower radiofrequency power and different target LSI values.
Methods
Eighty consecutive patients were prospectively enrolled and randomized to one of 4 combinations of radiofrequency power and target LSI for ablation on the left atrium posterior wall (20 W/LSI 4, 20 W/LSI 5, 40 W/LSI 4, and 40 W/LSI 5). The primary end point of the study was the occurrence and number of esophageal temperature alerts per patient during ablation. Acute indicators of procedure success were considered as secondary end points. Long-term follow-up data were also collected for all patients.
Results
Esophageal temperature alerts occurred in a similar proportion of patients in all groups. Significantly, shorter radiofrequency durations were required to achieve the target LSI in the 40 W groups. Less than 50% of the radiofrequency lesions reached the target LSI of 5 when using 20 W despite a longer radiofrequency duration. A lower rate of first-pass pulmonary vein isolation and a higher rate of acute pulmonary vein reconnection were recorded in the group 20 W/LSI 5. A lower atrial fibrillation recurrence rate was observed in the 40 W groups compared with the 20 W groups at 29 months follow-up.
Conclusions
When guided by LSI, posterior wall ablation with 40 W is associated with a similar rate of esophageal temperature alerts and a lower atrial fibrillation recurrence rate at follow-up if compared with 20 W. These data will provide a basis to plan future randomized trials. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02619396.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008316
Leo M, Pedersen M, Rajappan K, Ginks MR, ... Bashir Y, Betts TR
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008316 | PMID: 32898435
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-Term Outcome in High-Risk Patients With Hypertrophic Cardiomyopathy After Primary Prevention Defibrillator Implants.

Rowin EJ, Burrows A, Madias C, Estes NAM, ... Maron MS, Maron BJ
Background
The implantable cardioverter-defibrillator (ICD) is effective for preventing sudden death in patients with hypertrophic cardiomyopathy. However, data on performance and complications of implanted ICDs over particularly long time periods to inform clinical practice is presently incomplete.
Methods
The study cohort comprises 217 consecutive hypertrophic cardiomyopathy patients with primary prevention ICDs implanted before 2008 and followed for ≥10 years (mean 12±4; range to 31).
Results
Patients were 38±17 years at implant and 45 (21%) experienced appropriate interventions terminating ventricular tachycardia/ventricular fibrillation. The majority of ICD discharges occurred ≥5 years after implant (29 patients; 64%), including ≥10 years in 16 patients (36%). Initial device therapy increased in frequency from 2.3% of patients at <1 year to 8.5% of patients at ≥10-years after implant (=0.005). Inappropriate ICD shocks in 39 patients occurred most commonly <5 years after implant (54%) and decreased in frequency with increasing time from implant (from 9.7% of patients at <5 years to 3.8% at ≥10 years, =0.02). Other major device complications including infection and lead fractures and dislodgement occurred in 27 patients (12%) but did not increase in frequency over follow-up after implant (=0.47). There were no arrhythmic sudden death events among the 217 patients with ICD.
Conclusions
In hypertrophic cardiomyopathy, after a primary prevention implant, ICD therapy often followed prolonged periods of device dormancy and increased progressively in frequency over time, including one-third of patients with initial therapy after 5 to 9 years, and an additional one-third of patients at ≥10 years. Frequency of inappropriate shocks decreased over follow-up, likely reflecting standard changes in device programming, while occurrence of device complications, such as lead fractures/infection, did not increase during follow-up.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008123
Rowin EJ, Burrows A, Madias C, Estes NAM, ... Maron MS, Maron BJ
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008123 | PMID: 32897759
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting.

Kaneshiro T, Kamioka M, Hijioka N, Yamada S, ... Yoshihisa A, Takeishi Y
Background
The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation ablation using a HP-SD setting.
Methods
After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and low voltage area ablation in left atrium posterior wall, 271 consecutive patients (62±10 years, 56 women) who underwent pulmonary vein isolation by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45 to 50 W with an Ablation Index module was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20 to 30 W with contact force monitoring was used (conventional group). We performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of ETI.
Results
Although the incidence of ETI was significantly higher in the HP-SD group compared with the conventional group (37% versus 22%, =0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio, 6.09, <0.001), and the parameters that suggest anatomic proximity surrounding the esophagus, were independent predictors of ETI. However, the majority of ETI in the HP-SD group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the HP-SD setting.
Conclusions
Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008602
Kaneshiro T, Kamioka M, Hijioka N, Yamada S, ... Yoshihisa A, Takeishi Y
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008602 | PMID: 32915644
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cost-Effectiveness of an Antibacterial Envelope for Cardiac Implantable Electronic Device Infection Prevention in the US Healthcare System From the WRAP-IT Trial.

