Journal: Europace

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<div><h4>Catheter ablation improved ejection fraction in persistent AF patients: a DECAAF-II sub analysis.</h4><i>Mekhael M, Shan B, Noujaim C, Chouman N, ... Marrouche N, Donnellan E</i><br /><b>Aims</b><br />The aim of our study was to assess differences in post-ablation atrial fibrillation (AF) recurrence and burden and to quantify the change in LVEF across different congestive heart failure (CHF) subcategories of the DECAAF-II population.<br /><b>Methods and results</b><br />Differences in the primary outcome of AF recurrence between CHF and non-CHF groups was calculated. The same analysis was performed for the three subgroups of CHF and the non-CHF group. Differences in AF burden after the 3-month blanking period between CHF and non-CHF groups was calculated. Improvement in LVEF was calculated and compared across the three CHF groups. Improvement was also calculated across different fibrosis stages. There was no significant differences in AF recurrence and AF burden after catheter ablation between CHF and non-CHF patients and between different CHF subcategories. Patients with heart failure with reduced ejection fraction (HFrEF) experienced the greatest improvement in EF following catheter ablation (CA, 16.66% ± 11.98, P < 0.001) compared to heart failure with moderately reduced LVEF, and heart failure with preserved EF (10.74% ± 8.34 and 2.00 ± 8.34 respectively, P-value < 0.001). Moreover, improvement in LVEF was independent of the four stages of atrial fibrosis (7.71 vs. 9.53 vs. 5.72 vs. 15.88, from Stage I to Stage IV respectively, P = 0.115).<br /><b>Conclusion</b><br />Atrial fibrillation burden and recurrence after CA is similar between non-CHF and CHF patients, independent of the type of CHF. Of all CHF groups, those with HFrEF had the largest improvement in LVEF after CA. Moreover, the improvement in ventricular function seems to be independent of atrial fibrosis in patients with persistent AF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Feb 2023; epub ahead of print</small></div>
Mekhael M, Shan B, Noujaim C, Chouman N, ... Marrouche N, Donnellan E
Europace: 04 Feb 2023; epub ahead of print | PMID: 36738244
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<div><h4>Pulmonary vein isolation with the radiofrequency balloon catheter: a single centre prospective study.</h4><i>Del Monte A, Almorad A, Pannone L, Della Rocca DG, ... Chierchia GB, de Asmundis C</i><br /><b>Aims</b><br />The multielectrode radiofrequency balloon catheter (RFB) has been developed to achieve safe and effective pulmonary vein isolation (PVI) for atrial fibrillation (AF) ablation. This single-centre study aimed to evaluate the midterm clinical outcome and predictors of single-shot PVI with the novel RFB.<br /><b>Methods and results</b><br />All consecutive patients with symptomatic paroxysmal or persistent AF undergoing first-time PVI with the RFB were prospectively included. Clinical and procedural parameters were systematically collected. The primary safety endpoint was defined as any major periprocedural complications. The primary efficacy endpoint consisted of freedom from any atrial tachyarrhythmias (ATas) lasting >30 s during the follow-up after a 3-month blanking period. Persistent single-shot PVI was defined as PVI achieved with a single RFB application without acute reconnection.  A total of 104 consecutive patients (mean age 64.3 ± 11.4 years, 56.7% males) were included. 15 patients (14.4%) presented with persistent AF. The procedure time was 59.0 min with a dwell time of 20.0 min. One major complication occurred in one patient. At a mean follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. ATas occurred in 14 patients, 11/69 patients (15.9%) with paroxysmal AF and 3/13 (23.1%) with persistent AF. The best cut-offs to predict persistent single-shot PVI were impedance drop >19.2 Ω [area under the receiver operator characteristic curve (AUC) 0.74] and temperature rise >11.1° C (AUC 0.77).<br /><b>Conclusion</b><br />In a large cohort of patients undergoing PVI with the RFB, the complication rate was 1%. At a mid-term follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. Specific cut-offs of impedance drop and temperature rise may be useful to predict persistent single-shot isolation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Feb 2023; epub ahead of print</small></div>
Del Monte A, Almorad A, Pannone L, Della Rocca DG, ... Chierchia GB, de Asmundis C
Europace: 04 Feb 2023; epub ahead of print | PMID: 36738245
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<div><h4>360° Virtual reality to improve patient education and reduce anxiety towards atrial fibrillation ablation.</h4><i>Hermans ANL, Betz K, Verhaert DVM, den Uijl DW, ... Linz D, Weijs B</i><br /><b>Aims</b><br />Evaluation of (i) the effects of a virtual reality (VR) preprocedural patient education video on information provision, procedure-related knowledge, satisfaction, and the level of worries in patients planned for atrial fibrillation (AF) ablation and (ii) the feasibility of a disposable cardboard VR viewer for home use in this setting.<br /><b>Methods and results</b><br />In this prospective observational cohort study, patients were alternatively assigned in a 1:1 ratio to the control or VR group. Controls received standard preprocedural information. VR group received standard information and a VR video (via in-hospital VR headset and disposable cardboard). The Amsterdam Preoperative Anxiety and Information Scale (APAIS) together with additional questions concerning procedural experience and satisfaction was completed pre- and post-ablation. Of 134 patients [38.1% female, aged 66 (58-72) years] included, 49.2% were assigned to the control and 50.7% to the VR group. The number of patients that worried about the ablation procedure was lower in VR than in control patients (19.1% vs. 40.9%, P = 0.006). More VR females than males had worries about the procedure (34.8% vs. 11.1%, P = 0.026). The number of VR patients that were satisfied with the preprocedural information provision was higher post-ablation than pre-ablation (83.3% vs. 60.4%, P = 0.007). In total, 59.4% reported that the disposable cardboard was easy to use and led to a discussion with relatives in 68.8%.<br /><b>Conclusion</b><br />In patients scheduled for AF ablation, a VR preprocedural educational video led to better information provision and procedure-related knowledge, higher satisfaction, and less worries regarding the procedure. The disposable cardboard was feasible for home use.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Feb 2023; epub ahead of print</small></div>
Hermans ANL, Betz K, Verhaert DVM, den Uijl DW, ... Linz D, Weijs B
Europace: 04 Feb 2023; epub ahead of print | PMID: 36738261
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<div><h4>Epicardial vs. transvenous implantable cardioverter defibrillators in children.</h4><i>Le Bos PA, Pontailler M, Maltret A, Kraiche D, ... Bonnet D, Waldmann V</i><br /><b>Aims</b><br />The implantable cardioverter defibrillator (ICD) has been increasingly used in children. Both epicardial and transvenous approaches are used, with controversy regarding the best option with no specific recommendations. We aimed to compare outcomes associated with epicardial vs. transvenous ICDs in children.<br /><b>Methods and results</b><br />Data were analysed from a retrospective study including all patients <18-year-old implanted with an ICD in a tertiary centre from 2003 to 2021. Outcomes were compared between epicardial and transvenous ICDs. A total of 122 children with an ICD (mean age 11.5 ± 3.8 years, 57.4% males) were enrolled, with 84 (64.1%) epicardial ICDs and 38 (29.0%) transvenous ICDs. Early (<30 days) ICD-related complications were reported in 17 (20.2%) patients with an epicardial ICD vs. 0 (0.0%) with a transvenous ICD (P = 0.002). Over a mean follow-up of 4.8 ± 4.0 years, 25 (29.8%) patients with an epicardial ICD and 9 (23.7%) patients with a transvenous ICD experienced at least one late ICD-related complication [hazard ratio (HR) 1.8, 95% confidence interval (CI) 0.8-4.0]. Implantable cardioverter defibrillator lead dysfunction occurred in 19 (22.6%) patients with an epicardial ICD vs. 3 (7.9%) with a transvenous ICD (HR 5.7, 95% CI 1.3-24.5) and was associated with a higher incidence of ICD-related reintervention (HR 3.0, 95% CI 1.3-7.0). After considering potential confounders, especially age and weight at implantation, this association was no longer significant (P = 0.112). The freedom from ICD lead dysfunction was greater in patients with pleural coils than in those with epicardial coils (HR 0.38, 95% CI 0.15-0.96).<br /><b>Conclusion</b><br />In children, after a consideration of patient characteristics at implantation, the burden of complications and ICD lead dysfunction appears to be similar in patients with epicardial and transvenous devices. Pleural coils seem to be associated with better outcomes than epicardial coils in this population.<br /><b>Clinical trial registration</b><br />NCT05349162.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Le Bos PA, Pontailler M, Maltret A, Kraiche D, ... Bonnet D, Waldmann V
Europace: 03 Feb 2023; epub ahead of print | PMID: 36735263
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<div><h4>Real-world clinical outcomes with a next-generation left atrial appendage closure device: the FLXibility Post-Approval Study.</h4><i>Betts TR, Grygier M, Kudsk JEN, Schmitz T, ... Allocco DJ, FLXibility investigators</i><br /><b>Aims</b><br />The FLXibility Post-Approval Study collected data on unselected patients implanted with a WATCHMAN FLX in a commercial clinical setting.<br /><b>Methods and results</b><br />Patients were implanted with a WATCHMAN FLX per local standard of care, with a subsequent first follow-up visit from 45 to 120 days post-implant and a final follow-up at 1-year post-procedure. A Clinical Event Committee adjudicated all major adverse events and TEE/CT imaging results were adjudicated by a core laboratory. Among 300 patients enrolled at 17 centres in Europe, the mean age was 74.6 ± 8.0 years, mean CHA2DS2-VASc score was 4.3 ± 1.6, and 62.1% were male. The device was successfully implanted in 99.0% (297/300) of patients. The post-implant medication regimen was DAPT for 87.3% (262/300). At first follow-up, core-lab adjudicated complete seal was 88.2% (149/169), 9.5% (16/169) had leak <3 mm, 2.4 (4/169) had leak ≥3 mm to ≤5 mm, and 0% had >5 mm leak. At 1 year, 93.3% (280/300) had final follow-up; 60.5% of patients were on a single antiplatelet medication, 21.4% were on DAPT, 5.6% were on direct oral anticoagulation, and 12.1% were not taking any antiplatelet/anticoagulation medication. Adverse event rates through 1 year were: all-cause death 10.8% (32/295); CV/unexplained death 5.1% (15/295); disabling and non-disabling stroke each 1.0% (3/295, all non-fatal); pericardial effusion requiring surgery or pericardiocentesis 1.0% (3/295); and device-related thrombus 2.4% (7/295).<br /><b>Conclusion</b><br />The WATCHMAN FLX device had excellent procedural success rates, high LAA seal rates, and low rates of thromboembolic events in everyday clinical practice.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Betts TR, Grygier M, Kudsk JEN, Schmitz T, ... Allocco DJ, FLXibility investigators
Europace: 03 Feb 2023; epub ahead of print | PMID: 36734247
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<div><h4>Rotor mechanism and its mapping in atrial fibrillation.</h4><i>Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M</i><br /><AbstractText>Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the \'leading circle\' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a \'spiral wave generator\' is a curved \'vortex\' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M
Europace: 03 Feb 2023; epub ahead of print | PMID: 36734272
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<div><h4>Pulse arrival time variation as a non-invasive marker of acute response to cardiac resynchronization therapy.</h4><i>Villegas-Martinez M, Odland HH, Hammersbøen LE, Sletten OJ, ... Elle OJ, Remme EW</i><br /><b>Aims</b><br />Successful cardiac resynchronization therapy (CRT) shortens the pre-ejection period (PEP) which is prolonged in the left bundle branch block (LBBB). In a combined animal and patient study, we investigated if changes in the pulse arrival time (PAT) could be used to measure acute changes in PEP during CRT implantation and hence be used to evaluate acute CRT response non-invasively and in real time.<br /><b>Methods and results</b><br />In six canines, a pulse transducer was attached to a lower limb and PAT was measured together with left ventricular (LV) pressure by micromanometer at baseline, after induction of LBBB and during biventricular pacing. Time-to-peak LV dP/dt (Td) was used as a surrogate for PEP. In twelve LBBB patients during implantation of CRT, LV and femoral pressures were measured at baseline and during five different pacing configurations. PAT increased from baseline (277 ± 9 ms) to LBBB (313 ± 16 ms, P < 0.05) and shortened with biventricular pacing (290 ± 16 ms, P < 0.05) in animals. There was a strong relationship between changes in PAT and Td in patients (r2 = 0.91). Two patients were classified as non-responders at 6 months follow-up. CRT decreased PAT from 320 ± 41 to 298 ± 39 ms (P < 0.05) in the responders, while PAT increased by 5 and 8 ms in the two non-responders.<br /><b>Conclusion</b><br />This proof-of-concept study indicates that PAT can be used as a simple, non-invasive method to assess the acute effects of CRT in real time with the potential to identify long-term response in patients.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Villegas-Martinez M, Odland HH, Hammersbøen LE, Sletten OJ, ... Elle OJ, Remme EW
Europace: 03 Feb 2023; epub ahead of print | PMID: 36734281
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<div><h4>Comparison of methods for delivering cardiac resynchronization therapy: an acute electrical and haemodynamic within-patient comparison of left bundle branch area, His bundle, and biventricular pacing.</h4><i>Ali N, Arnold AD, Miyazawa AA, Keene D, ... Cole GD, Whinnett ZI</i><br /><b>Aims</b><br />Left bundle branch area pacing (LBBAP) is a promising method for delivering cardiac resynchronization therapy (CRT), but its relative physiological effectiveness compared with His bundle pacing (HBP) is unknown. We conducted a within-patient comparison of HBP, LBBAP, and biventricular pacing (BVP).<br /><b>Methods and results</b><br />Patients referred for CRT were recruited. We assessed electrical response using non-invasive mapping, and acute haemodynamic response using a high-precision haemodynamic protocol. Nineteen patients were recruited: 14 male, mean LVEF of 30%. Twelve had time for BVP measurements. All three modalities reduced total ventricular activation time (TVAT), (ΔTVATHBP -43 ± 14 ms and ΔTVATLBBAP -35 ± 20 ms vs. ΔTVATBVP -19 ± 30 ms, P = 0.03 and P = 0.1, respectively). HBP produced a significantly greater reduction in TVAT compared with LBBAP in all 19 patients (-46 ± 15 ms, -36 ± 17 ms, P = 0.03). His bundle pacing and LBBAP reduced left ventricular activation time (LVAT) more than BVP (ΔLVATHBP -43 ± 16 ms, P < 0.01 vs. BVP, ΔLVATLBBAP -45 ± 17 ms, P < 0.01 vs. BVP, ΔLVATBVP -13 ± 36 ms), with no difference between HBP and LBBAP (P = 0.65). Acute systolic blood pressure was increased by all three modalities. In the 12 with BVP, greater improvement was seen with HBP and LBBAP (6.4 ± 3.8 mmHg BVP, 8.1 ± 3.8 mmHg HBP, P = 0.02 vs. BVP and 8.4 ± 8.2 mmHg for LBBAP, P = 0.3 vs. BVP), with no difference between HBP and LBBAP (P = 0.8).<br /><b>Conclusion</b><br />HBP delivered better ventricular resynchronization than LBBAP because right ventricular activation was slower during LBBAP. But LBBAP was not inferior to HBP with respect to LV electrical resynchronization and acute haemodynamic response.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Abstract
<div><h4>Combination of current and new electrocardiographic-based criteria: a novel score for the discrimination of left bundle branch capture.</h4><i>Briongos-Figuero S, Estévez-Paniagua Á, Sánchez-Hernández A, Muñoz-Aguilera R</i><br /><b>Aims</b><br />Most of the criteria used to diagnose direct capture of the left bundle branch (LBB) have never been validated in an external sample. We hypothesized that lead aVL might add relevant information, and the combination of several electrocardiograph (ECG)-based criteria might discriminate better LBB capture from left ventricular septal (LVS) capture, than each criterion separately.<br /><b>Methods and results</b><br />Single-centre study involving all consecutive patients who received LBB area pacing. LBB capture was defined according to QRS morphology transition criteria during decremental pacing. Multivariate logistic regression analysis was performed to develop a predictive score for LBB capture. A total of 71 patients with confirmed LBB capture were analysed. The optimal cut-off values of R wave peak time (RWPT) in lead V6 (V6-RWPT) and V6-V1 interpeak interval for the discrimination of LBB capture were <83 ms and ≥33 ms, respectively. The RWPT in lead aVL (aVL-RWPT) showed a good discrimination power for the differential diagnosis of LBB capture and LVS capture. The optimal value for aVL-RWPT was 79 ms [sensitivity (SN) and specificity (SP) of 71.2% and 88.4%, respectively]. A new score, with a good diagnostic performance (area under the curve of 0.976), was constructed gathering the information from V6-RWPT, aVL-RWPT, and V6-V1 interpeak interval. The optimal score of 3 points showed a SN and SP of 89.2% and 100%, respectively for the differentiation of LBB capture.<br /><b>Conclusions</b><br />ECG-based criteria are useful to confirm the capture of the LBB. The combination of V6-RWPT, aVL-RWPT, and V6-V1 interpeak interval values demonstrated better diagnostic performance than isolated measurements.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Briongos-Figuero S, Estévez-Paniagua Á, Sánchez-Hernández A, Muñoz-Aguilera R
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691717
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<div><h4>Non-continuous mobile electrocardiogram monitoring for post-transcatheter aortic valve replacement delayed conduction disorders put to the test.</h4><i>De Lucia R, Giannini C, Parollo M, Barletta V, ... Bongiorni MG, Petronio AS</i><br /><b>Aims</b><br />Permanent pacemaker implantation (PPM-I) remains nowadays the most important drawback of transcatheter aortic valve replacement (TAVR) procedure and the optimal strategy of delayed conduction disturbances (CDs) in these patients is unclear. The study aimed to validate an ambulatory electrocardiogram (ECG) monitoring through a 30 s spot ambulatory digital mobile ECG (AeECG), by using KardiaMobile-6L device in a 30-day period after TAVR procedure.<br /><b>Methods and results</b><br />Between March 2021 and February 2022, we consecutively enrolled all patients undergoing TAVR procedure, except pacemaker (PM) carriers. At discharge, all patients were provided of a KardiaMobile-6L device and a spot digital ECG (eECG) recording 1 month schedule. Clinical and follow-up data were collected, and eECG schedule compliance and recording quality were explored. Among 151 patients without pre-existing PM, 23 were excluded for pre-discharge PPM-I, 18 failed the KardiaMobile-6L training phase, and 10 refused the device. Delayed CDs with a Class I/IIa indication for PPM-I occurred in eight patients (median 6 days). Delayed PPM-I vs. non-delayed PPM-I patients were more likely to have longer PR and QRS intervals at discharge. PR interval at discharge was the only independent predictor for delayed PPM-I at multivariate analysis. The overall eECG schedule compliance was 96.5%. None clinical adverse events CDs related were documented using this new AeECG monitoring modality.<br /><b>Conclusion</b><br />A strategy of 30 s spot AeECG is safe and efficacious in delayed CDs monitoring after TAVR procedure with a very high eECG schedule level of compliance.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
De Lucia R, Giannini C, Parollo M, Barletta V, ... Bongiorni MG, Petronio AS
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691737
