Journal: Heart Rhythm

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Abstract

Lights and shadows of subcutaneous implantable cardioverter defibrillator in Brugada syndrome.

Dendramis G, Brugada P
Currently the cornerstone of therapy for ventricular arrhythmic complications and sudden cardiac death prevention in Brugada syndrome (BrS) is an implantable cardioverter defibrillator (ICD). This patients population differs from the majority of patients with an ICD implanted for a structural heart disease and as widely known transvenous ICD systems have been associated with high complication rates in BrS patients. Technological evolutions of these devices have certainly reduced complications due to the device itself, but a careful pre-implant screening of these patients is still essential. To date criteria for an adequate screening process to select suitable candidates for a subcutaneous implantable cardioverter-defibrillator (S-ICD) among BrS patients are sometimes non standardized and often lacking of important precautions which are instead fundamental to select the most suitable type of ICD for these patients. To better select suitable candidates for S-ICD among BrS patients, a full screening process should include screening during or immediately after an exercise test and after a drug provocation challenge test. We report an analysis of the \" lights and shadows\" of S-ICD for a correct use of this device in BrS patients.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 23 Sep 2022; epub ahead of print
Dendramis G, Brugada P
Heart Rhythm: 23 Sep 2022; epub ahead of print | PMID: 36162769
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Abstract

LEFT BUNDLE AREA PACING: GUIDING IMPLANT DEPTH BY RING MEASUREMENTS.

Orlov MV, Nikolaychuk M, Koulouridis I, Goldman A, ... King M, Wylie J
Background
Criteria for successful left bundle area pacing (LBAP) are in flux and currently guided by lead tip measurements. Lead ring measurements during LBAP have not been well studied.
Objective
To investigate dynamics in pacing parameters during successful and unsuccessful lead implant attempts.
Methods
SelectSecure 3830 pacing leads (Medtronic, Inc) guided by C315 sheaths for LBAP were placed for standard pacing indications in 73 patients. Retrospective review of procedural, echocardiographic, and standard pacing data were performed. Depth and lead-septal angle of implanted electrodes were determined from fluoroscopy with septal contrast delineation. Depth was graded in 4 categories according to the degree of ring penetration into the septum. Successful implant was defined by the ability to advance the lead deep into the septum and achieve LBAP criteria (ventricular activation time, QRS width/shape).
Results
Ring impedance increased stepwise during successful attempts as opposed to unsuccessful (p = 0.039). A wider lead-septal angle at implant position correlated with higher ring impedance (p = 0.036), whereas no association was found with tip impedance. Unipolar ring threshold correlated with depth of lead implant (p = 0.029). Tip impedance measurements at implant position were less predictive of lead depth and did not correlate with septal thickness.
Conclusion
Ring pacing parameters are more predictive of lead progress than tip measurements. Lead depth and lead-septal angle can be determined from ring impedance measurements. These measurements may provide determination of lead depth and could obviate the need for contrast injection.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 21 Sep 2022; epub ahead of print
Orlov MV, Nikolaychuk M, Koulouridis I, Goldman A, ... King M, Wylie J
Heart Rhythm: 21 Sep 2022; epub ahead of print | PMID: 36152975
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Abstract

Clinical Benefits of Concomitant Surgical Ablation For Atrial Fibrillation Undergoing Mitral Valve Surgery: National Cohort Study.

Kim HJ, Han KD, Kim WK, Cho YH, Lee SH, Je HG
Background
The maze procedure is the dominant concomitant surgery performed with mitral valve (MV) surgery in patients with atrial fibrillation (AF). Most clinical recommendation regarding the maze procedure depends on individual maze expert centers.
Objective
The current study aimed to evaluate the clinical benefits of the maze procedure during MV surgery with national cohort.
Methods
Using the National Health Insurance Data Sharing Service of South Korea, subjects with AF who underwent MV surgery from 2009 to 2017 were reviewed. The outcomes of interest were mortality; occurrence of ischemic or hemorrhagic stroke; hospitalization for bleeding events; and the composite of death, cerebrovascular accident, and major bleeding. Propensity score (PS) matching was performed for baseline adjustment.
Results
Among 9,501 subjects, the maze procedure was performed in 5,508 subjects(58.0%). In the PS-matched cohort(3,376 pairs), the risk of the composite event was significantly lower in the maze group (hazard ratio 0.799; 95% confidence interval, 0.731-0.873) than in the non-maze group. The superiority of the maze was similar for individual clinical events, including death (0.795, 0.711-0.889), ischemic stroke (0.788, 0.67-0.926), and major bleeding (0.749, 0.627-0.895), but not hemorrhagic stroke (0.984, 0.768-1.262). In the subgroup analyses, concerning the composite events, these benefits were consistent in subjects aged ≥70 years or less, surgery types (replacement vs. repair), MV pathologies, and subjects with a CHA2DS2-VASc score of ≥4 or less.
Conclusion
The adding maze procedure during MV surgery provided protective effects in the composite outcome of interest.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 21 Sep 2022; epub ahead of print
Kim HJ, Han KD, Kim WK, Cho YH, Lee SH, Je HG
Heart Rhythm: 21 Sep 2022; epub ahead of print | PMID: 36152976
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Abstract