Wilkoff BL, Boriani G, Mittal S, Poole JE, ... Seshadri S, Tarakji KG
Background
In the WRAP-IT trial (Worldwide Randomized Antibiotic Envelope Infection Prevention), adjunctive use of an absorbable antibacterial envelope resulted in a 40% reduction of major cardiac implantable electronic device infection without increased risk of complication in 6983 patients undergoing cardiac implantable electronic device revision, replacement, upgrade, or initial cardiac resynchronization therapy defibrillator implant. There is limited information on the cost-effectiveness of this strategy. As a prespecified objective, we evaluated antibacterial envelope cost-effectiveness compared with standard-of-care infection prevention strategies in the US healthcare system.
Methods
A decision tree model was used to compare costs and outcomes of antibacterial envelope (TYRX) use adjunctive to standard-of-care infection prevention versus standard-of-care alone over a lifelong time horizon. The analysis was performed from an integrated payer-provider network perspective. Infection rates, antibacterial envelope effectiveness, infection treatment costs and patterns, infection-related mortality, and utility estimates were obtained from the WRAP-IT trial. Life expectancy and long-term costs associated with device replacement, follow-up, and healthcare utilization were sourced from the literature. Costs and quality-adjusted life years were discounted at 3%. An upper willingness-to-pay threshold of $150 000 per quality-adjusted life year was used to determine cost-effectiveness, in alignment with the American College of Cardiology/American Heart Association practice guidelines and as supported by the World Health Organization and contemporary literature.
Results
The base case incremental cost-effectiveness ratio of the antibacterial envelope compared with standard-of-care was $112 603/quality-adjusted life year. The incremental cost-effectiveness ratio remained lower than the willingness-to-pay threshold in 74% of iterations in the probabilistic sensitivity analysis and was most sensitive to the following model inputs: infection-related mortality, life expectancy, and infection cost.
Conclusions
The absorbable antibacterial envelope was associated with a cost-effectiveness ratio below contemporary benchmarks in the WRAP-IT patient population, suggesting that the envelope provides value for the US healthcare system by reducing the incidence of cardiac implantable electronic device infection. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02277990.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008503
Wilkoff BL, Boriani G, Mittal S, Poole JE, ... Seshadri S, Tarakji KG
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008503 | PMID: 32915063
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-Lasting Ventricular Fibrillation in Humans ECG Characteristics and Effect of Radiofrequency Ablation.

Maury P, Duchateau J, Rollin A, Hocini M, ... Haïssaguerre M, Dubois R
Background
Studies of ventricular fibrillation (VF) in humans are limited because of the short available duration. We sought to study surface ECG waveforms and effect of ablation in long-lasting VF in patients with left assist devices.
Methods
Continuous 12-lead ECG of 5 episodes of long-lasting VF occurring in 3 patients with left ventricular assist device were analyzed. Spectral analysis (dominant frequency) and quantification of waveform amplitude, regularity (Unbiased Regularity Index), and complexity (Nondipolar Index) were performed over a median of 24 minutes of VF. Radiofrequency ablation was performed during VF in 2 patients.
Results
There was a significant increase in dominant frequency between VF onset and termination but none of the other parameters significantly changed. Some VF parameters varied from patient to patient and from lead to lead. Dominant frequency decreased after radiofrequency ablation in both cases and VF terminated spontaneously shortly after ablation in one case. The previously incessant VFs in these 2 patients did not recur afterward.
Conclusions
VF rate increases over time in patients with left ventricular assist devices and is lowered by ablation. Long-lasting VF may be modified or even terminated by ablation.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008639
Maury P, Duchateau J, Rollin A, Hocini M, ... Haïssaguerre M, Dubois R
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008639 | PMID: 32911973
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Catheter-Free Arrhythmia Ablation Using Scanned Proton Beams: Electrophysiologic Outcomes, Biophysics, and Characterization of Lesion Formation in a Porcine Model.