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<div><h4>Outcomes after cryoballoon ablation of paroxysmal atrial fibrillation with the PolarX or the Arctic front advance pro: a prospective multicentre experience.</h4><i>Tanese N, Almorad A, Pannone L, Defaye P, ... de Asmundis C, Boveda S</i><br /><b>Aims</b><br />The aim of this study was to compare procedural efficacy and safety, including 1-year freedom from AF recurrence, between the novel cryoballoon system PolarX (Boston Scientific) and the Arctic Front Advance Pro (AFA-Pro) (Medtronic), in patients with paroxysmal AF undergoing PVI.<br /><b>Methods and results</b><br />This multicentre prospective observational study included 267 consecutive patients undergoing a first cryoablation procedure for paroxysmal AF (137 PolarX, 130 AFA-Pro). KM curves with the log-rank test was used to compare the 1-year freedom from AF recurrence between both groups. Multivariate Cox model was performed to evaluate whether the type of procedure (PolarX vs. AFA-Pro) had an impact on the occurrence of AF recurrences after adjustment on potentially confounding factors. The PolarX reaches lower temperatures than the AFA-Pro (LSPV 52 ± 5, vs. 59 ± 6; LIPV 49 ± 6 vs. 56 ± 6; right superior pulmonary vein: 49 ± 6 vs. 57 ± 7; right inferior pulmonary vein: 52 ± 6 vs. 59 ± 6; P < 0.0001). A higher rate of transient phrenic nerve palsy was found in patients treated with the PolarX system (15% vs. 7%, P = 0.05). After a mean follow-up of 15 ± 5 months, 20 patients (15%) had recurrences in AFA-Pro group and 27 patients (19%) in PolarX group (P = 0.35). Based on survival analysis, no significant difference was observed between both groups with a 12-month free of recurrence survival of 91.2% (85.1-95.4%) vs. 83.7% (76.0%-89.1%) (log-rank test P = 0.11). In multivariate Cox model hazard ratio of recurrence for PolarX vs. AFA-Pro was not significant [HR = 1.6 (0.9-2.8), P = 0.12].<br /><b>Conclusion</b><br />PolarX and AFA-Pro have comparable efficacy and safety profiles for pulmonary veins isolation in paroxysmal atrial fibrillation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Tanese N, Almorad A, Pannone L, Defaye P, ... de Asmundis C, Boveda S
Europace: 24 Jan 2023; epub ahead of print | PMID: 36695332
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<div><h4>Cost-effectiveness analysis of cardiac implantable electronic devices with reactive atrial-based antitachycardia pacing.</h4><i>Noda T, Ueda N, Tanaka Y, Ishiguro Y, ... Myung JE, Kusano K</i><br /><b>Aims</b><br />Reactive atrial-based anti-tachycardia pacing (rATP) in pacemakers (PMs) and cardiac resynchronization therapy defibrillators (CRT-Ds) has been reported to prevent progression of atrial fibrillation, and this reduced progression is expected to decrease the risk of complications such as stroke and heart failure (HF). This study aimed to assess the cost-effectiveness of rATP in PMs and CRT-Ds in the Japanese public health insurance system.<br /><b>Methods and results</b><br />We developed a Markov model comprising five states: bradycardia, post-stroke, mild HF, severe HF, and death. For devices with rATP and control devices without rATP, we compared the incremental cost-effectiveness ratio (ICER) from the payer\'s perspective. Costs were estimated from healthcare resource utilisation data in a Japanese claims database. We evaluated model uncertainty by analysing two scenarios for each device. The ICER was 763 729 JPY/QALY (5616 EUR/QALY) for PMs and 1,393 280 JPY/QALY (10 245 EUR/QALY) for CRT-Ds. In all scenarios, ICERs were below 5 million JPY/QALY (36 765 EUR/QALY), supporting robustness of the results.<br /><b>Conclusion</b><br />According to a willingness to pay threshold of 5 million JPY/QALY, the devices with rATP were cost-effective compared with control devices without rATP, showing that the higher reimbursement price of the functional categories with rATP is justified from a healthcare economic perspective.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Noda T, Ueda N, Tanaka Y, Ishiguro Y, ... Myung JE, Kusano K
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691793
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<div><h4>Major gaps in the information provided to patients before implantation of cardioverter defibrillators: a prospective patient European evaluation.</h4><i>Januszkiewicz Ł, Barra S, Marijon E, Providencia R, ... Conte G, Boveda S</i><br /><b>Aims</b><br />Information provided to patients prior to implantable cardioverter-defibrillator (ICD) insertion and their participation in the decision-making process are crucial for understanding ICD function and accepting this lifelong therapy. The aim of this study is to evaluate the extent to which different aspects related to ICD and quality of life were transmitted to patients prior to ICD implantation.<br /><b>Methods and results</b><br />Prospective, multicenter European study with an online questionnaire initiated by the European Heart Rhythm Association. The questionnaire was filled-in directly and personally by the ICD patients who were invited to participate. A total of 1809 patients (majority in their 40s-70s, with 624 women, 34.5%) from 10 European countries participated in the study. The median time from first ICD implantation was 5 years (interquartile range 2-10). Overall, 1155 patients (71.5%) felt optimally informed at the time of device implantation, however many respondents received no information about ICD-related complications (n = 801, 49.6%), driving restrictions (n = 718, 44.5%), and possibility of end-of-life ICD deactivation (n = 408, 25.4%). Of note, women were less frequently involved in the decision-making process than men (47.3% vs. 55.9%, P = 0.003) and reported to be less often optimally informed before ICD implantation than men (61.2% vs. 76.8%, P < 0.001). More women mentioned the desire to have learned more about ICD therapy and the benefit/risk balance (45.4% vs. 33.7% of men; P < 0.001).<br /><b>Conclusions</b><br />This patient-based evaluation provides alarming findings on the lack of information provided to patients prior ICD implantation, particularly for women.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Januszkiewicz Ł, Barra S, Marijon E, Providencia R, ... Conte G, Boveda S
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691111
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<div><h4>Mechanical extraction of implantable cardioverter-defibrillator leads with a dwell time of more than 10 years: insights from a single high-volume centre.</h4><i>Ząbek A, Boczar K, Ulman M, Holcman K, ... Lelakowski J, Małecka B</i><br /><b>Aims</b><br />To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems.<br /><b>Methods and results</b><br />Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B.<br /><b>Conclusion</b><br />The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 20 Jan 2023; epub ahead of print</small></div>
Ząbek A, Boczar K, Ulman M, Holcman K, ... Lelakowski J, Małecka B
Europace: 20 Jan 2023; epub ahead of print | PMID: 36660771
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<div><h4>Unipolar voltage mapping in right ventricular cardiomyopathy: pitfalls, solutions and advantages.</h4><i>Hoogendoorn JC, Venlet J, de Riva M, Wijnmaalen AP, Piers SRD, Zeppenfeld K</i><br /><b>Aims</b><br />Endocardial unipolar and bipolar voltage mapping (UVM/BVM) of the right ventricle (RV) are used for transmural substrate delineation. However, far-field electrograms (EGMs) and EGM changes due to injury current may influence automatically generated UVM. Epicardial BVM is considered less accurate due to the impact of fat thickness (FT). Data on epicardial UVM are sparse. The aim of the study is two-fold: to assess the influence of the manually corrected window-of-interest on UVM and the potential role of epicardial UVM in RV cardiomyopathies.<br /><b>Methods and results</b><br />Consecutive patients who underwent endo-epicardial RV mapping with computed-tomography (CT) integration were included. Mapping points were superimposed on short-axis CT slices and correlated with local FT. All points were manually re-analysed and the window-of-interest was adjusted to correct for false high unipolar voltage (UV). For opposite endo-epicardial point-pairs, endo-epicardial bipolar voltage (BV) and UV were correlated for different FT categories. A total of 3791 point-pairs of 33 patients were analysed. In 69% of endocardial points and 63% of epicardial points, the window-of-interest needed to be adjusted due to the inclusion of far-field EGMs, injury current components, or RV-pacing artifacts. The Pearson correlation between corrected endo-epicardial BV and UV was lower for point-pairs with greater FT; however, this correlation was much stronger and less influenced by fat for UV.<br /><b>Conclusion</b><br />At the majority of mapping sites, the window-of-interest needs to be manually adjusted for correct UVM. Unadjusted UVM underestimates low UV regions. Unipolar voltage seems to be less influenced by epicardial fat, suggesting a promising role for UVM in epicardial substrate delineation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 14 Jan 2023; epub ahead of print</small></div>
Hoogendoorn JC, Venlet J, de Riva M, Wijnmaalen AP, Piers SRD, Zeppenfeld K
Europace: 14 Jan 2023; epub ahead of print | PMID: 36639881
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<div><h4>Syncope in ICD recipients: a single centre experience.</h4><i>Khan P, Selvarajah K, Gohel S, Sidhu BS, ... Murgatroyd F, Scott PA</i><br /><b>Aims</b><br />There is little evidence of the impact of syncope in implantable cardioverter-defibrillator (ICD) patients in routine community hospital care. This single-centre retrospective study sought to evaluate the incidence and prognostic significance of syncope in consecutive ICD patients.<br /><b>Methods and results</b><br />Data were collected on consecutive patients undergoing first ICD implantation between January 2009 and December 2019. The primary endpoints were the first occurrence of all-cause syncope, all-cause mortality, and all-cause hospitalization. Multivariate Cox proportional hazard models were used to identify risk factors associated with syncope and to analyse the subsequent risk of mortality and hospitalization. 1003 patients (58% primary prevention) were included in the final analysis. During a mean follow-up of 1519 ± 1055 days, 106 (10.6%) experienced syncope, 304 died (30.3%), and 477 (47.5%) were hospitalized for any cause. In an analysis adjusted for baseline variables, the first occurrence of syncope was associated with a significantly increased risk of mortality (HR 2.82, P < 0.001) and the first occurrence of hospitalization (HR 2.46, P = 0.002).<br /><b>Conclusion</b><br />Syncope in ICD recipients is common and associated with a poor prognosis irrespective of baseline variables and ICD programming. The occurrence of syncope is associated with a significant increase in the risk of mortality and hospitalization.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 14 Jan 2023; epub ahead of print</small></div>
Khan P, Selvarajah K, Gohel S, Sidhu BS, ... Murgatroyd F, Scott PA
Europace: 14 Jan 2023; epub ahead of print | PMID: 36638366
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<div><h4>Reduction in long-term mortality using remote device monitoring in a large real-world population of patients with implantable defibrillators.</h4><i>Kolk MZH, Narayan SM, Clopton P, Wilde AAM, Knops RE, Tjong FVY</i><br /><b>Aims</b><br />Remote monitoring (RM) for implantable cardioverter-defibrillators (ICDs) is advocated for the potential of early detection of disease progression and device dysfunction. While studies have examined the effect of RM on clinical outcomes in carefully selected populations of heart failure patients implanted with ICDs from a single vendor, there is a paucity of data in real-world patients. We aimed to assess the long-term effect of RM in a representative ICD population using real-world data.<br /><b>Methods and results</b><br />This is an observational retrospective longitudinal study of 1004 patients implanted with an ICD or cardiac resynchronization therapy device (CRT-D) from all device vendors between 2010 and 2021. Patients started on RM (N = 403) within 90 days following de novo device implantation and yearly in-office visits were compared with patients with only bi-yearly in-office follow-up (non-RM, N = 601). In a propensity score matched cohort of 430 patients (mean age 61.4 ± 14.3 years, 26.7% female), all-cause mortality at 4-year was 12.6% in the RM and 27.7% in the non-RM group [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.32-0.82; P = 0.005]. No difference in inappropriate ICD-therapy (HR 1.90, 95% CI 0.86-4.21; P = 0.122) was observed. The risk of appropriate ICD-therapy (HR 1.71, 95% CI 1.07-2.74; P = 0.026) was higher in the RM group.<br /><b>Conclusion</b><br />Remote monitoring was associated with a reduction in long-term all-cause and cardiac mortality compared with traditional office visits in a real-world ICD population.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Kolk MZH, Narayan SM, Clopton P, Wilde AAM, Knops RE, Tjong FVY
Europace: 13 Jan 2023; epub ahead of print | PMID: 36636951
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<div><h4>Outcome and safety of intraoperative defibrillation testing during device replacement: the Simpler trial.</h4><i>Milman A, Nof E, Rav Acha M, Beinart R, ... Klempfner R, Glikson M</i><br /><b>Aims</b><br />Intraoperative defibrillation testing (DT) during implant or replacement of implantable cardioverter-defibrillators (ICDs) has been a matter of debate for many years. This debate was put to rest by the Simple and Nordic ICD trials, and the practice of testing during new implantations has essentially been almost abandoned. Old registries demonstrated an increased incidence of significant findings in DT during replacements. The aim of the present study was to evaluate frequency of significant findings and safety of DT in subjects undergoing device replacement.<br /><b>Methods and results</b><br />A prospective observational multi-centre study included consecutive patients undergoing ICD generator replacement. The primary outcome was a failure to terminate induced ventricular fibrillation (VF) with a single shock 10 J below the maximal capacity of the device. Secondary outcomes included complications of DT. Patients were followed-up at 1- and 6-months post-procedure.  A total of 92 patients were eligible, and consented to the study, of which 84 underwent DT during battery replacement. The median age was 68 years and 79.8% were males. Induction of VF was successful in 84 patients as was a successful conversion on the first attempt in all. There were no procedure-related complications. During follow up one patient had two appropriate ICD shock events. In four patients, ICD programming was changed. None suffered inappropriate shock. There was no evidence of lead malfunction. Two deaths occurred, none of which was related to arrhythmia.<br /><b>Conclusion</b><br />The present study found DT was not associated with complications in patients undergoing ICD generator replacement but produced no clinically important information.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Milman A, Nof E, Rav Acha M, Beinart R, ... Klempfner R, Glikson M
Europace: 13 Jan 2023; epub ahead of print | PMID: 36636968
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<div><h4>Anterior vs. posterior position of dispersive patch during radiofrequency catheter ablation: insights from in silico modelling.</h4><i>Irastorza RM, Maher T, Barkagan M, Liubasuskas R, Berjano E, d\'Avila A</i><br /><b>Aims</b><br />To test the hypothesis that the dispersive patch (DP) location does not significantly affect the current distribution around the catheter tip during radiofrequency catheter ablation (RFCA) but may affect lesions size through differences in impedance due to factors far from the catheter tip.<br /><b>Methods</b><br />An in silico model of RFCA in the posterior left atrium and anterior right ventricle was created using anatomic measurements from patient thoracic computed tomography scans and tested the effect of anterior vs. posterior DP locations on baseline impedance, myocardial power delivery, radiofrequency current path, and predicted lesion size.<br /><b>Results</b><br />For posterior left atrium ablation, the baseline impedance, total current delivered, current distribution, and proportion of power delivered to the myocardium were all similar with both anterior and posterior DP locations, resulting in similar RFCA lesion sizes (< 0.2 mm difference). For anterior right ventricular (RV) ablation, an anterior DP location resulted in slightly higher proportion of power delivered to the myocardium and lower baseline impedance leading to slightly larger RFCA lesions (0.6 mm deeper and 0.8 mm wider).<br /><b>Conclusions</b><br />An anterior vs. posterior DP location will not meaningfully affect RFCA for posterior left atrial ablation, and the slightly larger lesions predicted with anterior DP location for anterior RV ablation are of unclear clinical significance.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Irastorza RM, Maher T, Barkagan M, Liubasuskas R, Berjano E, d'Avila A
Europace: 13 Jan 2023; epub ahead of print | PMID: 36635956
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<div><h4>Premature atrial contractions promote local directional heterogeneities in conduction velocity vectors.</h4><i>van Schie MS, Misier NLR, Razavi Ebrahimi P, Heida A, ... Taverne YJHJ, de Groot NMS</i><br /><b>Aims</b><br />Loss of cell-to-cell communication results in local conduction disorders and directional heterogeneity (LDH) in conduction velocity (CV) vectors, which may be unmasked by premature atrial contractions (PACs). We quantified LDH and examined differences between sinus rhythm (SR) and spontaneous PACs in patients with and without atrial fibrillation (AF).<br /><b>Methods and results</b><br />Intra-operative epicardial mapping of the right and left atrium (RA, LA), Bachmann\'s bundle (BB) and pulmonary vein area (PVA) was performed in 228 patients (54 with AF). Conduction velocity vectors were computed at each electrode using discrete velocity vectors. Directions and magnitudes of individual vectors were compared with surrounding vectors to identify LDH. Five hundred and three PACs [2 (1-3) per patient; prematurity index of 45 ± 12%] were included. During SR, most LDH were found at BB and LA [11.9 (8.3-14.9) % and 11.3 (8.0-15.2) %] and CV was lowest at BB [83.5 (72.4-94.3) cm/s, all P < 0.05]. Compared with SR, the largest increase in LDH during PAC was found at BB and PVA [+13.0 (7.7, 18.3) % and +12.5 (10.8, 14.2) %, P < 0.001]; CV decreased particularly at BB, PVA and LA [-10.0 (-13.2, -6.9) cm/s, -9.3 (-12.5, -6.2) cm/s and -9.1 (-11.7, -6.6) cm/s, P < 0.001]. Comparing patients with and without AF, more LDH were found during SR in AF patients at PVA and BB, although the increase in LDH during PACs was similar for all sites.<br /><b>Conclusion</b><br />Local directional heterogeneity is a novel methodology to quantify local heterogeneity in CV as a possible indicator of electropathology. Intra-operative high-resolution mapping indeed revealed that LDH increased during PACs particularly at BB and PVA. Also, patients with AF already have more LDH during SR, which becomes more pronounced during PACs.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
van Schie MS, Misier NLR, Razavi Ebrahimi P, Heida A, ... Taverne YJHJ, de Groot NMS
Europace: 13 Jan 2023; epub ahead of print | PMID: 36637110
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<div><h4>Electrocardiographic findings in patients with arrhythmogenic cardiomyopathy and right bundle branch block ventricular tachycardia.</h4><i>Laredo M, Tovia-Brodie O, Milman A, Michowitz Y, ... Hauer R, Belhassen B</i><br /><b>Aims</b><br />Little is known about patients with right bundle branch block (RBBB)-ventricular tachycardia (VT) and arrhythmogenic cardiomyopathy (ACM). Our aims were: (i) to describe electrocardiogram (ECG) characteristics of sinus rhythm (SR) and VT; (ii) to correlate SR with RBBB-VT ECGs; and (iii) to compare VT ECGs with electro-anatomic mapping (EAM) data.<br /><b>Methods and results</b><br />From the European Survey on ACM, 70 patients with spontaneous RBBB-VT were included. Putative left ventricular (LV) sites of origin (SOOs) were estimated with a VT-axis-derived methodology and confirmed by EAM data when available.  Overall, 49 (70%) patients met definite Task Force Criteria. Low QRS voltage predominated in lateral leads (n = 37, 55%), but QRS fragmentation was more frequent in inferior leads (n = 15, 23%). T-wave inversion (TWI) was equally frequent in inferior (n = 28, 42%) and lateral (n = 27, 40%) leads. TWI in inferior leads was associated with reduced LV ejection fraction (LVEF; 46 ± 10 vs. 53 ± 8, P = 0.02). Regarding SOOs, the inferior wall harboured 31 (46%) SOOs, followed by the lateral wall (n = 17, 25%), the anterior wall (n = 15, 22%), and the septum (n = 4, 6%). EAM data were available for 16 patients and showed good concordance with the putative SOOs. In all patients with superior-axis RBBB-VT who underwent endo-epicardial VT activation mapping, VT originated from the LV.<br /><b>Conclusions</b><br />In patients with ACM and RBBB-VT, RBBB-VTs originated mainly from the inferior and lateral LV walls. SR depolarization and repolarization abnormalities were frequent and associated with underlying variants.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Laredo M, Tovia-Brodie O, Milman A, Michowitz Y, ... Hauer R, Belhassen B