Improving guideline-based anticoagulation in atrial fibrillation: A systematic literature review of prospective trials.

Sporn ZA, Berman AN, Daly D, Wasfy JH
Background
Guidelines for anticoagulation in patients with atrial fibrillation (AF) aim to decrease the risk of ischemic stroke. However, there is a gap in actual practice between patients who have an indication for anticoagulation and those who are actually prescribed anticoagulation.
Objective
We sought to evaluate the efficacy of prior population-based interventions aimed at decreasing this AF anticoagulation gap.
Methods
This study was prospectively registered in the PROSPERO international database (CRD42021287875). A systematic literature review (SLR) was conducted to obtain all prospective individually and cluster-randomized trials by searching 4 electronic databases (PubMed, Google Scholar, Web of Science, and Medline).
Results
After review of 1474 studies, 20 trials were included in this SLR. 45% were effective in decreasing the AF anticoagulation gap. Trial interventions that improved anticoagulation prescribing included 6 trials of electronic risk assessment or decision support, 1 trial of provider education, 2 trials of a new protocol or pathway, and 2 trials of patient education. 6 out of 15 ambulatory trials, 2 out of 4 inpatient trials, and 1 trial that spanned inpatient and outpatient settings improved anticoagulation prescribing rates. Interventions focused on patient education, provider education, and electronic risk assessment or decision support increased absolute appropriate anticoagulation prescribing 8.3%, 4.9%, and 2.0% respectively.
Conclusion
Interventions aimed at improving anticoagulation prescribing patterns in AF can be effective although there is heterogeneity in outcomes across intervention type. The most effective interventions appeared to target patient education, provider education, and electronic risk assessment or decision support.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 16 Sep 2022; epub ahead of print
Sporn ZA, Berman AN, Daly D, Wasfy JH
Heart Rhythm: 16 Sep 2022; epub ahead of print | PMID: 36122695
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Abstract

Gaps after linear ablation of persistent atrial fibrillation, (Marshall-PLAN): clinical implication.

Takagi T, Derval N, Duchateau J, Chauvel R, ... Haïssaguerre M, Pambrun T
Background
Beyond pulmonary vein (PV) isolation, anatomic isthmuses transection is an adjunctive strategy for persistent atrial fibrillation (AF). Data on the durability of multiple lines of block remain scarce.
Objective
To evaluate the impact of gaps within such a lesion set.
Methods
We followed 291 consecutive patients who underwent: (1) vein of Marshall ethanol infusion, (2) PV isolation, and (3) mitral, cavotricuspid, and dome isthmuses transection. Dome transection relied on two distinct strategies over time. A single roof line with touch-ups applied in case of gap demonstrated by conventional maneuvers (first leg). An alternative floor line if the roof line exhibited a gap during high-density mapping with careful electrogram reannotation (second leg).
Results
12-month sinus rhythm maintenance was 70% after 1 procedure, and 94% after 1 or 2 procedures. Event-free survival after first procedure was lower in case of residual gaps within the lesion set (log rank=0.004). Delayed gaps were found in 94% of second procedure performed in the 69 patients relapsing despite complete lesion set with PV gaps increasing the risk of recurrence into AF (67% vs 34%; p=0.02), and anatomic isthmuses gaps supporting a majority of ATs (60%). Between first leg and second leg, a significant decrease was found in roof lines considered blocked during first procedure (99% vs 78%; p<0.001), and in delayed dome gaps observed during second procedure (68% vs 43%; p=0.05).
Conclusion
Gaps are arrhythmogenic, and can be reduced by optimized ablation and assessment of lines of block. Closing these gaps improves sinus rhythm maintenance.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 14 Sep 2022; epub ahead of print
Takagi T, Derval N, Duchateau J, Chauvel R, ... Haïssaguerre M, Pambrun T
Heart Rhythm: 14 Sep 2022; epub ahead of print | PMID: 36115541
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Abstract

Three-Dimensional Functional Anatomy of Human Sinoatrial node for Epicardial and Endocardial Mapping and Ablation.