Suzuki A, Deisher AJ, Rettmann ME, Lehmann HI, ... Herman MG, Packer DL
Background
Proton beam therapy offers radiophysical properties that are appealing for noninvasive arrhythmia elimination. This study was conducted to use scanned proton beams for ablation of cardiac tissue, investigate electrophysiological outcomes, and characterize the process of lesion formation in a porcine model using particle therapy.
Methods
Twenty-five animals received scanned proton beam irradiation. ECG-gated computed tomography scans were acquired at end-expiration breath hold. Structures (atrioventricular junction or left ventricular myocardium) and organs at risk were contoured. Doses of 30, 40, and 55 Gy were delivered during expiration to the atrioventricular junction (n=5) and left ventricular myocardium (n=20) of intact animals.
Results
In this study, procedural success was tracked by pacemaker interrogation in the atrioventricular junction group, time-course magnetic resonance imaging in the left ventricular group, and correlation of lesion outcomes displayed in gross and microscopic pathology. Protein extraction (active caspase-3) was performed to investigate tissue apoptosis. Doses of 40 and 55 Gy caused slowing and interruption of cardiac impulse propagation at the atrioventricular junction. In 40 left ventricular irradiated targets, all lesions were identified on magnetic resonance after 12 weeks, being consistent with outcomes from gross pathology. In the majority of cases, lesion size plateaued between 12 and 16 weeks. Active caspase-3 was seen in lesions 12 and 16 weeks after irradiation but not after 20 weeks.
Conclusions
Scanned proton beams can be used as a tool for catheter-free ablation, and time-course of tissue apoptosis was consistent with lesion maturation.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008838
Suzuki A, Deisher AJ, Rettmann ME, Lehmann HI, ... Herman MG, Packer DL
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008838 | PMID: 32921132
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Optical Mapping-Validated Machine Learning Improves Atrial Fibrillation Driver Detection by Multi-Electrode Mapping.

Zolotarev AM, Hansen BJ, Ivanova EA, Helfrich KM, ... Dylov DV, Fedorov VV
Background
Atrial fibrillation (AF) can be maintained by localized intramural reentrant drivers. However, AF driver detection by clinical surface-only multielectrode mapping (MEM) has relied on subjective interpretation of activation maps. We hypothesized that application of machine learning to electrogram frequency spectra may accurately automate driver detection by MEM and add some objectivity to the interpretation of MEM findings.
Methods
Temporally and spatially stable single AF drivers were mapped simultaneously in explanted human atria (n=11) by subsurface near-infrared optical mapping (NIOM; 0.3 mm resolution) and 64-electrode MEM (higher density or lower density with 3 and 9 mm resolution, respectively). Unipolar MEM and NIOM recordings were processed by Fourier transform analysis into 28 407 total Fourier spectra. Thirty-five features for machine learning were extracted from each Fourier spectrum.
Results
Targeted driver ablation and NIOM activation maps efficiently defined the center and periphery of AF driver preferential tracks and provided validated annotations for driver versus nondriver electrodes in MEM arrays. Compared with analysis of single electrogram frequency features, averaging the features from each of the 8 neighboring electrodes, significantly improved classification of AF driver electrograms. The classification metrics increased when less strict annotation, including driver periphery electrodes, were added to driver center annotation. Notably, f1-score for the binary classification of higher-density catheter data set was significantly higher than that of lower-density catheter (0.81±0.02 versus 0.66±0.04, <0.05). The trained algorithm correctly highlighted 86% of driver regions with higher density but only 80% with lower-density MEM arrays (81% for lower-density+higher-density arrays together).
Conclusions
The machine learning model pretrained on Fourier spectrum features allows efficient classification of electrograms recordings as AF driver or nondriver compared with the NIOM gold-standard. Future application of NIOM-validated machine learning approach may improve the accuracy of AF driver detection for targeted ablation treatment in patients.



Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008249
Zolotarev AM, Hansen BJ, Ivanova EA, Helfrich KM, ... Dylov DV, Fedorov VV
Circ Arrhythm Electrophysiol: 29 Sep 2020; 13:e008249 | PMID: 32921129
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.