Europace: 13 Jan 2023; epub ahead of print | PMID: 36635857
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<div><h4>Association of electrocardiographic spatial heterogeneity of repolarization and spatial heterogeneity of atrial depolarization with left ventricular fibrosis.</h4><i>Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, ... Huikuri HV, Perkiömäki JS</i><br /><b>Aims</b><br />To evaluate the relationship between spatial heterogeneity of electrocardiographic repolarization and spatial heterogeneity of atrial depolarization with arrhythmic substrate represented by left ventricular fibrosis.<br /><b>Methods and results</b><br />We assessed the associations of T- and P-wave morphology parameters analysed from the standard 12-lead electrocardiograms with left ventricular fibrosis in 378 victims of unexpected sudden cardiac death (SCD) who underwent medico-legal autopsy. Based on autopsy findings, the SCD victims were categorized into four different groups according to different stages of severity of left ventricular fibrosis (substantial fibrosis, moderate patchy fibrosis, scattered mild fibrosis, no fibrosis). T-wave and P-wave area dispersion (TWAd: 0.0841 ± 0.496, 0.170 ± 0.492, 0.302 ± 404, 0.296 ± 0.476, P = 0.008; PWAd: 0.574 ± 0.384, 0.561 ± 0.367, 0.654 ± 0.281, 0.717 ± 0.257, P = 0.011, respectively; low values abnormal), non-dipolar components of T-wave and P-wave morphology (T_NonDipolarABS: 0.0496 ± 0.0377, 0.0571 ± 0.0487, 0.0432 ± 0.0476, 0.0380 ± 0.0377, P = 0.027; P_NonDipolarABS: 0.0132 ± 0.0164, 0.0130 ± 0.0135, 0.0092 ± 0.0117, 0.0069 ± 0.00472, P = 0.005, respectively, high values abnormal), T-wave morphology dispersion (TMD: 45.9 ± 28.3, 40.5 ± 25.8, 35.5 ± 24.9, 33.0 ± 24.6, P = 0.030, respectively, high values abnormal), and P-wave heterogeneity (PWH: 20.0 ± 9.44, 19.7 ± 8.87, 17.9 ± 9.78, 15.4 ± 4.60, P = 0.019, respectively, high values abnormal) differed significantly between the groups with different stages of left ventricular fibrosis. After adjustment with heart weight, T_NonDipolarABS [standardized β (sβ) = 0.131, P = 0.014], PWAd (sβ = -0.161, P = 0.003), P_NonDipolarABS (sβ = 0.174, P = 0.001), and PWH (sβ = 0.128, P = 0.015) retained independent association, and TWAd (sβ = -0.091, P = 0.074) and TMD (sβ = 0.097, P = 0.063) tended to retain their association with the degree of myocardial fibrosis.<br /><b>Conclusion</b><br />Our findings suggest that abnormal values of T- and P-wave morphology are associated with arrhythmic substrate represented by ventricular fibrosis partly explaining the mechanism behind their prognostic significance.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, ... Huikuri HV, Perkiömäki JS
Europace: 13 Jan 2023; epub ahead of print | PMID: 36635858
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<div><h4>Right ventricular epicardial arrhythmogenic substrate in long-QT syndrome patients at risk of sudden death.</h4><i>Pappone C, Ciconte G, Anastasia L, Gaita F, ... Vicedomini G, Santinelli V</i><br /><b>Aims</b><br />The long-QT syndrome (LQTS) represents a leading cause of sudden cardiac death (SCD). The aim of this study was to assess the presence of an underlying electroanatomical arrhythmogenic substrate in high-risk LQTS patients.<br /><b>Methods and results</b><br />The present study enrolled 11 consecutive LQTS patients who had experienced frequent implantable cardioverter-defibrillator (ICD discharges triggered by ventricular fibrillation (VF). We acquired electroanatomical biventricular maps of both endo and epicardial regions for all patients and analyzed electrograms sampled from several myocardial regions. Abnormal electrical activities were targeted and eliminated by the means of radiofrequency catheter ablation. VF episodes caused a median of four ICD discharges in eleven patients (6 male, 54.5%; mean age 44.0 ± 7.8 years, range 22-53) prior to our mapping and ablation procedures. The average QTc interval was 500.0 ± 30.2 ms. Endo-epicardial biventricular maps displayed abnormally fragmented, low-voltage (0.9 ± 0.2 mV) and prolonged electrograms (89.9 ± 24.1 ms) exclusively localized in the right ventricular epicardium. We found electrical abnormalities extending over a mean epicardial area of 15.7 ± 3.1 cm2. Catheter ablation of the abnormal epicardial area completely suppressed malignant arrhythmias over a mean 12 months of follow-up (median VF episodes before vs. after ablation, 4 vs. 0; P = 0.003). After the procedure, the QTc interval measured in a 12-lead ECG analysis shortened to a mean of 461.8 ± 23.6 ms (P = 0.004).<br /><b>Conclusion</b><br />This study reveals that, among high-risk LQTS patients, regions localized in the epicardium of the right ventricle harbour structural electrophysiological abnormalities. Elimination of these abnormal electrical activities successfully prevented malignant ventricular arrhythmia recurrences.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 05 Jan 2023; epub ahead of print</small></div>
Pappone C, Ciconte G, Anastasia L, Gaita F, ... Vicedomini G, Santinelli V
Europace: 05 Jan 2023; epub ahead of print | PMID: 36610790
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<div><h4>Exploring the incremental utility of circulating biomarkers for robust risk prediction of incident atrial fibrillation in European cohorts using regressions and modern machine learning methods.</h4><i>Toprak B, Brandt S, Brederecke J, Gianfagna F, ... Zeller T, Schnabel RB</i><br /><b>Aims</b><br />To identify robust circulating predictors for incident atrial fibrillation (AF) using classical regressions and machine learning (ML) techniques within a broad spectrum of candidate variables.<br /><b>Methods and results</b><br />In pooled European community cohorts (n = 42 280 individuals), 14 routinely available biomarkers mirroring distinct pathophysiological pathways including lipids, inflammation, renal, and myocardium-specific markers (N-terminal pro B-type natriuretic peptide [NT-proBNP], high-sensitivity troponin I [hsTnI]) were examined in relation to incident AF using Cox regressions and distinct ML methods. Of 42 280 individuals (21 843 women [51.7%]; median [interquartile range, IQR] age, 52.2 [42.7, 62.0] years), 1496 (3.5%) developed AF during a median follow-up time of 5.7 years. In multivariable-adjusted Cox-regression analysis, NT-proBNP was the strongest circulating predictor of incident AF [hazard ratio (HR) per standard deviation (SD), 1.93 (95% CI, 1.82-2.04); P < 0.001]. Further, hsTnI [HR per SD, 1.18 (95% CI, 1.13-1.22); P < 0.001], cystatin C [HR per SD, 1.16 (95% CI, 1.10-1.23); P < 0.001], and C-reactive protein [HR per SD, 1.08 (95% CI, 1.02-1.14); P = 0.012] correlated positively with incident AF. Applying various ML techniques, a high inter-method consistency of selected candidate variables was observed. NT-proBNP was identified as the blood-based marker with the highest predictive value for incident AF. Relevant clinical predictors were age, the use of antihypertensive medication, and body mass index.<br /><b>Conclusion</b><br />Using different variable selection procedures including ML methods, NT-proBNP consistently remained the strongest blood-based predictor of incident AF and ranked before classical cardiovascular risk factors. The clinical benefit of these findings for identifying at-risk individuals for targeted AF screening needs to be elucidated and tested prospectively.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Toprak B, Brandt S, Brederecke J, Gianfagna F, ... Zeller T, Schnabel RB
Europace: 04 Jan 2023; epub ahead of print | PMID: 36610061
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<div><h4>Improved prediction of sudden cardiac death in patients with heart failure through digital processing of electrocardiography.</h4><i>Shiraishi Y, Goto S, Niimi N, Katsumata Y, ... Yoshikawa T, Kohsaka S</i><br /><b>Aims</b><br />Available predictive models for sudden cardiac death (SCD) in heart failure (HF) patients remain suboptimal. We assessed whether the electrocardiography (ECG)-based artificial intelligence (AI) could better predict SCD, and also whether the combination of the ECG-AI index and conventional predictors of SCD would improve the SCD stratification among HF patients.<br /><b>Methods and results</b><br />In a prospective observational study, 4 tertiary care hospitals in Tokyo enrolled 2559 patients hospitalized for HF who were successfully discharged after acute decompensation. The ECG data during the index hospitalization were extracted from the hospitals\' electronic medical record systems. The association of the ECG-AI index and SCD was evaluated with adjustment for left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, and competing risk of non-SCD. The ECG-AI index plus classical predictive guidelines (i.e. LVEF ≤35%, NYHA Class II and III) significantly improved the discriminative value of SCD [receiver operating characteristic area under the curve (ROC-AUC), 0.66 vs. 0.59; P = 0.017; Delong\'s test] with good calibration (P = 0.11; Hosmer-Lemeshow test) and improved net reclassification [36%; 95% confidence interval (CI), 9-64%; P = 0.009]. The Fine-Gray model considering the competing risk of non-SCD demonstrated that the ECG-AI index was independently associated with SCD (adjusted sub-distributional hazard ratio, 1.25; 95% CI, 1.04-1.49; P = 0.015). An increased proportional risk of SCD vs. non-SCD with an increasing ECG-AI index was also observed (low, 16.7%; intermediate, 18.5%; high, 28.7%; P for trend = 0.023). Similar findings were observed in patients aged ≤75 years with a non-ischaemic aetiology and an LVEF of >35%.<br /><b>Conclusion</b><br />To improve risk stratification of SCD, ECG-based AI may provide additional values in the management of patients with HF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Shiraishi Y, Goto S, Niimi N, Katsumata Y, ... Yoshikawa T, Kohsaka S
Europace: 04 Jan 2023; epub ahead of print | PMID: 36610062
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<div><h4>Feasibility and safety of a three-dimensional anatomic map-guided transseptal puncture for left-sided catheter ablation procedures.</h4><i>Bohnen M, Minners J, Eichenlaub M, Weber R, ... Arentz T, Lehrmann H</i><br /><b>Aims</b><br />Transseptal puncture (TP) for left-sided catheter ablation procedures is routinely performed under fluoroscopic or echocardiographic guidance [transoesophageal echocardiography (TEE) or intracardiac echocardiography (ICE)], although three-dimensional (3D) mapping systems are readily available in most electrophysiology laboratories. Here, we sought to assess the feasibility and safety of a right atrial (RA) 3D map-guided TP.<br /><b>Methods and results</b><br />In 104 patients, 3D RA mapping was performed to identify the fossa ovalis (FO) using the protrusion technique. The radiofrequency transseptal needle was visualized and navigated to the desired potential FO-TP site. Thereafter, the interventionalist was unblinded to TEE and the potential FO-TP site was reassessed regarding its convenience and safety. After TP, the exact TP site was documented using a 17-segment-FO model. Reliable identification of the FO was feasible in 102 patients (98%). In these, 114 3D map-guided TP attempts were performed, of which 96 (84%) patients demonstrated a good position and 18 (16%) an adequate position after TEE unblinding. An out-of-FO or dangerous position did not occur. A successful 3D map-guided TP was performed in 110 attempts (97%). Four attempts (3%) with adequate positions were aborted in order to seek a more convenient TP site. The median time from RA mapping until the end of the TP process was 13 (12-17) min. No TP-related complications occurred. Ninety-eight TP sites (85.1%) were in the central portion or in the inner loop of the FO.<br /><b>Conclusion</b><br />A 3D map-guided TP is feasible and safe. It may assist to decrease radiation exposure and the need for TEE/ICE during left-sided catheter ablation procedures.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Bohnen M, Minners J, Eichenlaub M, Weber R, ... Arentz T, Lehrmann H
Europace: 04 Jan 2023; epub ahead of print | PMID: 36610064
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<div><h4>Electrophysiological characteristics and long-term outcome of substrate-based catheter ablation for left posterior fascicular ventricular tachycardia targeting fragmented antegrade Purkinje potentials during sinus rhythm.</h4><i>Wei HQ, Liao Z, Liang Y, Fang X, ... Wu S, Zhan X</i><br /><b>Aims</b><br />The aim of this study was to investigate the electrophysiological characteristics and long-term outcome of patients undergoing substrate-based ablation of left posterior fascicular ventricular tachycardia (LPF-VT) guided by targeting of fragmented antegrade Purkinje potentials (FAPs) during sinus rhythm.<br /><b>Methods and results</b><br />This study retrospectively analysed 50 consecutive patients referred for ablation. Substrate mapping during sinus rhythm was performed to identify the FAP that was targeted by ablation. FAPs were recorded in 48 of 50 (96%) patients during sinus rhythm. The distribution of FAPs was located at the proximal segment of posterior septal left ventricle (LV) in two (4.2%) patients, middle segment in 33 (68.8%) patients, and distal segment in 13 (27.1%) patients. In 32 of 48 (66.7%) patients, the FAP displayed a continuous multicomponent fragmented electrogram, while a fragmented, split, and uncoupled electrogram was recorded in 16 (33.3%) patients. Entrainment attempts at FAP region were performed successfully in seven patients, demonstrating concealed fusion and the critical isthmus of LPF-VT. Catheter ablation targeting at the FAPs successfully terminated the LPF-VT in all 48 patients in whom they were seen. Left posterior fascicular (LPF) block occurred in four (8%) patients after ablation. During a median follow-up period of 61.2 ± 16.8 months, 47 of 50 (94%) patients remained free from recurrent LPF-VT.<br /><b>Conclusion</b><br />Ablation of LPF-VT targeting FAP during sinus rhythm results in excellent long-term clinical outcome. FAPs were commonly located at the middle segment of posterior septal LV. Region with FAPs during sinus rhythm was predictive of critical site for re-entry.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Abstract
<div><h4>Scar conducting channel characterization to predict arrhythmogenicity during ventricular tachycardia ablation.</h4><i>Sanchez-Somonte P, Garre P, Vázquez-Calvo S, Quinto L, ... Mont L, Roca-Luque I</i><br /><b>Aims</b><br />Heterogeneous tissue channels (HTCs) detected by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) are related to ventricular arrhythmias, but there are few published data about their arrhythmogenic characteristics.<br /><b>Methods and results</b><br />We enrolled 34 consecutive patients with ischaemic and non-ischaemic cardiomyopathy who were referred for ventricular tachycardia (VT) ablation. LGE-CMR was performed prior to ablation, and the HTCs were analyzed. Arrhythmogenic HTCs linked to induced VT were identified during the VT ablation procedure. The characteristics of arrhythmogenic HTCs were compared with those of non-arrhythmogenic HTCs. Three patients were excluded due to low-quality LGE-CMR images. A total of 87 HTCs were identified on LGE-CMR in 31 patients (age:63.8 ± 12.3 years; 96.8% male; left ventricular ejection fraction: 36.1 ± 10.7%). Of the 87 HTCs, only 31 were considered arrhythmogenic because of their relation to a VT isthmus. The HTCs related to a VT isthmus were longer [64.6 ± 49.4 vs. 32.9 ± 26.6 mm; OR: 1.02; 95% CI: (1.01-1.04); P < 0.001] and had greater mass [2.5 ± 2.2 vs. 1.2 ± 1.2 grams; OR: 1.62; 95% CI: (1.18-2.21); P < 0.001], a higher degree of protectedness [26.19 ± 19.2 vs. 10.74 ± 8.4; OR 1.09; 95% CI: (1.04-1.14); P < 0.001], higher transmurality [number of wall layers with CCs: 3.8 ± 2.4 vs. 2.4 ± 2.0; OR: 1.31; 95% CI: (1.07-1.60); P = 0.008] and more ramifications [3.8 ± 2.0 vs. 2.7 ± 1.1; OR: 1.59; 95% CI: (1.15-2.19); P = 0.002] than non-arrhythmogenic HTCs. Multivariate logistic regression analysis revealed that protectedness was the strongest predictor of arrhythmogenicity.<br /><b>Conclusion</b><br />The protectedness of an HTC identified by LGE-CMR is strongly related to its arrhythmogenicity during VT ablation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Sanchez-Somonte P, Garre P, Vázquez-Calvo S, Quinto L, ... Mont L, Roca-Luque I
Europace: 04 Jan 2023; epub ahead of print | PMID: 36607130
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<div><h4>Electroanatomic visualization of coronary arteries: a case series to elicit safety, feasibility, and diagnostic value in complex ablation procedures.</h4><i>Fries B, Johnson V, Schneider N, Dörr O, ... Hamm CW, Schmitt J</i><br /><b>Aims</b><br />The goal of this case series was to evaluate the feasibility, safety, and advantages of a wire-based approach for the live visualization of coronary arteries (CAs) in an electroanatomic mapping (EAM) system and to assess its diagnostic information.<br /><b>Methods and results</b><br />For this single-centre case series, we included procedures in which close proximity of a possible ablation site to any epicardial vessel was suspected. An uncoated-tip guidewire was introduced into the relevant CAs after exclusion of critical CA stenosis by coronary angiography. By connecting this wire to the EAM system using a clip and pin connection, mapping and live visualization of the wire tip is possible, as well as the assessment of the local electrograms within the respective CAs. Procedural wire insertion and intracoronary mapping was performed by EP specialists and was assisted to judge the relevance of CA disease by an interventional cardiologist.  A total of nine procedures in nine patients were included in this case series, four ventricular tachycardia ablation procedures and five procedures for the ablation of premature ventricular contractions. The left CAs were mapped in eight cases and the right CA was mapped in one case. In two cases, epicardial mapping was combined with visualization of the right or left CAs. There were no complications attributed to coronary wiring and mapping in this case.<br /><b>Conclusion</b><br />We demonstrated the feasibility and safety of CA visualization and integration in an EAM. The live visualization of the CAs added valuable information without the need for preprocedural planning or the purchase of separate software. Electroanatomic visualization was achieved intraprocedurally in a safe and straightforward manner, adding critical diagnostic information without excessive costs or risks.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Fries B, Johnson V, Schneider N, Dörr O, ... Hamm CW, Schmitt J
Europace: 04 Jan 2023; epub ahead of print | PMID: 36607137
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<div><h4>Orientation of conduction velocity vectors on cardiac mapping surfaces.</h4><i>Padilla JR, Anderson RD, Joens C, Masse S, ... Vigmond E, Nanthakumar K</i><br /><b>Aims</b><br />Electroanatomical maps using automated conduction velocity (CV) algorithms are now being calculated using two-dimensional (2D) mapping tools. We studied the accuracy of mapping surface 2D CV, compared to the three-dimensional (3D) vectors, and the influence of mapping resolution in non-scarred animal and human heart models.<br /><b>Methods and results</b><br />Two models were used: a healthy porcine Langendorff model with transmural needle electrodes and a computer stimulation model of the ventricles built from an MRI-segmented, excised human heart. Local activation times (LATs) within the 3D volume of the mesh were used to calculate true 3D CVs (direction and velocity) for different pixel resolutions ranging between 500 μm and 4 mm (3D CVs). CV was also calculated for endocardial surface-only LATs (2D CV). In the experimental model, surface (2D) CV was faster on the epicardium (0.509 m/s) compared to the endocardium (0.262 m/s). In stimulation models, 2D CV significantly exceeded 3D CVs across all mapping resolutions and increased as resolution decreased. Three-dimensional and 2D left ventricle CV at 500 μm resolution increased from 429.2 ± 189.3 to 527.7 ± 253.8 mm/s (P < 0.01), respectively, with modest correlation (R = 0.64). Decreasing the resolution to 4 mm significantly increased 2D CV and weakened the correlation (R = 0.46). The majority of CV vectors were not parallel (<30°) to the mapping surface providing a potential mechanistic explanation for erroneous LAT-based CV over-estimation.<br /><b>Conclusion</b><br />Ventricular CV is overestimated when using 2D LAT-based CV calculation of the mapping surface and significantly compounded by mapping resolution. Three-dimensional electric field-based approaches are needed in mapping true CV on mapping surfaces.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Padilla JR, Anderson RD, Joens C, Masse S, ... Vigmond E, Nanthakumar K