Kalyanasundaram A, Li N, Augostini RS, Weiss R, Hummel JD, Fedorov VV
The sinoatrial node (SAN) is the primary pacemaker of the human heart. It is a single, elongated three-dimensional (3D) intramural fibrotic structure located at the junction of the superior vena cava intercaval region bordering the crista terminalis (CT). SAN activation originates in the intranodal pacemakers and is conducted to the atria through one or more discrete sinoatrial conduction pathways. The complexity of the 3D SAN pacemaker structure and intramural conduction are underappreciated during clinical multi-electrode mapping and ablation procedures of SAN and atrial arrhythmias. In fact, defining and targeting SAN is extremely challenging because even during sinus rhythm, surface only multi-electrode mapping may not define the leading pacemaker sites in intramural SAN but instead misinterpret them as epicardial or endocardial exit sites through sinoatrial conduction pathways. These SAN exit sites may be distributed up to 50 mm along the CT beyond the ∼20 mm long anatomical SAN structure. Moreover, since SAN reentry tachycardia beats may exit through the same sinoatrial conduction pathway as during sinus rhythm, many SAN arrhythmias are underdiagnosed. Misinterpretation of arrhythmia sources and/or mechanisms (e.g., enhanced automaticity, intranodal vs CT reentry) limit diagnosis and success of catheter ablation treatments for poorly understood SAN arrhythmias. The aim of this review is to provide a state-of-the-art overview of the 3D structure and function of the human SAN complex, mechanisms of SAN arrhythmias and available approaches for electrophysiological mapping, 3D structural imaging, pharmacological interventions and ablation to improve diagnosis and mechanistic treatment of SAN and atrial arrhythmias.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 13 Sep 2022; epub ahead of print
Kalyanasundaram A, Li N, Augostini RS, Weiss R, Hummel JD, Fedorov VV
Heart Rhythm: 13 Sep 2022; epub ahead of print | PMID: 36113768
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Abstract

CHARACTERIZATION OF VENTRICULAR ARRHYTHMIAS AND SUDDEN CARDIAC DEATH IN SUBJECTS WITH MITRAL VALVE PROLAPSE AND MITRAL ANNULAR DISJUNCTION.

Raina A, Gersh BJ, Asirvatham SJ, Del-Carpio Munoz F
Sudden cardiac death is reported as the leading cause of mortality in developed nations. Arrhythmic mitral valve disease, encompassing mitral valve prolapse and/or mitral annular disjunction, is thought to be responsible in a sizable portion of these deaths. Despite this evidence, there are no reliable methods nor clinically useful risk stratification schemes to determine which group of patients are at higher risk or may benefit from interventions like catheter ablation or prophylactic implantation of a defibrillator. The reasons for this lack of guidance include our incomplete understanding of the mechanisms of ventricular arrhythmias and the fact that mitral valve prolapse and disjunction are frequently diagnosed, yet carry an overall low risk of sudden cardiac death. This heterogeneity makes the development of a reliable prediction model based on the presence of common risk factors very difficult. In this review, we summarize the relevant literature regarding the epidemiology, diagnosis, pathophysiology, and management of mitral valve prolapse and mitral annular disjunction and elucidate their role in sudden cardiac death.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 13 Sep 2022; epub ahead of print
Raina A, Gersh BJ, Asirvatham SJ, Del-Carpio Munoz F
Heart Rhythm: 13 Sep 2022; epub ahead of print | PMID: 36113769
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Abstract

Ambulatory AV synchronous pacing over time using a leadless ventricular pacemaker: Primary results from the AccelAV study.