Europace: 04 Jan 2023; epub ahead of print | PMID: 36609707
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Abstract
<div><h4>Global burden of atrial fibrillation/atrial flutter and its attributable risk factors from 1990 to 2019.</h4><i>Dong XJ, Wang BB, Hou FF, Jiao Y, ... Lv SP, Li FH</i><br /><b>Aims</b><br />The aim of this study was to estimate the global burden of atrial fibrillation (AF)/atrial flutter (AFL) and its attributable risk factors from 1990 to 2019.<br /><b>Methods and results</b><br />The data on AF/AFL were retrieved from the Global Burden of Disease Study (GBD) 2019. Incidence, disability-adjusted life years (DALYs), and deaths were metrics used to measure AF/AFL burden. The population attributable fractions (PAFs) were used to calculate the percentage contributions of major potential risk factors to age-standardized AF/AFL death. The analysis was performed between 1990 and 2019. Globally, in 2019, there were 4.7 million [95% uncertainty interval (UI): 3.6 to 6.0] incident cases, 8.4 million (95% UI: 6.7 to 10.5) DALYs cases, and 0.32 million (95% UI: 0.27 to 0.36) deaths of AF/AFL. The burden of AF/AFL in 2019 and their temporal trends from 1990 to 2019 varied widely due to gender, Socio-Demographic Index (SDI) quintile, and geographical location. Among all potential risk factors, age-standardized AF/AFL death worldwide in 2019 were primarily attributable to high systolic blood pressure [34.0% (95% UI: 27.3 to 41.0)], followed by high body mass index [20.2% (95% UI: 11.2 to 31.2)], alcohol use [7.4% (95% UI: 5.8 to 9.0)], smoking [4.3% (95% UI: 2.9 to 5.9)], diet high in sodium [4.2% (95% UI: 0.8 to 10.5)], and lead exposure [2.3% (95% UI: 1.3 to 3.4)].<br /><b>Conclusion</b><br />Our study showed that AF/AFL is still a major public health concern. Despite the advancements in the prevention and treatment of AF/AFL, especially in regions in the relatively SDI quintile, the burden of AF/AFL in regions in lower SDI quintile is increasing. Since AF/AFL is largely preventable and treatable, there is an urgent need to implement more cost-effective strategies and interventions to address modifiable risk factors, especially in regions with high or increased AF/AFL burden.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Jan 2023; epub ahead of print</small></div>
Dong XJ, Wang BB, Hou FF, Jiao Y, ... Lv SP, Li FH
Europace: 04 Jan 2023; epub ahead of print | PMID: 36603845
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<div><h4>Electroanatomical mapping-guided left bundle branch area pacing in patients with structural heart disease and advanced conduction abnormalities.</h4><i>Richter S, Gebauer R, Ebert M, Moscoso Ludueña C, ... Hindricks G, Döring M</i><br /><b>Aims</b><br />Left bundle branch area pacing (LBBAP) can be technically challenging and fluoroscopy-intense. Three-dimensional electroanatomical mapping (EAM) facilitates non-fluoroscopic lead navigation and electrogram mapping. We sought to prospectively evaluate the feasibility, safety, and outcomes of routine EAM-guided LBBAP in patients with structural heart disease (SHD) and advanced conduction abnormalities.<br /><b>Methods and results</b><br />Consecutive patients with SHD and conduction abnormalities who underwent an attempt at EAM-guided LBBAP were included. The feasibility, safety, procedural, and mid-term outcomes were evaluated. Electrical, echocardiographic, and clinical parameters were assessed at implantation and last follow-up. Thirty-two patients (68 ± 18 years; 19% female) were included, of which 75% had intrinsic QRS > 150 ms, 53% left bundle branch block, and 25% right bundle branch block. Primary EAM-guided LBBAP was successful in 29 patients (91%). The procedural duration was 95 (70-110) min, total fluoroscopy time 0.93 (0.40-1.73) min, and total fluoroscopy dose 35.4 (20.5-77.2) cGy cm2. Paced QRS duration (QRSd) was significantly shorter than intrinsic QRSd (121.9 ± 10.7 vs. 159.2 ± 34.4 ms; P < 0.001) and remained stable during the mean follow-up of 7.0 ± 5.9 months. The LBBAP capture threshold was 0.57 ± 0.23 V/0.4 ms at implantation and remained low during follow-up (0.58 ± 0.18 V/0.5 ± 0.2 ms; P = 0.877). Overall left ventricular ejection fraction improved significantly from 44.2 ± 14.3% at baseline to 49.4 ± 13.1% at follow-up (P = 0.009), New York Heart Association class from 2.4 ± 0.6 to 1.8 ± 0.6 (P = 0.002), respectively. No complications occurred that required intervention.<br /><b>Conclusion</b><br />Routine near-zero fluoroscopy EAM-guided LBBAP can safely be performed in patients with SHD and advanced conduction abnormalities with high success rates and favourable mid-term outcomes. Further studies are needed to investigate whether the use of EAM improves the overall outcome of conduction system pacing and to identify specific patient populations who benefit the most from EAM-guided lead implantation.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 30 Dec 2022; epub ahead of print</small></div>
Richter S, Gebauer R, Ebert M, Moscoso Ludueña C, ... Hindricks G, Döring M
Europace: 30 Dec 2022; epub ahead of print | PMID: 36581450
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<div><h4>Ablation versus anti-arrhythmic therapy for reducing all hospital episodes from recurrent atrial fibrillation: a prospective, randomized, multi-centre, open label trial.</h4><i>Kanagaratnam P, McCready J, Tayebjee M, Shepherd E, ... Shah J, Poulter N</i><br /><b>Aims</b><br />There is rising healthcare utilization related to the increasing incidence and prevalence of atrial fibrillation (AF) worldwide. Simplifying therapy and reducing hospital episodes would be a valuable development. The efficacy of a streamlined AF ablation approach was compared to drug therapy and a conventional catheter ablation technique for symptom control in paroxysmal AF.<br /><b>Methods and results</b><br />We recruited 321 patients with symptomatic paroxysmal AF to a prospective randomized, multi-centre, open label trial at 13 UK hospitals. Patients were randomized 1:1:1 to cryo-balloon ablation without electrical mapping with patients discharged same day [Ablation Versus Anti-arrhythmic Therapy for Reducing All Hospital Episodes from Recurrent (AVATAR) protocol]; optimization of drug therapy; or cryo-balloon ablation with confirmation of pulmonary vein isolation and overnight hospitalization. The primary endpoint was time to any hospital episode related to treatment for atrial arrhythmia. Secondary endpoints included complications of treatment and quality-of-life measures. The hazard ratio (HR) for a primary endpoint event occurring when comparing AVATAR protocol arm to drug therapy was 0.156 (95% CI, 0.097-0.250; P < 0.0001 by Cox regression). Twenty-three patients (21%) recorded an endpoint event in the AVATAR arm compared to 76 patients (74%) within the drug therapy arm. Comparing AVATAR and conventional ablation arms resulted in a non-significant HR of 1.173 (95% CI, 0.639-2.154; P = 0.61 by Cox regression) with 23 patients (21%) and 19 patients (18%), respectively, recording primary endpoint events (P = 0.61 by log-rank test).<br /><b>Conclusion</b><br />The AVATAR protocol was superior to drug therapy for avoiding hospital episodes related to AF treatment, but conventional cryoablation was not superior to the AVATAR protocol. This could have wide-ranging implications on how demand for AF symptom control is met.<br /><b>Trial registration</b><br />Clinical Trials Registration: NCT02459574.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Dec 2022; epub ahead of print</small></div>
Kanagaratnam P, McCready J, Tayebjee M, Shepherd E, ... Shah J, Poulter N
Europace: 28 Dec 2022; epub ahead of print | PMID: 36576323
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<div><h4>Scar border zone mass and presence of border zone channels assessed with cardiac magnetic resonance imaging are associated with ventricular arrhythmia in patients with ST-segment elevation myocardial infarction.</h4><i>Thomsen AF, Bertelsen L, Jøns C, Jabbari R, ... Vejlstrup N, Jacobsen PK</i><br /><b>Aims</b><br />Late gadolinium enhancement cardiac magnetic resonance (CMR) permits characterization of left ventricular ischaemic scars. We aimed to evaluate if scar core mass, border zone (BZ) mass, and BZ channels are risk markers for subsequent ventricular arrhythmia (VA) in ST-segment elevation myocardial infarction (STEMI).<br /><b>Methods and results</b><br />A sub-study of the DANish Acute Myocardial Infarction-3 multi-centre trial and Danegaptide phase II proof-of-concept clinical trial in which a total of 843 STEMI patients had a 3-month follow-up CMR. Of these, 21 patients subsequently experienced VA during 100 months of follow-up and were randomly matched 1:5 with 105 controls. A VA event was defined as: ventricular tachycardia, ventricular fibrillation, or sudden cardiac death. Ischaemic scar characteristics were automatically detected by specialized software. We included 126 patients with a median left ventricular ejection fraction of 51.0 ± 11.6% in cases with VA vs. 55.5 ± 8.5% in controls (P = 0.10). Cases had a larger mean BZ mass and more often BZ channels compared to controls [BZ mass: 17.2 ± 10.3 g vs. 10.3 ± 6.0 g; P = 0.0002; BZ channels: 17 (80%) vs. 44 (42%); P = 0.001]. A combination of ≥17.2 g BZ mass and the presence of BZ channels was five times more prevalent in cases vs. controls (P ≤ 0.00001) with an odds ratio of 9.40 (95% confidence interval 3.26-27.13; P ≤ 0.0001) for VA. This identified cases with 52% sensitivity and 90% specificity.<br /><b>Conclusion(s)</b><br />Scar characterization with CMR indicates that a combination of ≥17.2 g BZ mass and the presence of BZ channels had the strongest association with subsequent VA in STEMI patients.<br /><b>Clinicaltrials.gov</b><br />Unique identifier: NCT01435408 (DANAMI 3-iPOST and DANAMI 3-DEFER), NCT01960933 (DANAMI 3-PRIMULTI), and NCT01977755 (Danegaptide).<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Dec 2022; epub ahead of print</small></div>
Thomsen AF, Bertelsen L, Jøns C, Jabbari R, ... Vejlstrup N, Jacobsen PK
Europace: 28 Dec 2022; epub ahead of print | PMID: 36576342
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<div><h4>Same-day discharge after transvenous lead extraction: feasibility and outcomes.</h4><i>Atteya G, Alston M, Sweat A, Saleh M, ... John RM, Epstein LM</i><br /><b>Aims</b><br />Same-day discharge (SDD) is safe for patients undergoing electrophysiology procedures. There is no existing data regarding SDD for patients undergoing transvenous lead extraction (TLE). We report our experience with SDD for patients undergoing TLE.<br /><b>Methods and results</b><br />The study group included patients undergoing TLE between February 2020 and July 2021 without an infectious indication. A modified SDD protocol for device implants/ablations was applied to TLE patients. Patient characteristics, extraction details, outcomes, and complications were reviewed. Of 239 patients undergoing TLE, 210 were excluded (94 infections and 116 did not meet SDD criteria). Of the remaining 29 patients, seven stayed due to patient preference and 22 were discharged home the same day. The SDD group had an average age of 65.9 ± 12 (47-84), 41% female, and LVEF of 52.2 ± 18% (10-80). The indication for TLE was malfunction (20), upgrade (4), advisory lead (2), and magnetic resonance imaging compatibility (1). Extractions included four implantable cardioverter-defibrillators (ICDs), 17 pacemakers (PPM), and one cardiac resynchronization therapy (CRT)-P system. The leads were 9.6 years (1.5-21.7) old, and 1.8 leads were removed per patient (1-3); the lead extraction difficulty (LED) score was 11.6 ± 7. Twenty underwent cardiovascular implantable electronic device (CIED) re-implantation (2 ICD, 3 CRT-D, 13 PPM, and 2 CRT-P). For CIED re-implants, patients sent a remote transmission the next day, and all patients received a next-day call. There were no procedure or device-related issues, morbidities, or mortalities in the 30 days after discharge.<br /><b>Conclusion</b><br />Same-day discharge after TLE for non-infectious aetiologies is safe and feasible in a select group of patients with early procedure completion who meet strict SDD criteria.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 28 Dec 2022; epub ahead of print</small></div>
Atteya G, Alston M, Sweat A, Saleh M, ... John RM, Epstein LM
Europace: 28 Dec 2022; epub ahead of print | PMID: 36575941
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<div><h4>Revisiting the characteristics and ablation strategy of biatrial tachycardias: a case series and systematic review.</h4><i>Lai Y, Guo Q, Sang C, Gao M, ... Dong J, Ma C</i><br /><b>Aims</b><br />To describe the role of left atrial (LA) epicardial conduction and targets of ablation in biatrial tachycardias (BiATs).<br /><b>Methods and results</b><br />Consecutive patients with BiAT diagnosed by high-density mapping and appropriate entrainment were enrolled. A systematic review of case reports or series was then performed. Biatrial tachycardia was identified in 20 patients aged 63.5 ± 11.1 years. Among them, eight had LA epicardial conduction, including four via the ligament of Marshall, two via myocardial fibres between the great cardiac vein (GCV) and LA, one via septopulmonary bundle, and one via myocardial fibres between the posterior wall and coronary sinus. Ablation was targeted at the anatomical isthmus in 14, including 5 undergoing vein of Marshall ethanol infusion and 2 undergoing ablation in the GCV. Another six underwent ablation at interatrial connections, including one with septopulmonary bundle at the fossa ovalis and five at the atrial insertions of Bachmann\'s bundle. After a mean follow-up of 8.7 ± 3.8 months, five patients had recurrence of atrial fibrillation/flutter. Systematic review enrolled 87 patients in previous and the present reports, showing a higher risk of impairment in atrial physiology in those targeting interatrial connections (30.4 vs. 5.0%, P < 0.001) but no significant difference in short- and long-term effectiveness.<br /><b>Conclusion</b><br />Left atrial epicardial conduction is common in BiATs and affects the ablation strategy. Atrial physiology is a major concern in selecting the target of intervention.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 23 Dec 2022; epub ahead of print</small></div>
Lai Y, Guo Q, Sang C, Gao M, ... Dong J, Ma C
Europace: 23 Dec 2022; epub ahead of print | PMID: 36563053
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<div><h4>Very high-power short-duration ablation for pulmonary vein isolation utilizing a very-close protocol-the FAST AND FURIOUS PVI study.</h4><i>Heeger CH, Sano M, Popescu SȘ, Subin B, ... Kuck KH, Tilz RR</i><br /><b>Aims</b><br />The very high-power short-duration (vHP-SD) radiofrequency (RF) ablation concept of atrial fibrillation (AF) treatment by pulmonary vein isolation (PVI) aims for safer, more effective, and faster procedures. Utilizing conventional ablation, the \'close protocol\' has been verified. Since lesion formation of vHP-SD ablation creates wider but shallower lesions we adapted the close protocol to an individualized and tighter \'very-close protocol\' of 3-4 mm of inter-lesion distance (ILD) at the anterior and 5-6 mm at the posterior aspect of the left atrium using vHP-SD only. Here, we evaluated the safety and efficacy of vHP-SD ablation for PVI utilizing a very-close protocol in comparison with standard ablation.<br /><b>Methods and results</b><br />A total of 50 consecutive patients with symptomatic AF were treated with a very-close protocol utilizing vHP-SD (vHP-SD group). The data were compared with 50 consecutive patients treated by the ablation-index-guided strategy (control group). The mean RF time was 352 ± 81 s (vHP-SD) and 1657 ± 570 s (control, P < 0.0001), and the mean procedure duration was 59 ± 13 (vHP-SD) and 101 ± 38 (control, P < 0.0001). The first-pass isolation rate was 74% (vHP-SD) and 76% (control, P = 0.817). Severe adverse events were reported in 1 (2%, vHP-SD) and 3 (6%, control) patients (P = 0.307). A 12-month recurrence-free survival was 78% (vHP-SD) and 64% (control, P = 0.142). PVI durability assessed during redo-procedures was 75% (vHP-SD) vs. 33% (control, P < 0.001).<br /><b>Conclusions</b><br />PVI solely utilizing vHP-SD via a very-close protocol provides safe and effective procedures with a high rate of first-pass isolations. The procedure duration and ablation time were remarkably low. A 12-month follow-up and PVI durability are promising.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 22 Dec 2022; epub ahead of print</small></div>
Heeger CH, Sano M, Popescu SȘ, Subin B, ... Kuck KH, Tilz RR
Europace: 22 Dec 2022; epub ahead of print | PMID: 36546582
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<div><h4>Autoimmune diseases and new-onset atrial fibrillation: a UK Biobank study.</h4><i>Tilly MJ, Geurts S, Zhu F, Bos MM, ... de Groot NMS, Kavousi M</i><br /><b>Aims</b><br />The underlying mechanisms of atrial fibrillation (AF) are largely unknown. Inflammation may underlie atrial remodelling. Autoimmune diseases, related to increased systemic inflammation, may therefore be associated with new-onset AF.<br /><b>Methods and results</b><br />Participants from the population-based UK Biobank were screened for rheumatic fever, gastrointestinal autoimmune diseases, autoimmune diseases targeting the musculoskeletal system and connective tissues, and neurological autoimmune diseases. Between 2006 and 2022, participants were followed for incident AF. Cox proportional hazards regression analyses were performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) to quantify associations. 494 072 participants free from AF were included (median age 58.0 years, 54.8% women). After a median of 12.8 years, 27 194 (5.5%) participants were diagnosed with new-onset AF. Rheumatic fever without heart involvement (HR, 95% CI: 1.47, 1.26-1.72), Crohn\'s disease (1.23, 1.05-1.45), ulcerative colitis (1.17, 1.06-1.31), rheumatoid arthritis (1.39, 1.28-1.51), polyarteritis nodosa (1.82, 1.04-3.09), systemic lupus erythematosus (1.82, 1.41-2.35), and systemic sclerosis (2.32, 1.57-3.44) were associated with a larger AF risk. In sex-stratified analyses, rheumatic fever without heart involvement, multiple sclerosis, Crohn\'s disease, seropositive rheumatoid arthritis, psoriatic and enteropathic arthropathies, systemic sclerosis and ankylosing spondylitis were associated with larger AF risk in women, whereas only men showed a larger AF risk associated with ulcerative colitis.<br /><b>Conclusions</b><br />Various autoimmune diseases are associated with new-onset AF, more distinct in women. Our findings elaborate on the pathophysiological differences in autoimmunity and AF risk between men and women.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 22 Dec 2022; epub ahead of print</small></div>
Tilly MJ, Geurts S, Zhu F, Bos MM, ... de Groot NMS, Kavousi M
Europace: 22 Dec 2022; epub ahead of print | PMID: 36546587
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<div><h4>Lipomatous metaplasia prolongs repolarization and increases repolarization dispersion within post-infarct ventricular tachycardia circuit cites.</h4><i>Xu L, Zahid S, Khoshknab M, Moss J, ... Trayanova N, Nazarian S</i><br /><b>Aims</b><br />Post-infarct myocardium contains viable corridors traversing scar or lipomatous metaplasia (LM). Ventricular tachycardia (VT) circuitry has been separately reported to associate with corridors that traverse LM and with repolarization heterogeneity. We examined the association of corridor activation recovery interval (ARI) and ARI dispersion with surrounding tissue type.<br /><b>Methods and results</b><br />The cohort included 33 post-infarct patients from the prospective Intra-Myocardial Fat Deposition and Ventricular Tachycardia in Cardiomyopathy (INFINITY) study. We co-registered scar and corridors from late gadolinium enhanced magnetic resonance, and LM from computed tomography with intracardiac electrogram locations. Activation recovery interval was calculated during sinus or ventricular pacing, as the time interval from the minimum derivative within the QRS to the maximum derivative within the T-wave on unipolar electrograms. Regional ARI dispersion was defined as the standard deviation (SD) of ARI per AHA segment (ARISD). Lipomatous metaplasia exhibited higher ARI than scar [325 (interquartile range 270-392) vs. 313 (255-374), P < 0.001]. Corridors critical to VT re-entry were more likely to traverse through or near LM and displayed prolonged ARI compared with non-critical corridors [355 (319-397) vs. 302 (279-333) ms, P < 0.001]. ARISD was more closely associated with LM than with scar (likelihood ratio χ2 50 vs. 12, and 4.2-unit vs. 0.9-unit increase in 0.01*Log(ARISD) per 1 cm2 increase per AHA segment). Additionally, LM and scar exhibited interaction (P < 0.001) in their association with ARISD.<br /><b>Conclusion</b><br />Lipomatous metaplasia is closely associated with prolonged local action potential duration of corridors and ARI dispersion, which may facilitate the propensity of VT circuit re-entry.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Dec 2022; epub ahead of print</small></div>
Xu L, Zahid S, Khoshknab M, Moss J, ... Trayanova N, Nazarian S
Europace: 15 Dec 2022; epub ahead of print | PMID: 36519747
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<div><h4>Long-term risk of new-onset arrhythmia in ST-segment elevation myocardial infarction according to revascularization status.</h4><i>Thomsen AF, Jøns C, Jabbari R, Jacobsen MR, ... Engstrøm T, Jacobsen PK</i><br /><b>Aims</b><br />Emerging data show that complete revascularization (CR) reduces cardiovascular death and recurrent myocardial infarction in ST-segment elevation myocardial infarction (STEMI). However, the influence of revascularization status on development of arrhythmia in the long-term post-STEMI phase is poorly described. We hypothesized that incomplete revascularization (ICR) compared with CR in STEMI is associated with an increased long-term risk of new-onset arrhythmia.<br /><b>Methods and results</b><br />Patients with STEMI treated with primary percutaneous coronary intervention (PPCI) at Copenhagen University Hospital, Rigshospitalet, Denmark, with CR or ICR were identified via the Eastern Danish Heart registry from 2009 to 2016. Using unique Danish administrative registries, the outcomes were assessed. The primary outcome was new-onset arrhythmia defined as a composite of atrial fibrillation/flutter (AF), sinoatrial block, advanced second- or third-degree atrioventricular block, ventricular tachycardia/fibrillation (VT), or cardiac arrest (CA), with presentation >7 days post-PPCI. Secondary outcomes were the components of the primary outcome and all-cause mortality. A total of 5103 patients (median age: 62.0 years; 76% men) were included, of whom 4009 (79%) and 1094 (21%) patients underwent CR and ICR, respectively. Compared with CR, ICR was associated with a higher risk of new-onset arrhythmia [hazard ratio (HR), 1.33; 95% confidence interval (CI), 1.07-1.66; P = 0.01], AF (HR, 1.29; 95% CI, 1.00-1.66; P = 0.05), a combined outcome of VT and CA (HR, 1.77; 95% CI, 1.10-2.84; P = 0.02) and all-cause mortality (HR, 1.27; 95% CI, 1.05-1.53; P = 0.01). All HRs adjusted.<br /><b>Conclusion</b><br />Among patients with STEMI, ICR was associated with an increased long-term risk of new-onset arrhythmia and all-cause mortality compared with CR.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 15 Dec 2022; epub ahead of print</small></div>
Thomsen AF, Jøns C, Jabbari R, Jacobsen MR, ... Engstrøm T, Jacobsen PK
Europace: 15 Dec 2022; epub ahead of print | PMID: 36520640
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<div><h4>Fascicular ventricular tachycardia arising from the left side His and its adjacent region: a subset of upper septal idiopathic left ventricular tachycardia.</h4><i>Li MM, Wu XY, Jiang CX, Ning M, ... Dong JZ, Ma CS</i><br /><b>Aims</b><br />Fascicular ventricle tachycardia (FVT) arising from the proximal aspect of left His-Purkinje system (HPS) has not been specially addressed. Current study was to investigate its clinical, electrocardiographic, and electrophysiological characteristics.<br /><b>Methods and results</b><br />Eighteen patients who were identified as this rare FVT were consecutively enrolled, and their scalar electrocardiogram and electrophysiological data were collected and analysed. The ventricular tachycardia (VT) morphology was similar to sinus rhythm (SR) in eight patients, left bundle branch block type in one patient, right bundle branch block type in seven patients, and both narrow and wide QRS type in two patients. During VT, right-sided His potential preceded the QRS with His-ventricle (H-V) interval of 36.3 ± 12.4 ms, which was shorter than that during SR (-51.4 ± 8.6 ms) (P = 0.002). The earliest Purkinje potentials (PPs) were recorded within 7 ± 3 mm of left-side His and preceded the QRS by 49.1 ± 14.0 ms. Mapping along the left anterior fascicle and left posterior fascicle revealed an antegrade activation sequence in all with no P1 potentials recorded. In the two patients with two VT morphologies, the earliest PP was documented at the same site, and the activation sequence of HPS remained antegrade. Ablation at the earliest PP successfully eliminated the tachycardia, except one patient who developed complete atrial-ventricular block and two patients who abandoned ablations. After at least 12 months follow-up, 15 patients were free from any recurrences.<br /><b>Conclusions</b><br />Fascicular ventricle tachycardia arising from the proximal aspect of left HPS was featured by recording slightly shorter H-V interval and absence of P1 potentials. Termination of VT requires ablation at the left-sided His or its adjacent region.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 14 Dec 2022; epub ahead of print</small></div>
Li MM, Wu XY, Jiang CX, Ning M, ... Dong JZ, Ma CS
Europace: 14 Dec 2022; epub ahead of print | PMID: 36514946
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<div><h4>Patient selection, peri-procedural management, and ablation techniques for catheter ablation of atrial fibrillation: an EHRA survey.</h4><i>Iliodromitis K, Lenarczyk R, Scherr D, Conte G, ... Simovic S, Potpara T</i><br /><AbstractText>Catheter ablation (CA) of atrial fibrillation (AF) is the therapy of choice for the maintenance of sinus rhythm in patients with symptomatic AF. Time towards interventional treatment and peri-procedural management of patients undergoing AF ablation may vary in daily practice. The scope of this European Heart Rhythm Association (EHRA) survey was to report the current clinical practice regarding the management of patients undergoing AF ablation and physician\'s adherence to the European Society of Cardiology Guidelines and the EHRA/HRS/ECAS expert consensus statement on the CA for AF. This physician-based survey was conducted among EHRA members, using an internet-based questionnaire developed by the EHRA Scientific Initiatives Committee. A total of 258 physicians participated in the survey. In patients with paroxysmal or persistent AF, 42 and 9% of the physicians would routinely perform AF ablation as first-line therapy respectively, whereas 71% of physicians would consider ablation as first-line therapy in patients with symptomatic AF and left ventricular ejection fraction <35%. Only 14% of the respondents manage cardiovascular risk factors in patients referred for CA using a dedicated AF risk factor management programme. Radiofrequency CA is the preferred technology for first-time AF (56%), followed by cryo-balloon CA (40%). This EHRA survey demonstrated a considerable variation in the management of patients undergoing AF ablation in routine practice and deviations between guideline recommendations and clinical practice.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Dec 2022; epub ahead of print</small></div>
Iliodromitis K, Lenarczyk R, Scherr D, Conte G, ... Simovic S, Potpara T
Europace: 13 Dec 2022; epub ahead of print | PMID: 36512365
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<div><h4>Safety profile and long-term efficacy of very high-power short-duration (60-70 W) catheter ablation for atrial fibrillation: results of a large comparative analysis.</h4><i>Popa MA, Bourier F, Lengauer S, Krafft H, ... Deisenhofer I, Kottmaier M</i><br /><b>Aims</b><br />This retrospective study sought to compare complication rates and efficacy of power-controlled very high-power short-duration (vHPSD) and conventional catheter ablation in a large cohort of patients with atrial fibrillation (AF).<br /><b>Methods and results</b><br />We analyzed 1115 consecutive patients with AF (38.7% paroxysmal, 61.3% persistent) who received first-time catheter ablation at our centre from 2015 to 2021. Circumferential pulmonary vein isolation ± additional substrate ablation using an irrigated-tip catheter was performed with vHPSD (70 W/5-7 s or 60 W/7-10 s) in 574 patients and with conventional power (30-35 W/15-30 s) in 541 patients. Baseline characteristics were well-balanced between groups (mean age 65.1 ± 11.2 years, 63.4% male). The 30-day incidence of cardiac tamponade [2/574 (0.35%) vs. 1/541 (0.18%), P = 0.598], pericardial effusion ≥ 10 mm [2/574 (0.35%) vs. 1/541 (0.18%), P = 0.598] and transient ischaemic attack [1/574 (0.17%) vs. 2/541 (0.37%), P = 0.529] was not significantly different between vHPSD and conventional ablation. No stroke, atrio-esophageal fistula, cardiac arrest or death occurred. Procedure (122.2 ± 46.8 min vs. 155.0 ± 50.5 min, P < 0.001), radiofrequency (22.4 ± 19.3 min vs. 52.9 ± 22.0 min, P < 0.001), and fluoroscopy (8.1 ± 7.2 vs. 9.2 ± 7.4, P = 0.016) duration were significantly shorter in the vHPSD group. At 12 months follow-up, freedom of any atrial arrhythmia was 44.1% vs. 34.2% (P = 0.010) in persistent AF and 78.1% vs. 70.2% in paroxysmal AF (P = 0.068).<br /><b>Conclusion</b><br />vHPSD ablation is as safe as conventional ablation and is associated with an improved long-term efficacy in persistent AF.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
Popa MA, Bourier F, Lengauer S, Krafft H, ... Deisenhofer I, Kottmaier M
Europace: 12 Dec 2022; epub ahead of print | PMID: 36504120
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<div><h4>Familial atrial fibrillation mutation M1875T-SCN5A increases early sodium current and dampens the effect of flecainide.</h4><i>O\'Reilly M, Sommerfeld LC, O\'Shea C, Broadway-Stringer S, ... Kirchhof P, Fabritz L</i><br /><b>Aims</b><br />Atrial fibrillation (AF) is the most common cardiac arrhythmia. Pathogenic variants in genes encoding ion channels are associated with familial AF. The point mutation M1875T in the SCN5A gene, which encodes the α-subunit of the cardiac sodium channel Nav1.5, has been associated with increased atrial excitability and familial AF in patients.<br /><b>Methods and results</b><br />We designed a new murine model carrying the Scn5a-M1875T mutation enabling us to study the effects of the Nav1.5 mutation in detail in vivo and in vitro using patch clamp and microelectrode recording of atrial cardiomyocytes, optical mapping, electrocardiogram, echocardiography, gravimetry, histology, and biochemistry. Atrial cardiomyocytes from newly generated adult Scn5a-M1875T+/- mice showed a selective increase in the early (peak) cardiac sodium current, larger action potential amplitude, and a faster peak upstroke velocity. Conduction slowing caused by the sodium channel blocker flecainide was less pronounced in Scn5a-M1875T+/- compared to wildtype atria. Overt hypertrophy or heart failure in Scn5a-M1875T+/- mice could be excluded.<br /><b>Conclusion</b><br />The Scn5a-M1875T point mutation causes gain-of-function of the cardiac sodium channel. Our results suggest increased atrial peak sodium current as a potential trigger for increased atrial excitability.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
O'Reilly M, Sommerfeld LC, O'Shea C, Broadway-Stringer S, ... Kirchhof P, Fabritz L
Europace: 12 Dec 2022; epub ahead of print | PMID: 36504385
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<div><h4>Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis.</h4><i>Nguyen ST, Belley-Côté EP, Ibrahim O, Um KJ, ... Baranchuk A, McIntyre WF</i><br /><b>Aims</b><br />Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients.<br /><b>Methods and results</b><br />We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29-2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04-1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33-1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21-3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06-1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97-1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96-1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91-1.34; cumulative: four trials, RR 0.98, 95% CI 0.89-1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92-1.07).<br /><b>Conclusions</b><br />Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
Nguyen ST, Belley-Côté EP, Ibrahim O, Um KJ, ... Baranchuk A, McIntyre WF
Europace: 12 Dec 2022; epub ahead of print | PMID: 36503970
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<div><h4>EASY-WPW: a novel ECG-algorithm for easy and reliable localization of manifest accessory pathways in children and adults.</h4><i>El Hamriti M, Braun M, Molatta S, Imnadze G, ... Guckel D, Sommer P</i><br /><b>Aims</b><br />Accessory pathway (AP) ablation is a standard procedure for the treatment of Wolff-Parkinson-White syndrome (WPW). Twelve-lead electrocardiogram (ECG)-based delta wave analysis is essential for predicting ablation sites. Previous algorithms have shown to be complex, time-consuming, and unprecise. We aimed to retrospectively develop and prospectively validate a new, simple ECG-based algorithm considering the patients\' heart axis allowing for exact localization of APs in patients undergoing ablation for WPW.<br /><b>Methods and results</b><br />Our multicentre study included 211 patients undergoing ablation of a single manifest AP due to WPW between 2013 and 2021. The algorithm was developed retrospectively and validated prospectively by comparing its efficacy to two established ones (Pambrun and Arruda). All patients (32 ± 19 years old, 47% female) underwent successful pathway ablation. Prediction of AP-localization was correct in 197 patients (93%) (sensitivity 92%, specificity 99%, PPV 96%, and NPV 99%). Our algorithm was particularly useful in correctly localizing antero-septal/-lateral (sensitivity and specificity 100%) and posteroseptal (sensitivity 98%, specificity 92%) AP in proximity to the tricuspid valve. The accuracy of EASY-WPW was superior compared to the Pambrun (93% vs. 84%, P = 0.003*) and the Arruda algorithm (94% vs. 75%, P < 0.001*). A subgroup analysis of children (n = 58, 12 ± 4 years old, 55% female) revealed superiority to the Arruda algorithm (P < 0.001*). The reproducibility of our algorithm was excellent (ϰ>0.8; P < 0.001*).<br /><b>Conclusion</b><br />The novel EASY-WPW algorithm provides reliable and accurate pre-interventional ablation site determination in WPW patients. Only two steps are necessary to locate left-sided AP, and three steps to determine right-sided AP.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
El Hamriti M, Braun M, Molatta S, Imnadze G, ... Guckel D, Sommer P
Europace: 12 Dec 2022; epub ahead of print | PMID: 36504238
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<div><h4>Three-dimensional electroanatomical mapping guided right bundle branch pacing in congenitally corrected transposition of great arteries.</h4><i>Namboodiri N, Kakarla S, Mohanan Nair KK, Abhilash SP, ... Sasikumar D, Valaparambil AK</i><br /><b>Aims</b><br />The ideal pacing strategy has been the Achilles\' heel for patients with congenitally corrected transposition of great arteries (ccTGA) with bradycardia. Various pacing modalities were documented in the literature. This article describes a novel pacing strategy and its feasibility in ccTGA with an intact ventricular septum.<br /><b>Methods and results</b><br />We prospectively recruited three patients with ccTGA who presented with symptomatic complete heart block to our institute and were evaluated. All patients were planned for conduction system pacing. Those who had more than moderate or severe systemic atrioventricular regurgitation and systemic ventricular dysfunction were planned for conduction system pacing with an additional lead in the coronary sinus (CS) tributary, i.e. bundle branch pacing optimized cardiac resynchronization therapy with the intention to achieve incremental benefit. Since right bundle pacing is not described previously and in view of anatomical complexity in location, three-dimensional (3D) anatomical mapping was done with the EnSite system and later right bundle capture is identified conventionally as that of a left bundle in a normal heart. All three patients have stable lead positions and adequate thresholds at short-term follow-up.<br /><b>Conclusion</b><br />In this report, we demonstrated the feasibility of permanent physiological pacing of the systemic ventricle by capturing the right bundle with 3D anatomical mapping guidance, which results in physiological activation of the systemic ventricle.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
Namboodiri N, Kakarla S, Mohanan Nair KK, Abhilash SP, ... Sasikumar D, Valaparambil AK
Europace: 12 Dec 2022; epub ahead of print | PMID: 36504239
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<div><h4>Incidence of thyroid dysfunction following initiation of amiodarone treatment in patients with and without heart failure: a nationwide cohort study.</h4><i>Ali SA, Ersbøll M, Vinding NE, Butt JH, ... Køber L, Kristensen SL</i><br /><b>Aims</b><br />Thyroid dysfunction is considered the most frequent complication to amiodarone treatment, but data on its occurrence outside clinical trials are sparse. The present study aimed to examine the incidence of thyroid dysfunction following initiation of amiodarone treatment in a nationwide cohort of patients with and without heart failure (HF).<br /><b>Methods and results</b><br />In Danish registries, we identified all patients with first-time amiodarone treatment during the period 2000-18, without prior thyroid disease or medication. The primary outcome was a composite of thyroid diagnoses and initiation of thyroid drugs. Outcomes were assessed at 1-year follow-up, and for patients free of events in the first year, in a landmark analysis for the subsequent 5 years. We included 43 724 patients with first-time amiodarone treatment, of whom 16 939 (38%) had HF. At 1-year follow-up, the cumulative incidence and adjusted hazard ratio (HR) of the primary outcome were 5.3% and 1.37 (95% confidence interval 1.25-1.50) in patients with a history of HF and 4.2% in those without HF (reference). In the 1-year landmark analysis, the subsequent 5-year cumulative incidences and adjusted HRs of the primary outcome were 5.3% (reference) in patients with 1-year accumulated dose <27.38 g [corresponding to average daily dose (ADD <75 mg)], 14.0% and HR 2.74 (2.46-3.05) for 27.38-45.63 g (ADD 75-125 mg), 20.0% and HR 4.16 (3.77-4.59) for 45.64-63.88 g (ADD 126-175 mg), and 24.5% and HR 5.30 (4.82-5.90) for >63.88 g (ADD >175 mg).<br /><b>Conclusion</b><br />Among patients who initiated amiodarone treatment, around 5% had thyroid dysfunction at 1-year follow-up, with a slightly higher incidence in those with HF. A dose-response relationship was observed between the 1-year accumulated amiodarone dose and the subsequent 5-year cumulative incidence of thyroid dysfunction.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
Ali SA, Ersbøll M, Vinding NE, Butt JH, ... Køber L, Kristensen SL
Europace: 12 Dec 2022; epub ahead of print | PMID: 36504263
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<div><h4>The adjunctive effect for left pulmonary vein isolation of vein of Marshall ethanol infusion in persistent atrial fibrillation.</h4><i>Huang L, Gao M, Lai Y, Guo Q, ... Dong J, Ma CS</i><br /><b>Objective</b><br />This study sought to assess the effect of ethanol infusion into the vein of Marshall (EIVOM) on the acute success of left pulmonary vein (LPV) isolation in persistent atrial fibrillation (PeAF).<br /><b>Methods and results</b><br />A total of 313 patients with drug-resistant PeAF were enrolled (135 in Group 1 and 178 in Group 2). In Group 1, EIVOM was firstly performed, followed by radiofrequency ablation (RFA) including bilateral pulmonary vein isolation (PVI) and linear ablation at roofline, cavotricuspid isthmus, and mitral isthmus (MI). In Group 2, PVI and linear ablations were completed with RFA. First-pass isolation of the LPV was achieved in 119 (88.1%) and 132 (74.2%) patients in Groups 1 and 2, respectively (P = 0.002). The rate of acute pulmonary vein reconnection (PVR) was significantly lower in Group 1 (9.6% vs. 22.5%, P = 0.003). About half of acute PVR occurred in the carina with or without EIVOM.<br /><b>Conclusion</b><br />EIVOM is effective in achieving a higher first-pass isolation and a lower acute PVR of LPV in PeAF.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Dec 2022; epub ahead of print</small></div>