Chinitz LA, El-Chami MF, Sagi V, Garcia H, ... Fagan DH, Sun Chan JY
Background
Prior studies demonstrated that accelerometer-based mechanically-timed AV synchrony (AVS) is feasible using a leadless ventricular pacemaker.
Objective
This study reports on the performance of a leadless ventricular pacemaker with accelerometer-based algorithms that provide AVS pacing.
Methods
AccelAV was a prospective single-arm study to characterize AVS in patients implanted with a Micra AV, which uses the device accelerometer to mechanically detect atrial contractions and promote VDD pacing. The primary objective was to characterize resting AVS at 1-month in patients with complete AV block (AVB) and normal sinus function.
Results
A total of 152 patients (age 77±11 years, 48% female) from 20 centers were enrolled and implanted with a leadless pacemaker. Among patients with normal sinus function and complete AVB (n=54), mean resting AVS was 85.4% at 1-month, while ambulatory AVS was 74.8%. In the subset of patients (n=20) with programming optimization, mean ambulatory AVS was 82.6%, representing a 10.5% improvement (P<0.001). Quality of life as measured by the EQ-5D-3L improved significantly from pre-implant to 3 months (P=0.031). In 37 patients with AVB at both 1-month and 3-months, mean AVS during rest did not differ (86.1% vs 84.1%, P=0.43). There were no upgrades to dual-chamber devices or CRT through 3 months.
Conclusion
Accelerometer-based mechanical atrial sensing provided by a leadless pacemaker implanted in the right ventricle significantly improves quality of life in a select cohort of patients with AV block and normal sinus function. AVS remained stable through 3 months and there were no system upgrades to dual-chamber pacemakers.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 05 Sep 2022; epub ahead of print
Chinitz LA, El-Chami MF, Sagi V, Garcia H, ... Fagan DH, Sun Chan JY
Heart Rhythm: 05 Sep 2022; epub ahead of print | PMID: 36075532
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Abstract

Causes of sudden cardiac death according to age and sex among persons aged 1-49 years.

Lynge TH, Nielsen JL, Risgaard B, van der Werf C, Winkel BG, Tfelt-Hansen J
Background
Knowledge of causes of sudden cardiac death (SCD) according to age is important in clinical decision-making and to lower the risk of SCD in family members of SCD victims.
Objective
To report overall and sex-stratified causes of SCD according to age in persons aged 1-49 years.
Methods
The study population consisted of all persons in Denmark aged 1-35 years in 2000-09 and 36-49 years in 2007-09, which equals 27.1 million person-years. Danish death certificates, discharge summaries, autopsy reports, and data from nationwide registries were used to identify all SCD cases. The SCD cases were divided into 5-year age groups.
Results
In the 10-year study period, there were 14,294 deaths, of which 1,362 (10%) were classified as SCD. Potentially inherited cardiac disease accounted for a large proportion (43-78%) of autopsied SCD in all age groups. A significant proportion (19-54%) of SCD was caused by sudden arrhythmic death syndrome in all age groups. Autopsy rates among both sudden unexpected death cases and SCD cases declined significantly with increasing age (74% in the youngest age group vs. 35% in the oldest).
Conclusion
The proportion of SCD cases that were identified with a potentially inherited cardiac disease postmortem was high in all studied age groups, while autopsy rates among cases of sudden and unexpected death declined markedly with increasing age. Our findings indicate that diagnoses of inherited heart disease are likely missed in some SCD cases, along with the opportunity for treatment and prevention among surviving relatives.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 05 Sep 2022; epub ahead of print
Lynge TH, Nielsen JL, Risgaard B, van der Werf C, Winkel BG, Tfelt-Hansen J
Heart Rhythm: 05 Sep 2022; epub ahead of print | PMID: 36075534
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Abstract

GJA1 gene polymorphism is a genetic predictor of recurrence following pulmonary vein isolation in patients with paroxysmal atrial fibrillation.