Huang L, Gao M, Lai Y, Guo Q, ... Dong J, Ma CS
Europace: 12 Dec 2022; epub ahead of print | PMID: 36504017
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<div><h4>The transmural activation interval: a new mapping tool to identify ventricular tachycardia substrates in right ventricular cardiomyopathy.</h4><i>Venlet J, Piers SR, Hoogendoorn J, Androulakis AFA, ... van der Geest RJ, Zeppenfeld K</i><br /><b>Aims</b><br />In right ventricular cardiomyopathy (RVCM), intramural scar may prevent rapid transmural activation, which may facilitate subepicardial ventricular tachycardia (VT) circuits. A critical transmural activation delay determined during sinus rhythm (SR) may identify VT substrates in RVCM.<br /><b>Methods and results</b><br />Consecutive patients with RVCM who underwent detailed endocardial-epicardial mapping and ablation for scar-related VT were enrolled. The transmural activation interval (TAI, first endocardial to first epicardial activation) and maximal activation interval (MAI, first endocardial to last epicardial activation) were determined in endocardial-epicardial point pairs located <10 mm apart. VT-related sites were determined by conventional substrate mapping and limited activation mapping when possible. Nineteen patients (46 ± 16 years, 84% male, 63% arrhythmogenic right ventricular cardiomyopathy, 37% exercise-induced arrhythmogenic remodelling) were inducible for 44 VT [CL 283 (interquartile range, IQR 240-325)ms]. A total of 2569 endocardial-epicardial coupled point pairs were analysed, including 98 (4%) epicardial VT-related sites.The TAI and MAI were significantly longer at VT-related sites compared with other electroanatomical scar sites [TAI median 31 (IQR 11-50) vs. 2 (-7-11)ms, P < 0.001; MAI median 65 (IQR 45-87) vs. 23 (13-39)ms, P < 0.001]. TAI and MAI allowed highly accurate identification of epicardial VT-related sites (optimal cut-off TAI 17 ms and MAI 45 ms, both AUC 0.81). Both TAI and MAI had a better predictive accuracy for VT-related sites than endocardial and epicardial voltage and electrogram (EGM) duration (AUC 0.51-0.73).<br /><b>Conclusion</b><br />The transmural activation delay in SR can be used to identify VT substrates in patients with RVCM and predominantly hemodynamically non-tolerated VT, and may be an important new mapping tool for substrate-based ablation.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 08 Dec 2022; epub ahead of print</small></div>
Venlet J, Piers SR, Hoogendoorn J, Androulakis AFA, ... van der Geest RJ, Zeppenfeld K
Europace: 08 Dec 2022; epub ahead of print | PMID: 36480385
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<div><h4>Short- and long-term risk of atrial fibrillation recurrence after first time ablation according to body mass index: a nationwide Danish cohort study.</h4><i>Tønnesen J, Pallisgaard J, Ruwald MH, Rasmussen PV, ... Gislason G, Hansen ML</i><br /><b>Aims</b><br />Overweight is associated with increased risk of atrial fibrillation (AF), but the impact of overweight and AF recurrence after ablation is less clear. Despite this, an increasing number of AF ablations are carried out in overweight patients. We investigated the impact of body mass index (BMI) on AF recurrence rates after ablation.<br /><b>Methods and results</b><br />Through Danish nationwide registers, all patients undergoing first-time AF ablation between 2010 and 2018 were identified. Exposure of interest was BMI. The primary outcome was recurrent AF, defined from either any usage of antiarrhythmic medication, AF hospitalization, cardioversion, or re-ablation. A total of 9188 patients were included. Median age and interquartile range was 64 (60-75) in the normal-weight group and 60 (53-66) in the morbidly obese. There was an increase in comorbidity burden with increasing BMI, including a higher prevalence of heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. At 1- and 5-year follow ups, recurrence rates of AF increased incrementally by BMI categories. The hazard ratios and 95% confidence intervals of recurrent AF after ablation were 1.15 (1.07-1.23), 1.18 (1.09-1.28), and 1.26 (1.13-1.41) in overweight, obese, and morbidly obese, respectively, compared with normal-weight patients. Procedure duration and X-ray dose exposure also increased with increasing BMI.<br /><b>Conclusion</b><br />Following AF ablation, recurrence rates of AF increased incrementally with increasing BMI. Therefore, aggressive weight management pre ablation in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 08 Dec 2022; epub ahead of print</small></div>
Tønnesen J, Pallisgaard J, Ruwald MH, Rasmussen PV, ... Gislason G, Hansen ML
Europace: 08 Dec 2022; epub ahead of print | PMID: 36480430
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<div><h4>Left bundle branch area pacing in patients with baseline narrow, left, or right bundle branch block QRS patterns: insights into electrocardiographic and echocardiographic features.</h4><i>Mirolo A, Chaumont C, Auquier N, Savoure A, ... Eltchaninoff H, Anselme F</i><br /><b>Aims</b><br />Left bundle branch area pacing (LBBAP) is a recent technique aiming at preservation of physiological ventricular electrical activation. Our goal was to assess mechanical synchrony parameters in relation to electrocardiographic features during LBBAP performed in routine practice.<br /><b>Methods and results</b><br />From June 2020 to August 2021, all patients of our institution with permanent pacemaker implantation indication were eligible for LBBAP. A \'qR\' pattern in V1 and a delay from pacing spike to the peak of the R-wave in V6 < 80 ms defined a successful LBBAP. Electrocardiogram and echocardiography were performed during spontaneous rhythm and LBBAP: left ventricular mechanical synchrony (LVMS) parameters using 2D Speckle tracking and interventricular mechanical delay (IVMD) were collected. LBBAP was attempted with success in 134/163 patients (82.2%). During LBBAP, the mean QRS width was 104 ± 12 ms. In patients with left bundle branch block (n = 47), LBBAP provided a significant decrease of QRS width from 139 ± 16 to 105 ± 12 ms (P < 0.001) with reduction of LVMS (53 ± 21 vs. 90 ± 46 ms, P = 0.009), and IVMD (14 ± 13 vs. 49 ± 18 ms, P < 0.001). In patients with right bundle branch block (n = 38), LBBAP led to a significant decrease of QRS width from 134 ± 14 to 106 ± 13 ms (P < 0.001) with no effect on LVMS and a reduction of IVMD (17 ± 14 vs. 50 ± 16 ms, P < 0.001).<br /><b>Conclusion</b><br />LBBAP in routine practice preserved intra-ventricular mechanical synchrony in patients with narrow and RBBB QRS and improved asynchrony parameters in patients with LBBB.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 08 Dec 2022; epub ahead of print</small></div>
Mirolo A, Chaumont C, Auquier N, Savoure A, ... Eltchaninoff H, Anselme F
Europace: 08 Dec 2022; epub ahead of print | PMID: 36480437
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<div><h4>Electrocardiographic imaging demonstrates electrical synchrony improvement by dynamic atrioventricular delays in patients with left bundle branch block and preserved atrioventricular conduction.</h4><i>Waddingham PH, Mangual JO, Orini M, Badie N, ... Lambiase PD, Chow AW</i><br /><b>Aims</b><br />Cardiac resynchronization therapy programmed to dynamically fuse pacing with intrinsic conduction using atrioventricular (AV) timing algorithms (e.g. SyncAV) has shown promise; however, mechanistic data are lacking. This study assessed the impact of SyncAV on electrical dyssynchrony across various pacing modalities using non-invasive epicardial electrocardiographic imaging (ECGi).<br /><b>Methods and results</b><br />Twenty-five patients with left bundle-branch block (median QRS duration (QRSd) 162.7 ms) and intact AV conduction (PR interval 174.0 ms) were prospectively enrolled. ECGi was performed acutely during biventricular pacing with fixed nominal AV delays (BiV) and using SyncAV (optimized for the narrowest QRSd) during: BiV + SyncAV, LV-only single-site (LVSS + SyncAV), MultiPoint pacing (MPP + SyncAV), and LV-only MPP (LVMPP + SyncAV). Dyssynchrony was quantified via ECGi (LV activation time, LVAT; RV activation time, RVAT; LV electrical dispersion index, LVEDi; ventricular electrical uncoupling index, VEU; and biventricular total activation time, VVtat). Intrinsic conduction LVAT (124 ms) was significantly reduced by BiV pacing (109 ms) (P = 0.001) and further reduced by LVSS + SyncAV (103 ms), BiV + SyncAV (103 ms), LVMPP + SyncAV (95 ms), and MPP + SyncAV (90 ms). Intrinsic RVAT (93 ms), VVtat (130 ms), LVEDi (36 ms), VEU (50 ms), and QRSd (163 ms) were reduced by SyncAV across all pacing modes. More patients exhibited minimal LVAT, VVtat, LVEDi, and QRSd with MPP + SyncAV than any other modality.<br /><b>Conclusion</b><br />Dynamic AV delay programming targeting fusion with intrinsic conduction significantly reduced dyssynchrony, as quantified by ECGi and QRSd for all evaluated pacing modes. MPP + SyncAV achieved the greatest synchrony overall but not for all patients, highlighting the value of pacing mode individualization during fusion optimization.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 08 Dec 2022; epub ahead of print</small></div>
Waddingham PH, Mangual JO, Orini M, Badie N, ... Lambiase PD, Chow AW
Europace: 08 Dec 2022; epub ahead of print | PMID: 36480445
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<div><h4>Fluorescence in situ hybridization and polymerase chain reaction to detect infections of cardiac implantable electronic devices.</h4><i>Just IA, Barthel F, Moter A, Kikhney J, ... Starck C, Schoenrath F</i><br /><b>Aims</b><br />In patients with infections of cardiac implantable electronic devices (CIEDs), the identification of causative pathogens is complicated by biofilm formations and previous antibiotic therapy. In this work, the impact of an additional fluorescence in situ hybridization (FISH), in combination with polymerase chain reaction and sequencing (FISHseq) was investigated.<br /><b>Methods and results</b><br />In 36 patients with CIED infections, FISHseq of explanted devices was performed and compared with standard microbiological cultivation of preoperative and intraoperative samples. The mean age was 61.9 (±16.2) years; 25 (69.4%) were males. Most patients (62.9%) had heart failure with reduced ejection fraction. Infections occurred as endoplastits (n = 26), isolated local generator pocket infection (n = 8), or both (n = 2); CIED included cardiac resynchronization therapy defibrillator (n = 17), implantable cardioverter defibrillator (n = 11), and pacemaker (n = 8) devices. The overall positive FISHseq detection rate was 97%. Intraoperatively, pathogens were isolated in 42 vs. 53% in standard cultivation vs. FISHseq, respectively. In 16 of 17 FISHseq-negative patients, the nucleic acid strain DAPI (4\',6-diamidino-2-phenylindole) indicated inactive microorganisms, which were partially organized in biofilms (n = 4) or microcolonies (n = 2). In 13 patients in whom no pathogen was identified preoperatively, standard cultivation and FISHseq identified pathogens in 3 (23%) vs. 8 (62%), respectively. For the confirmation of preoperatively known bacteria, a combined approach was most efficient.<br /><b>Conclusion</b><br />Fluorescence in situ hybridization sequencing is a valuable tool to detect causative microorganisms in CIED infections. The combination of FISHseq with preoperative cultivation showed the highest efficacy in detecting pathogens. Additional cultivation of intraoperative tissue samples or swabs yielded more confirmation of pathogens known from preoperative culture.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 07 Dec 2022; epub ahead of print</small></div>
Just IA, Barthel F, Moter A, Kikhney J, ... Starck C, Schoenrath F
Europace: 07 Dec 2022; epub ahead of print | PMID: 36477494
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<div><h4>Findings from repeat ablation using high-density mapping after pulmonary vein isolation with pulsed field ablation.</h4><i>Tohoku S, Chun KRJ, Bordignon S, Chen S, ... Bologna F, Schmidt B</i><br /><b>Aims</b><br />Pulsed-field ablation (PFA) can offer a novel perspective for atrial fibrillation (AF) ablation. We aimed to characterize the incidence of pulmonary vein (PV) reconnection, types of recurrent atrial tachyarrhythmia (ATa) and lesion quality after PFA-guided PV isolation (PVI).<br /><b>Methods and results</b><br />Patients undergoing second ablation for recurrent ATa following the initial PVI using the pentaspline PFA catheter were investigated. The rate of PV reconnection, the features of recurrent ATa, and the amount of isolated posterior wall (PW) surface area (ISAPW%) (ratio of the isolated- to total surface area on PW) were analyzed.<br /><b>Results</b><br />Among 360 patients treated with PFA, 25 patients (paroxysmal AF, n = 19) with 99 PVs underwent a second procedure 6.1 ± 4.0 months after the initial procedure. The rate of PV reconnection was 9.1% (9 PVs). Patients presented with atrial tachycardia (AT) (n = 16), AF (n = 8) and typical atrial flutter (n = 1). The mechanism of all but one AT was macro-reentry. The critical isthmus was found to be linked to the initial lesion set at the left atrial (LA) PW in eight patients and linked to pre-existing substrate at the LA anterior wall in four patients. One AT had a focal origin at the septum. In three patients, AT were unmappable. Mean ISAPW% was 72.7 ± 19.0%.<br /><b>Conclusion</b><br />We revealed a remarkable low reconnection rate with a large antral lesion at the PW after pentaspline PFA catheter-guided PVI. However, macro-reentrant AT with a critical isthmus at the LAPW linked to the PVI lesion set was commonly observed.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 25 Nov 2022; epub ahead of print</small></div>
Tohoku S, Chun KRJ, Bordignon S, Chen S, ... Bologna F, Schmidt B
Europace: 25 Nov 2022; epub ahead of print | PMID: 36427201
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<div><h4>Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry.</h4><i>Ding WY, Blomström-Lundqvist C, Fauchier L, Marin F, ... Lip GYH, ESC-EHRA EORP-AF Long-Term General Registry Investigators</i><br /><b>Background</b><br />Risk stratification in patients with atrial fibrillation (AF) is important to facilitate guideline-directed therapies. The Calculator of Absolute Stroke Risk (CARS) scheme enables an individualized estimation of 1-year absolute risk of stroke in AF. We aimed to investigate the predicted and absolute risks of ischaemic stroke, and evaluate whether CARS (and CHA2DS2-VASc score) may be useful for identifying high risk patients with AF despite contemporary treatment.<br /><b>Methods</b><br />We utilized the EORP-AF General Long-Term Registry which prospectively enrolled patients with AF from 250 centres across 27 participating European countries. Patients with sufficient data to determine CARS and CHA2DS2-VASc score, and reported outcomes of ischaemic stroke were included in this analysis. The primary outcome of ischaemic stroke was recorded over a 2-year follow-up period.<br /><b>Results</b><br />A total of 9444 patients were included (mean age 69.1 [±11.4] years; 3776 [40.0%] females). There was a high uptake (87.9%) of anticoagulation therapy, predominantly with vitamin K antagonist (50.0%). Over a mean follow-up period of 24 months, there were a total of 101 (1.1%) ischaemic stroke events. In the entire cohort, the median CARS and absolute annual risks of ischaemic stroke were 2.60 (IQR 1.60-4.00) and 0.53% (95%CI 0.43-0.64%), respectively. There was no statistical difference between the predictive performance of CARS and CHA2DS2-VASc score (0.621 [95%CI 0.563-0.678] vs. 0.626 [95%CI 0.573-0.680], P = 0.725).<br /><b>Conclusion</b><br />Contemporary management of AF was associated with a low risk of ischaemic stroke. CARS and CHA2DS2-VASc score may be useful to identify high risk patients despite treatment who may benefit from more aggressive treatment and follow-up.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 25 Nov 2022; epub ahead of print</small></div>
Ding WY, Blomström-Lundqvist C, Fauchier L, Marin F, ... Lip GYH, ESC-EHRA EORP-AF Long-Term General Registry Investigators
Europace: 25 Nov 2022; epub ahead of print | PMID: 36427202
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<div><h4>Impact of cryoballoon application abortion due to phrenic nerve injury on reconnection rates: a YETI subgroup analysis.</h4><i>Heeger CH, Popescu SȘ, Sohns C, Pott A, ... Sommer P, Tilz RR</i><br /><b>Aims</b><br />Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury (PNI) which is leading to premature abortion of the freeze cycle. Here, we analysed reconnection rates after CB-based PVI and PNI in a large-scale population during repeat procedures.<br /><b>Methods and results</b><br />In the YETI registry, a total of 17 356 patients underwent CB-based PVI in 33 centres, and 731 (4.2%) patients experienced PNI. A total of 111/731 (15.2%) patients received a repeat procedure for treatment of recurrent AF. In 94/111 (84.7%) patients data on repeat procedures were available. A total of 89/94 (94.7%) index pulmonary veins (PVs) have been isolated during the initial PVI. During repeat procedures, 22 (24.7%) of initially isolated index PVs showed reconnection. The use of a double stop technique did non influence the PV reconnection rate (P = 0.464). The time to PNI was 140.5 ± 45.1 s in patients with persistent PVI and 133.5 ± 53.8 s in patients with reconnection (P = 0.559). No differences were noted between the two populations in terms of CB temperature at the time of PNI (P = 0.362). The only parameter associated with isolation durability was CB temperature after 30 s of freezing. The PV reconnection did not influence the time to AF recurrence.<br /><b>Conclusion</b><br />In patients with cryoballon application abortion due to PNI, a high rate of persistent PVI rate was found at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures.<br /><b>Clinical trial registration</b><br />https://clinicaltrials.gov/ct2/show/NCT03645577?term=YETI&cntry=DE&draw=2&rank=1 ClinicalTrials.gov Identifier: NCT03645577.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 23 Nov 2022; epub ahead of print</small></div>
Heeger CH, Popescu SȘ, Sohns C, Pott A, ... Sommer P, Tilz RR
Europace: 23 Nov 2022; epub ahead of print | PMID: 36414239
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<div><h4>3 Tesla magnetic resonance imaging in patients with cardiac implantable electronic devices: a single centre experience.</h4><i>Fluschnik N, Tahir E, Erley J, Müllerleile K, ... Tönnis T, Nikorowitsch J</i><br /><b>Aims</b><br />Three Tesla (T) magnetic resonance imaging (MRI) provides critical imaging information for many conditions. Owing to potential interactions of the magnetic field, it is largely withheld from patients with cardiac implantable electronic devices (CIEDs). Therefore, we assessed the safety of 3T MRI in patients with \'3T MRI-conditional\' and \'non-3T MRI-conditional\' CIEDs.<br /><b>Methods and results</b><br />We performed a retrospective single-centre analysis of clinically indicated 3T MRI examinations in patients with conventional pacemakers, cardiac resynchronization devices, and implanted defibrillators from April 2020 to May 2022. All CIEDs were interrogated and programmed before and after scanning. Adverse events included all-cause death, arrhythmias, loss of capture, inappropriate anti-tachycardia therapies, electrical reset, and lead or generator failure during or shortly after MRI. Changes in signal amplitude and lead impedance were systematically assessed. Statistics included median and interquartile range. A total of 132 MRI examinations were performed on a 3T scanner in 97 patients. Thirty-five examinations were performed in patients with \'non-3T MRI-conditional\' CIEDs. Twenty-six scans were performed in pacemaker-dependent patients. No adverse events occurred during or shortly after MRI. P-wave or R-wave reductions ≥ 50 and ≥ 25%, respectively, were noted after three (2.3%) scans, all in patients with \'3T MRI-conditional\' CIEDs. Pacing and shock impedance changed by ± 30% in one case (0.7%). Battery voltage and stimulation thresholds did not relevantly change after MRI.<br /><b>Conclusion</b><br />Pending verification in independent series, our data suggest that clinically indicated MRI scans at 3T field strength should not be withheld from patients with cardiac pacemakers or defibrillators.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 23 Nov 2022; epub ahead of print</small></div>
Fluschnik N, Tahir E, Erley J, Müllerleile K, ... Tönnis T, Nikorowitsch J
Europace: 23 Nov 2022; epub ahead of print | PMID: 36413601
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<div><h4>Efficacy and safety of dronedarone across age and sex subgroups: a post hoc analysis of the ATHENA study among patients with non-permanent atrial fibrillation/flutter.</h4><i>Curtis AB, Zeitler EP, Malik A, Bogard A, ... Stewart J, Hohnloser SH</i><br /><b>Aims</b><br />Age and sex may impact the efficacy of antiarrhythmic drugs on cardiovascular outcomes and arrhythmia recurrences in patients with atrial fibrillation (AF). We report on a post hoc analysis of the ATHENA study (NCT00174785), which examined cardiovascular outcomes in patients with non-permanent AF treated with dronedarone vs. placebo.<br /><b>Methods and results</b><br />Efficacy and safety of dronedarone were assessed in patients according to age and sex. Baseline characteristics were comparable across subgroups, except for cardiovascular comorbidities, which were more frequent with increasing age. Dronedarone significantly reduced the risk of cardiovascular hospitalization or death due to any cause among patients 65-74 [n = 1830; hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.60-0.83; P < 0.0001] and ≥75 (n = 1925; HR 0.75, 95% CI 0.65-0.88; P = 0.0002) years old and among males (n = 2459; HR 0.74, 95% CI 0.64-0.84; P < 0.00001) and females (n = 2169; HR 0.77, 95% CI 0.67-0.89; P = 0.0002); outcomes were similar for time to AF/AFL recurrence. Among patients aged <65 years (n = 873), cardiovascular hospitalization or death due to any cause with dronedarone vs. placebo was associated with an HR of 0.89 (95% CI 0.71-1.11; P = 0.3). The incidence of all treatment-emergent adverse events (TEAEs) and TEAEs leading to treatment discontinuation was comparable among males and females, and increased with increasing age.<br /><b>Conclusions</b><br />These results support the use of dronedarone for the improvement of clinical outcomes among patients aged ≥65 years and regardless of sex.<br /><br />© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 22 Nov 2022; 24:1754-1762</small></div>
Curtis AB, Zeitler EP, Malik A, Bogard A, ... Stewart J, Hohnloser SH
Europace: 22 Nov 2022; 24:1754-1762 | PMID: 34374766
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<div><h4>Conduction system pacing in everyday clinical practice: EHRA physician survey.</h4><i>Kircanski B, Boveda S, Prinzen F, Sorgente A, ... Conte G, Burri H</i><br /><AbstractText>With the increasing interest in conduction system pacing (CSP) over the last few years and the inclusion of this treatment modality in the current guidelines, our aim was to provide a snapshot of current practice across Europe. An online questionnaire was sent to physicians participating in the European Heart Rhythm Association research network as well as to national societies and over social media. Data on previous experience with CSP, current indications, preferred tools, unmet needs, and perceptions for the future are reported and discussed.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 22 Nov 2022; epub ahead of print</small></div>
Kircanski B, Boveda S, Prinzen F, Sorgente A, ... Conte G, Burri H
Europace: 22 Nov 2022; epub ahead of print | PMID: 36413604
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<div><h4>P-wave duration and atrial fibrillation recurrence after catheter ablation: a systematic review and meta-analysis.</h4><i>Intzes S, Zagoridis K, Symeonidou M, Spanoudakis E, ... Koutalas E, Nedios S</i><br /><b>Aims</b><br />Atrial fibrillation (AF) is a global health problem with high morbidity and mortality. Catheter ablation (CA) can reduce AF burden and symptoms, but AF recurrence (AFr) remains an issue. Simple AFr predictors like P-wave duration (PWD) could help improve AF therapy. This updated meta-analysis reviews the increasing evidence for the association of AFr with PWD and offers practical implications.<br /><b>Methods and results</b><br />Publication databases were systematically searched and cohort studies reporting PWD and/or morphology at baseline and AFr after CA were included. Advanced interatrial block (aIAB) was defined as PWD ≥ 120 ms and biphasic morphology in inferior leads. Random-effects analysis was performed using the Review Manager 5.3 and R programs after study selection, quality assessment, and data extraction, to report odds ratio (OR) and confidence intervals. : Among 4175 patients in 22 studies, 1138 (27%) experienced AFr. Patients with AFr had longer PWD with a mean pooled difference of 7.8 ms (19 studies, P < 0.001). Pooled OR was 2.04 (1.16-3.58) for PWD > 120 ms (13 studies, P = 0.01), 2.42 (1.12-5.21) for PWD > 140 ms (2 studies, P = 0.02), 3.97 (1.79-8.85) for aIAB (5 studies, P < 0.001), and 10.89 (4.53-26.15) for PWD > 150 ms (4 studies, P < 0.001). There was significant heterogeneity but no publication bias detected.<br /><b>Conclusion</b><br />P-wave duration is an independent predictor for AF recurrence after left atrium ablation. The AFr risk is increasing exponentially with PWD prolongation. This could facilitate risk stratification by identifying high-risk patients (aIAB, PWD > 150 ms) and adjusting follow up or interventions.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 22 Nov 2022; epub ahead of print</small></div>
Intzes S, Zagoridis K, Symeonidou M, Spanoudakis E, ... Koutalas E, Nedios S
Europace: 22 Nov 2022; epub ahead of print | PMID: 36413611
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<div><h4>Conflicts of interest in electrophysiology and devices presentations.</h4><i>Camm CF, Crawford W, Prachee I, Olivarius-McAllister J, ... Ginks M, Nicol ED</i><br /><b>Aims</b><br />Industry collaboration with arrhythmia and devices research is common. However, this results in conflicts of interest (CoI) for researchers that should be disclosed. This study aimed to examine the quality of CoI disclosures in arrhythmia and devices presentations.<br /><b>Methods</b><br />Recorded presentations from the Arrhythmia & Devices section of the ESC Annual Congress 2016-2020 were assessed. The number of words, conflicts, and time displayed was documented for CoI declarations. Meta-data including sponsorship by an industry partner, presenter sex, and institution were obtained.<br /><b>Results</b><br />Of 1153 presentations assessed, 999 were suitable for inclusion. CoI statements were missing from 7.2% of presentations, and 58% reported ≥1 conflict. Those with conflicts spent less time-per-word on their disclosures (median 150 ms, interquartile range [IQR] 83-273 ms) compared with those without conflicts (median 250 ms, IQR 125-375 ms). One-in-eight presentations were sponsored (12.8%, n = 128). CoI statements were more likely to be missing in sponsored presentations (14.8%, n = 19) compared with non-sponsored presentations (6.1%, n = 53), P = 0.0003. Sponsored presentations contained a greater median number of CoIs (10, IQR 6-18) compared with non-sponsored sessions (1, IQR 0-5), P < 0.0001. Time-per-word spent on COI disclosures was 50% lower in sponsored sessions (125 ms, IQR 75-231 ms) compared with non-sponsored sessions (250 ms, IQR 125-375 ms), P < 0.0001.<br /><b>Conclusion</b><br />The majority of those presenting arrhythmia and devices research have CoIs to declare. Declarations were often missing or displayed for short periods of time. Presenters in sponsored sessions, while being more conflicted, had a lower standard of declaration suggesting a higher risk of potential bias which viewers had insufficient opportunity to assess.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 22 Nov 2022; epub ahead of print</small></div>
Camm CF, Crawford W, Prachee I, Olivarius-McAllister J, ... Ginks M, Nicol ED
Europace: 22 Nov 2022; epub ahead of print | PMID: 36413616
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<div><h4>Rhythm monitoring, success definition, recurrence, and anticoagulation after atrial fibrillation ablation: results from an EHRA survey.</h4><i>Schwab AC, Anic A, Farkowski MM, Guerra J, ... Chun JKR, Boveda S</i><br /><AbstractText>Atrial fibrillation (AF) is a major challenge for the healthcare field. Pulmonary vein isolation is the most effective treatment for the maintenance of sinus rhythm. However, clinical endpoints for the procedure vary significantly among studies. There is no consensus on the definition of recurrence and no clear roadmap on how to deal with recurrences after a failed ablation. The purpose of this study was to perform a survey in order to show how clinicians currently approach this knowledge gap. An online survey, supported by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, was conducted between 1 April 2022 and 8 May 2022. An anonymous questionnaire was disseminated via social media and EHRA newsletters, for clinicians to complete. This consisted of 18 multiple-choice questions regarding rhythm monitoring, definitions of a successful ablation, clinical practices after a failed AF ablation, and the continuance of anticoagulation. A total of 107 replies were collected across Europe. Most respondents (82%) perform routine monitoring for AF recurrences after ablation, with 51% of them preferring a long-term monitoring strategy. Cost was reported to have an impact on the choice of monitoring strategy. Self-screening was recommended by most (71%) of the respondents. The combination of absence of symptoms and recorded AF was the definition of success for most (83%) of the respondents. Cessation of anticoagulation after ablation was an option mostly for patients with paroxysmal AF and a low CHA2DS2-VASc score. The majority of physicians perform routine monitoring after AF ablation. For most physicians, the combination of the absence of symptoms and electrocardiographic endpoints defines a successful result after AF ablation.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 14 Nov 2022; epub ahead of print</small></div>
Schwab AC, Anic A, Farkowski MM, Guerra J, ... Chun JKR, Boveda S
Europace: 14 Nov 2022; epub ahead of print | PMID: 36372986
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<div><h4>Non-invasive localization of post-infarct ventricular tachycardia exit sites to guide ablation planning: a computational deep learning platform utilizing the 12-lead electrocardiogram and intracardiac electrograms from implanted devices.</h4><i>Monaci S, Qian S, Gillette K, Puyol-Antón E, ... King AP, Bishop MJ</i><br /><b>Aims</b><br />Existing strategies that identify post-infarct ventricular tachycardia (VT) ablation target either employ invasive electrophysiological (EP) mapping or non-invasive modalities utilizing the electrocardiogram (ECG). Their success relies on localizing sites critical to the maintenance of the clinical arrhythmia, not always recorded on the 12-lead ECG. Targeting the clinical VT by utilizing electrograms (EGM) recordings stored in implanted devices may aid ablation planning, enhancing safety and speed and potentially reducing the need of VT induction. In this context, we aim to develop a non-invasive computational-deep learning (DL) platform to localize VT exit sites from surface ECGs and implanted device intracardiac EGMs.<br /><b>Methods and results</b><br />A library of ECGs and EGMs from simulated paced beats and representative post-infarct VTs was generated across five torso models. Traces were used to train DL algorithms to localize VT sites of earliest systolic activation; first tested on simulated data and then on a clinically induced VT to show applicability of our platform in clinical settings. Localization performance was estimated via localization errors (LEs) against known VT exit sites from simulations or clinical ablation targets. Surface ECGs successfully localized post-infarct VTs from simulated data with mean LE = 9.61 ± 2.61 mm across torsos. VT localization was successfully achieved from implanted device intracardiac EGMs with mean LE = 13.10 ± 2.36 mm. Finally, the clinically induced VT localization was in agreement with the clinical ablation volume.<br /><b>Conclusion</b><br />The proposed framework may be utilized for direct localization of post-infarct VTs from surface ECGs and/or implanted device EGMs, or in conjunction with efficient, patient-specific modelling, enhancing safety and speed of ablation planning.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Nov 2022; epub ahead of print</small></div>
Abstract
<div><h4>Repeatability of ventricular arrhythmia characteristics on the exercise-stress test in RYR2-mediated catecholaminergic polymorphic ventricular tachycardia.</h4><i>Peltenburg PJ, Pultoo SNJ, Tobert KE, Bos JM, ... Wilde AAM, van der Werf C</i><br /><b>Aims</b><br />In catecholaminergic polymorphic ventricular tachycardia (CPVT), the exercise-stress test (EST) is the cornerstone for the diagnosis, risk stratification, and assessment of therapeutic efficacy, but its repeatability is unknown. We aimed to test the repeatability of ventricular arrhythmia characteristics on the EST in patients with CPVT.<br /><b>Methods and results</b><br />EST-pairs (ESTs performed within 18 months between 2005 and 2021, on the same protocol, and without or on the exact same treatment) of patients with RYR2-mediated CPVT from two specialized centres were included. The primary endpoint was the repeatability of the maximum ventricular arrhythmia score [VAS: 0 for the absence of premature ventricular contractions (PVCs); 1 for isolated PVCs; 2 for bigeminal PVCs; 3 for couplets; and 4 for non-sustained ventricular tachycardia]. Secondary outcomes were the repeatability of the heart rate at the first PVC and the ΔVAS (the absolute difference in VAS between the EST-pairs). A total of 104 patients with 349 EST-pairs were included. The median duration between ESTs was 343 (interquartile range, 189-378) days. Sixty (17.2%) EST-pairs were off therapy. The repeatability of the VAS was moderate {Krippendorf α, 0.56 [95% confidence interval (CI), 0.48-0.64]}, and the repeatability of the heart rate at the first PVC was substantial [intra-class correlation coefficient, 0.78 (95% CI, 0.71-0.84)]. The use of medication was associated with a higher odds for a ΔVAS > 1 (odds ratio = 3.52; 95% CI, 2.46-4.57; P = 0.020).<br /><b>Conclusion</b><br />The repeatability of ventricular arrhythmia characteristics was moderate to substantial. This underlines the need for multiple ESTs in CPVT patients and CPVT suspicious patients and it provides the framework for assessing the therapeutic efficacy of novel CPVT therapies.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 12 Nov 2022; epub ahead of print</small></div>
Peltenburg PJ, Pultoo SNJ, Tobert KE, Bos JM, ... Wilde AAM, van der Werf C
Europace: 12 Nov 2022; epub ahead of print | PMID: 36369981
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<div><h4>Left bundle branch area pacing in congenital heart disease.</h4><i>O\'Connor M, Riad O, Shi R, Hunnybun D, ... Gatzoulis MA, Wong T</i><br /><b>Aims</b><br />Left bundle branch area pacing (LBBAP) has been shown to be effective and safe. Limited data are available on LBBAP in the congenital heart disease (CHD) population. This study aims to describe the feasibility and safety of LBBAP in CHD patients compared with non-CHD patients.<br /><b>Methods and results</b><br />This is a single-centre, non-randomized observational study recruiting consecutive patients with bradycardia indication. Demographic data, ECGs, imaging, and procedural data including lead parameters were recorded. A total of 39 patients were included: CHD group (n = 13) and non-CHD group (n = 26). Congenital heart disease patients were younger (55 ± 14.5 years vs. 73.2 ± 13.1, P < 0.001). Acute success was achieved in all CHD patients and 96% (25/26) of non-CHD patients. No complications were encountered in either group. The procedural time for CHD patients was comparable (96.4 ± 54 vs. 82.1 ± 37.9 min, P = 0.356). Sheath reshaping was required in 7 of 13 CHD patients but only in 1 of 26 non-CHD patients, reflecting the complex and distorted anatomy of the patients in this group. Lead parameters were similar in both groups; R wave (11 ± 7 mV vs. 11.5 ± 7.5, P = 0.881) and pacing threshold (0.6 ± 0.3 V vs. 0.7 ± 0.3, P = 0.392). Baseline QRS duration was longer in the CHD group (150 ± 28.2 vs. 118.6 ± 26.6 ms, P = 0.002). Despite a numerically greater reduction in QRS and a similar left ventricular activation time (65.9 ± 6.2 vs. 67 ± 16.8 ms, P = 0.840), the QRS remained longer in the CHD group (135.5 ± 22.4 vs. 106.9 ± 24.7 ms, P = 0.005).<br /><b>Conclusion</b><br />Left bundle branch area pacing is feasible and safe in CHD patients as compared to that in non-CHD patients. Procedural and fluoroscopy times did not differ between both groups. Lead parameters were satisfactory and stable over a short-term follow-up.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 11 Nov 2022; epub ahead of print</small></div>
O'Connor M, Riad O, Shi R, Hunnybun D, ... Gatzoulis MA, Wong T
Europace: 11 Nov 2022; epub ahead of print | PMID: 36358001
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<div><h4>Disease progression rate is a strong predictor of ventricular arrhythmias in patients with cardiac laminopathies: a primary prevention cohort study.</h4><i>Rootwelt-Norberg C, Skjølsvik ET, Chivulescu M, Bogsrud MP, ... Lie ØH, Haugaa KH</i><br /><b>Aims</b><br />Cardiac disease progression prior to first ventricular arrhythmia (VA) in LMNA genotype-positive patients is not described.<br /><b>Methods and results</b><br />We performed a primary prevention cohort study, including consecutive LMNA genotype-positive patients from our centre. Patients underwent repeated clinical, electrocardiographic, and echocardiographic examinations. Electrocardiographic and echocardiographic disease progression as a predictor of first-time VA was evaluated by generalized estimation equation analyses. Threshold values at transition to an arrhythmic phenotype were assessed by threshold regression analyses. We included 94 LMNA genotype-positive patients without previous VA (age 38 ± 15 years, 32% probands, 53% females). Nineteen (20%) patients experienced VA during 4.6 (interquartile range 2.1-7.3) years follow up, at mean age 50 ± 11 years. We analysed 536 echocardiographic and 261 electrocardiogram examinations. Individual patient disease progression was associated with VA [left ventricular ejection fraction (LVEF) odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.6 per 5% reduction, left ventricular end-diastolic volume index (LVEDVi) OR 1.2 (95% CI 1.1-1.3) per 5 mL/m2 increase, PR interval OR 1.2 (95% CI 1.1-1.4) per 10 ms increase]. Threshold values for transition to an arrhythmic phenotype were LVEF 44%, LVEDVi 77 mL/m2, and PR interval 280 ms.<br /><b>Conclusions</b><br />Incidence of first-time VA was 20% during 4.6 years follow up in LMNA genotype-positive patients. Individual patient disease progression by ECG and echocardiography were strong predictors of VA, indicating that disease progression rate may have additional value to absolute measurements when considering primary preventive ICD. Threshold values of LVEF <44%, LVEDVi >77 mL/m2, and PR interval >280 ms indicated transition to a more arrhythmogenic phenotype.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Rootwelt-Norberg C, Skjølsvik ET, Chivulescu M, Bogsrud MP, ... Lie ØH, Haugaa KH
Europace: 10 Nov 2022; epub ahead of print | PMID: 36352512
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<div><h4>Upgrading right ventricular pacemakers to biventricular pacing or conduction system pacing: a systematic review and meta-analysis.</h4><i>Kaza N, Htun V, Miyazawa A, Simader F, ... Shun-Shin MJ, Keene D</i><br /><AbstractText>Guidelines recommend patients undergoing a first pacemaker implant who have even mild left ventricular (LV) impairment should receive biventricular or conduction system pacing (CSP). There is no corresponding recommendation for patients who already have a pacemaker. We conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies assessing device upgrades. The primary outcome was the echocardiographic change in LV ejection fraction (LVEF). Six RCTs (randomizing 161 patients) and 47 observational studies (2644 patients) assessing the efficacy of upgrade to biventricular pacing were eligible for analysis. Eight observational studies recruiting 217 patients of CSP upgrade were also eligible. Fourteen additional studies contributed data on complications (25 412 patients). Randomized controlled trials of biventricular pacing upgrade showed LVEF improvement of +8.4% from 35.5% and observational studies: +8.4% from 25.7%. Observational studies of left bundle branch area pacing upgrade showed +11.1% improvement from 39.0% and observational studies of His bundle pacing upgrade showed +12.7% improvement from 36.0%. New York Heart Association class decreased by -0.4, -0.8, -1.0, and -1.2, respectively. Randomized controlled trials of biventricular upgrade found improvement in Minnesota Heart Failure Score (-6.9 points) and peak oxygen uptake (+1.1 mL/kg/min). This was also seen in observational studies of biventricular upgrades (-19.67 points and +2.63 mL/kg/min, respectively). In studies of the biventricular upgrade, complication rates averaged 2% for pneumothorax, 1.4% for tamponade, and 3.7% for infection over 24 months of mean follow-up. Lead-related complications occurred in 3.3% of biventricular upgrades and 1.8% of CSP upgrades. Randomized controlled trials show significant physiological and symptomatic benefits of upgrading pacemakers to biventricular pacing. Observational studies show similar effects between biventricular pacing upgrade and CSP upgrade.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Kaza N, Htun V, Miyazawa A, Simader F, ... Shun-Shin MJ, Keene D
Europace: 10 Nov 2022; epub ahead of print | PMID: 36352513
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<div><h4>Role of genetic testing in young patients with idiopathic atrioventricular conduction disease.</h4><i>Auricchio A, Demarchi A, Özkartal T, Campanale D, ... Klersy C, Conte G</i><br /><b>Aims</b><br />To investigate the role of genetic testing in patients with idiopathic atrioventricular conduction disease requiring pacemaker (PM) implantation before the age of 50 years.<br /><b>Methods and results</b><br />All consecutive PM implantations in Southern Switzerland between 2010 and 2019 were evaluated. Inclusion criteria were: (i) age at the time of PM implantation: < 50 years; (ii) atrioventricular block (AVB) of unknown aetiology. Study population was investigated by ajmaline challenge and echocardiographic assessment over time. Genetic testing was performed using next-generation sequencing panel, containing 174 genes associated to inherited cardiac diseases, and Sanger sequencing confirmation of suspected variants with clinical implication. Of 2510 patients who underwent PM implantation, 15 (0.6%) were young adults (median age: 44 years, male predominance) presenting with advanced AVB of unknown origin. The average incidence of idiopathic AVB computed over the 2010-2019 time window was 0.7 per 100 000 persons per year (95% CI 0.4-1.2). Most of patients (67%) presented with specific genetic findings (pathogenic variant) or variants of uncertain significance (VUS). A pathogenic variant of PKP2 gene was found in one patient (6.7%) with no overt structural cardiac abnormalities. A VUS of TRPM4, MYBPC3, SCN5A, KCNE1, LMNA, GJA5 genes was found in other nine cases (60%). Of these, three unrelated patients (20%) presented the same heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene. Diagnostic re-assessment over time led to a diagnosis of Brugada syndrome and long-QT syndrome in two patients (13%). No cardiac events occurred during a median follow-up of 72 months.<br /><b>Conclusion</b><br />Idiopathic AVB in adults younger than 50 years is a very rare condition with an incidence of 0.7 per 100 000 persons/year. Systematic investigations, including genetic testing and ajmaline challenge, can lead to the achievement of a specific diagnosis in up to 20% of patients. Heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene was found in an additional 20% of unrelated patients, suggesting possible association of the variant with the disease.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Auricchio A, Demarchi A, Özkartal T, Campanale D, ... Klersy C, Conte G
Europace: 10 Nov 2022; epub ahead of print | PMID: 36352534
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<div><h4>Simplified stepwise anatomical ablation strategy for mitral isthmus: efficacy, efficiency, safety, and outcome.</h4><i>Li X, Li M, Zhang Y, Zhang H, ... Tang Q, Fu B</i><br /><b>Aims</b><br />Bidirectional and durable block of mitral isthmus (MI) is essential for catheter ablation of persistent atrial fibrillation (PeAF) and perimitral flutter (PMF), but it remains a challenge. The aim of this study was to create a simple anatomical ablation strategy with minimal fluoroscopy that would yield a high success rate for MI block.<br /><b>Methods and results</b><br />Patients with PeAF or PMF were included. Mitral isthmus was ablated in a stepwise strategy. In Step 1, endocardial MI linear ablation was performed; in Step 2, ablation was targeted to the posterolateral portion of the left atrium along the MI line; in Step 3, epicardial ablation within the coronary sinus (CS) was performed across the MI line to the ostium of the vein of Marshall (VOM) or performed within the VOM if available; in Step 4, the catheter was rotated and ablated in the CS to isolate the CS; and in Step 5, the early activation site with complex component potential above the MI line during distal CS pacing was considered as the ablation target. All patients were followed up. A total of 178 (17 patients with mechanical prosthetic mitral valve) were included. One hundred and sixty-six patients achieved a confirmed MI bidirectional conduction block (93%). One patient had cardiac tamponade. Four patients showed re-conduction across the MI line during a repeated ablation. In the latest follow-up [12 (7, 16) months], 161 of 178 (90%) patients maintained their sinus rhythm.<br /><b>Conclusion</b><br />A simple stepwise anatomical ablation strategy for MI shows a high success rate with low fluoroscopy exposure.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Li X, Li M, Zhang Y, Zhang H, ... Tang Q, Fu B
Europace: 10 Nov 2022; epub ahead of print | PMID: 36353823
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<div><h4>A head-to-head comparison of laser vs. powered mechanical sheaths as first choice and second line extraction tools.</h4><i>Zsigmond EJ, Saghy L, Benak A, Miklos M, ... Agocs S, Vamos M</i><br /><b>Aims</b><br />During transvenous lead extraction (TLE) longer dwelling time often requires the use of powered sheaths. This study aimed to compare outcomes with the laser and powered mechanical tools.<br /><b>Methods and results</b><br />Single-centre data from consecutive patients undergoing TLE between 2012 and 2021 were retrospectively analysed. Efficacy and safety of the primary extraction tool were compared. Procedures requiring crossover between powered sheaths were also analysed. Moreover, we examined the efficacy of each level of the stepwise approach. Out of 166 patients, 142 (age 65.4 ± 13.7 years) underwent TLE requiring advanced techniques with 245 leads (dwelling time 9.4 ± 6.3 years). Laser sheaths were used in 64.9%, powered mechanical sheaths in 35.1% of the procedures as primary extraction tools. Procedural success rate was 85.5% with laser and 82.5% with mechanical sheaths (P = 0.552). Minor and major complications were observed in similar rate. Procedural mortality occurred only in the laser group in the case of three patients. Crossover was needed in 19.5% after laser and in 12.8% after mechanical extractions (P = 0.187). Among crossover procedures, only clinical success favoured the secondary mechanical arm (87.1 vs. 54.5%, aOR: 0.09, 95% CI: 0.01-0.79, P = 0.030). After step-by-step efficacy analysis, procedural success was 64.9% with the first-line extraction tool, 75.1% after crossover, 84.5% with bailout femoral snare, and 91.8% by non-emergency surgery.<br /><b>Conclusion</b><br />The efficacy and safety of laser and mechanical sheaths were similar, however in the subgroup of crossover procedures mechanical tools had better performance regarding clinical success. Device diversity seems to help improving outcomes, especially in the most complicated cases.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Zsigmond EJ, Saghy L, Benak A, Miklos M, ... Agocs S, Vamos M
Europace: 10 Nov 2022; epub ahead of print | PMID: 36352816
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<div><h4>Prevalence and risk factors of cardiac thrombus prior to ventricular tachycardia catheter ablation in structural heart disease.</h4><i>Bonnin T, Roumegou P, Sridi S, Mahida S, ... Cochet H, Sacher F</i><br /><b>Aims</b><br />Assess prevalence, risk factors, and management of patients with intra-cardiac thrombus referred for scar-related ventricular tachycardia (VT) ablation.<br /><b>Methods and results</b><br />Consecutive VT ablation referrals between January 2015 and December 2019 were reviewed (n = 618). Patients referred for de novo, scar-related VT ablation who underwent pre-procedure cardiac computed tomography (cCT) were included. We included 401 patients [61 ± 14 years; 364 male; left ventricular ejection fraction (LVEF) 40 ± 13%]; 45 patients (11%) had cardiac thrombi on cCT at 49 sites [29 LV; eight left atrial appendage (LAA); eight right ventricle (RV); four right atrial appendage]. Nine patients had pulmonary emboli. Overall predictors of cardiac thrombus included LV aneurysm [odds ratio (OR): 6.6, 95%, confidence interval (CI): 3.1-14.3], LVEF < 40% (OR: 3.3, CI: 1.5-7.3), altered RV ejection fraction (OR: 2.3, CI: 1.1-4.6), and electrical storm (OR: 2.9, CI: 1.4-6.1). Thrombus location-specific analysis identified LV aneurysm (OR: 10.9, CI: 4.3-27.7) and LVEF < 40% (OR: 9.6, CI: 2.6-35.8) as predictors of LV thrombus and arrhythmogenic right ventricular cardiomyopathy (OR: 10.6, CI: 1.2-98.4) as a predictor for RV thrombus. Left atrial appendage thrombi exclusively occurred in patients with atrial fibrillation. Ventricular tachycardia ablation was finally performed in 363 including 7 (16%) patients with thrombus but refractory electrical storm. These seven patients had tailored ablation with no embolic complications. Only one (0.3%) ablation-related embolic event occurred in the entire cohort.<br /><b>Conclusion</b><br />Cardiac thrombus can be identified in 11% of patients referred for scar-related VT ablation. These findings underscore the importance of systematic thrombus screening to minimize embolic risk.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Bonnin T, Roumegou P, Sridi S, Mahida S, ... Cochet H, Sacher F
Europace: 10 Nov 2022; epub ahead of print | PMID: 36355748
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<div><h4>A novel and practical method to add video monitoring to tilt table testing.</h4><i>de Lange FJ, Hofland WPME, Ferrara A, Gargaro A, Brignole M, van Dijk JG</i><br /><b>Aims</b><br />We describe a novel, practical, and inexpensive method to add video recording during tilt table testing (TTT): Open-Access-Video-TTT.<br /><b>Methods and results</b><br />The Open-Access-Video-TTT set-up uses a personal computer (PC) to capture screen video data from a non-invasive-beat-to-beat (NIBTB) haemodynamic blood pressure (BP) device, combined with video recording of a patient, using Open Broadcaster Software (OBS®). The new Open-Access-Video-TTT set up was tested with both the Finometer (model Finapres Nova®, Medical Systems, the Netherlands) and the Task Force® Touch Cardio monitor (CNSystems, Austria). For this, the Finapres Nova® was enabled in \'remote\' mode and Real Video Network Computing (RealVNC®) was installed on the PC/laptop. The Task Force® has a DisplayPort (DP) port, for which a DP/ high-definition multimedia interface (HDMI) cable and a video capture card is used to merge the signals to the PC/laptop. With this method the combined images are stored as a new video signal. TTT can be performed with any routine protocol.<br /><b>Conclusions</b><br />Open Access-Video-TTT worked well for both the Finapres NOVA® and the Task Force Monitor ®. This novel method can be used easily by all physicians who wish to add video recording during TTT who do not have access to an electroencephalogram machine.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
de Lange FJ, Hofland WPME, Ferrara A, Gargaro A, Brignole M, van Dijk JG
Europace: 10 Nov 2022; epub ahead of print | PMID: 36351661
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<div><h4>Sense-B-noise: an enigmatic cause for inappropriate shocks in subcutaneous implantable cardioverter defibrillators.</h4><i>Haeberlin A, Burri H, Schaer B, Koepfli P, ... Reichlin T, Noti F</i><br /><b>Aims</b><br />Subcutaneous implantable cardioverter defibrillators (S-ICDs) are well established. However, inappropriate shocks (IAS) remain a source of concern since S-ICDs offer very limited troubleshooting options. In our multicentre case series, we describe several patients who experienced IAS due to a previously unknown S-ICD system issue.<br /><b>Methods and results</b><br />We observed six patients suffering from this novel IAS entity. The IAS occurred exclusively in primary or alternate S-ICD sensing vector configuration (therefore called \'Sense-B-noise\'). IAS were caused by non-physiologic oversensing episodes characterized by intermittent signal saturation, diminished QRS amplitudes, and disappearance of the artefacts after the IAS. Noise/oversensing could not be provoked by manipulation, X-ray did not show evidence for lead/header issues and impedance measurements were within normal limits. The pooled experience of our centres implies that up to ∼5% of S-ICDs may be affected. The underlying root cause was discussed extensively with the manufacturer but remains unknown and is under further investigation.<br /><b>Conclusion</b><br />Sense-B-noise is a novel cause for IAS due to non-physiologic signal oversensing, arising from a previously unknown S-ICD system issue. Sense-B-noise may be suspected if episodes of signal saturation in primary or alternate vector configuration are present, oversensing cannot be provoked, and X-ray and electrical measurements appear normal. The issue can be resolved by reprogramming the device to secondary sensing vector.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 10 Nov 2022; epub ahead of print</small></div>
Haeberlin A, Burri H, Schaer B, Koepfli P, ... Reichlin T, Noti F
Europace: 10 Nov 2022; epub ahead of print | PMID: 36353759
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<div><h4>Combined atrial fibrillation ablation and left atrial appendage occlusion procedure in the United States: a propensity score matched analysis from 2016-2019 national readmission database.</h4><i>Pasupula DK, Siddappa Malleshappa SK, Munir MB, Bhat AG, ... Olshansky B, Camm AJ</i><br /><b>Aims</b><br />The safety and feasibility of combining percutaneous catheter ablation (CA) for atrial fibrillation with left atrial appendage occlusion (LAAO) as a single procedure in the USA have not been investigated. We analyzed the US National Readmission Database (NRD) to investigate the incidence of combined LAAO + CA and compare major adverse cardiovascular events (MACEs) with matched LAAO-only and CA-only patients.<br /><b>Methods and results</b><br />In this retrospective study from NRD data, we identified patients undergoing combined LAAO and CA procedures on the same day in the USA from 2016 to 2019. A 1:1 propensity score match was performed to identify patients undergoing LAAO-only and CA-only procedures. The number of LAAO + CA procedures increased from 28 (2016) to 119 (2019). LAAO + CA patients (n = 375, mean age 74 ± 9.2 years, 53.4% were males) had non-significant higher MACE (8.1%) when compared with LAAO-only (n = 407, 5.3%) or CA-only patients (n = 406, 7.4%), which was primarily driven by higher rate of pericardial effusion (4.3%). All-cause 30-day readmission rates among LAAO + CA patients (10.7%) were similar when compared with LAAO-only (12.7%) or CA-only (17.5%) patients. The most frequent primary reason for readmissions among LAAO + CA and LAAO-only cohorts was heart failure (24.6 and 31.5%, respectively), while among the CA-only cohort, it was paroxysmal atrial fibrillation (25.7%).<br /><b>Conclusion</b><br />We report an 63% annual growth (from 28 procedures) in combined LAAO and CA procedures in the USA. There were no significant difference in MACE and all-cause 30-day readmission rates among LAAO + CA patients compared with matched LAAO-only or CA-only patients.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 09 Nov 2022; epub ahead of print</small></div>
Pasupula DK, Siddappa Malleshappa SK, Munir MB, Bhat AG, ... Olshansky B, Camm AJ
Europace: 09 Nov 2022; epub ahead of print | PMID: 36350997
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<div><h4>Atrial fibrillation onset before heart failure or vice versa: what is worst? A nationwide register study.</h4><i>Pallisgaard J, Greve AM, Lock-Hansen M, Thune JJ, ... Torp-Pedersen C, Bang CN</i><br /><b>Aims</b><br />Atrial fibrillation (AF) and heart failure (HF) often coexist. However, whether AF onset before HF or vice versa is associated with the worst outcome remains unclear. A consensus of large studies can guide future research and preventive strategies to better target high-risk patients.<br /><b>Methods and results</b><br />We included all Danish cases with the coexistence of AF and HF (2005-17) using nationwide registries. Patients were divided into three separate groups (i) AF before HF, (ii) HF before AF, or (iii) AF and HF diagnosed concurrently (±30 days). Adjusting landmark Cox analyses (index date was the time of the latter diagnosis of AF or HF) were used for evaluating the association of the three groups with a composite outcome of ischaemic stroke or death. Among a total of 49 042 patients included, 40% had AF before HF, 27% had HF before AF, and 33% had AF and HF diagnosed concurrently. The composite endpoint accrued more often in patients with HF before AF compared to the two other groups (<0.001), and this remained significant in the adjusted analyses with hazard ratios (95% confidence intervals) of 1.26 (1.22-1.30) compared to AF before HF. Finally, antihypertensive treatment, oral anticoagulants, amiodarone, statins, and AF ablation were associated with a lower hazard ratio of the composite endpoint (all < 0.001).<br /><b>Conclusions</b><br />In this large Danish national cohort, diagnosis of HF before AF was associated with an increased absolute risk of death compared to AF before HF and AF and HF diagnosed concurrently. Antihypertensive treatment, oral anticoagulants, amiodarone, statins, and AF ablation may improve prognosis.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 09 Nov 2022; epub ahead of print</small></div>
Pallisgaard J, Greve AM, Lock-Hansen M, Thune JJ, ... Torp-Pedersen C, Bang CN
Europace: 09 Nov 2022; epub ahead of print | PMID: 36349557
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Abstract
<div><h4>Quantitative assessment of transmural fibrosis profile in the human atrium: evidence for a three-dimensional arrhythmic substrate by slice-to-slice histology.</h4><i>Ravelli F, Masè M, Cristoforetti A, Avogaro L, ... Piccoli F, Graffigna A</i><br /><b>Aims</b><br />Intramural fibrosis represents a crucial factor in the formation of a three-dimensional (3D) substrate for atrial fibrillation (AF). However, the transmural distribution of fibrosis and its relationship with atrial overload remain largely unknown. The aim of this study is to quantify the transmural profile of atrial fibrosis in patients with different degrees of atrial dilatation and arrhythmic profiles by a high-resolution 3D histology method.<br /><b>Methods and results</b><br />Serial microtome-cut tissue slices, sampling the entire atrial wall thickness at 5 µm spatial resolution, were obtained from right atrial appendage specimens in 23 cardiac surgery patients. Atrial slices were picrosirius red stained, imaged by polarized light microscopy, and analysed by a custom-made segmentation algorithm. In all patients, the intramural fibrosis content displayed a progressive decrease alongside tissue depth, passing from 68.6 ± 11.6% in the subepicardium to 10-13% in the subendocardium. Distinct transmural fibrotic profiles were observed in patients with atrial dilatation with respect to control patients, where the first showed a slower decrease of fibrosis along tissue depth (exponential decay constant: 171.2 ± 54.5 vs. 80.9 ± 24.4 µm, P < 0.005). Similar slow fibrotic profiles were observed in patients with AF (142.8 ± 41.7 µm). Subepicardial and midwall levels of fibrosis correlated with the degree of atrial dilatation (ρ = 0.72, P < 0.001), while no correlation was found in subendocardial layers.<br /><b>Conclusions</b><br />Quantification of fibrosis transmural profile at high resolution is feasible by slice-to-slice histology. Deeper penetration of fibrosis in subepicardial and midwall layers in dilated atria may concur to the formation of a 3D arrhythmic substrate.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 09 Nov 2022; epub ahead of print</small></div>
Ravelli F, Masè M, Cristoforetti A, Avogaro L, ... Piccoli F, Graffigna A
Europace: 09 Nov 2022; epub ahead of print | PMID: 36349600
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