Okamura S, Ochi H, Onohara Y, Nakashima M, ... Kihara Y, Nakano Y
Background
Atrial fibrillation (AF) and recurrence of AF following pulmonary vein (PV) isolation (PVI) have been linked to sinus node dysfunction.
Objective
The purpose of this study was to investigate the association between the heart rate (HR)-associated single nucleotide polymorphisms (SNPs) identified in genome-wide association studies (GWAS) and recurrence of AF following the PVI.
Methods
In this study, patients with paroxysmal AF (PAF) who underwent an initial PVI, including 522 patients for screening and 172 patients for replication, were recruited and 21 HR-associated SNPs identified in GWAS were genotyped. The association between these SNPs and the recurrence of AF was investigated.
Results
Throughout the follow-up period of 21 ± 12 months, 119 patients with PAF (22.8%) exhibited AF recurrences in the screening set. The rate of AF recurrence was significantly associated with minor allele C of the gap junction alpha-1 protein (GJA1) rs1015451 (additive model, odds ratio [OR], 2.07; P = 9.32 × 10-7), but not with other SNPs. This association was confirmed in the replication set (allelic model OR, 1.81; P = 2.70 × 10-2). Multivariate analysis revealed that the recurrence of AF following AF ablation was independently related to the GJA1 SNP rs1015451 additive model, duration of AF longer than 1 year, AF from non-PV foci, and thicker interventricular septum.
Conclusions
The GJA1 SNP rs1015451, coding for gap junction protein (connexin-43), may be considered a novel genetic marker for AF recurrence following PVI.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 26 Aug 2022; epub ahead of print
Okamura S, Ochi H, Onohara Y, Nakashima M, ... Kihara Y, Nakano Y
Heart Rhythm: 26 Aug 2022; epub ahead of print | PMID: 36038005
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Abstract

Reduced sarcoplasmic reticulum Ca2+ pump activity is anti-arrhythmic in ischemic cardiomyopathy.

Xie A, Liu H, Kang GJ, Feng F, Dudley SC
Background
We have described an arrhythmic mechanism seen only in cardiomyopathy that involves increased mitochondrial Ca2+ handling and selective transfer of Ca2+ to the sarcoplasmic reticulum (SR). Modeling suggested mitochondrial Ca2+ transfer to the SR via the type 2a sarco/endoplasmic reticulum Ca2+-ATPase (SERCA2a) is a crucial element of this arrhythmic mechanism.
Objective
We tested the role of SERCA2a in arrhythmias during ischemic cardiomyopathy.
Methods
Myocardial infarction (MI) was induced in wild type (Wt) and SERCA2a heterozygous knockdown (SERCA+/-) mice.
Results
Compared to Wt MI mice, SERCA+/- MI mice had a substantial lower mortality after MI three weeks without a significant change in MI area. Aside from a significant delay of the cytoplasmic Ca2+ transient decay existed in SERCA+/- compared to Wt, SERCA+/- did not affect cardiac systolic and diastolic function at the whole organ or single cell levels either before or after MI. After MI, SERCA+/- mice had reduced SERCA2a expression in MI border zone when compared to the Wt MI mice. SERCA+/- mice had significantly decreased QTc intervals and less ventricular tachycardia compared to Wt MI mice. SERCA+/- cardiomyocytes from MI mice showed a reduced action potential duration and reduced triggered activity when compared to Wt MI cardiomyocytes. Reduction in arrhythmic risk was accompanied by reduced diastolic SR Ca2+ sparks, reduced SR Ca2+ content, reduced oxidized RyR and increased calsequestrin 2 in SERCA+/- MI mice.
Conclusion
SERCA2a knockdown was antiarrhythmic after MI without affecting overall systolic performance. Possible antiarrhythmic mechanisms included reduced SR free Ca2+ and reduced diastolic SR Ca2+ release.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 23 Aug 2022; epub ahead of print
Xie A, Liu H, Kang GJ, Feng F, Dudley SC
Heart Rhythm: 23 Aug 2022; epub ahead of print | PMID: 36028211
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Abstract

Disrupted Cav1.2 Selectivity Causes Overlapping Long QT and Brugada Syndrome Phenotypes in CACNA1C-E1115K iPS Cell Model.

Kashiwa A, Makiyama T, Kohjitani H, Maurissen TL, ... Makita N, Kimura T
Background
A missense mutation, in the α1c-subunit of voltage-gated L-type Ca2+ channel (LTCC)-coding CACNA1C-E1115K, located in the Ca2+ selectivity site, causes a variety of arrhythmogenic phenotypes.
Objective
We aimed to investigate the electrophysiological features and pathophysiological mechanisms of CACNA1C-E1115K in patient-specific induced pluripotent stem cell (iPSC)-derived cardiomyocytes (CMs).
Methods
We generated iPSCs from a patient carrying heterozygous CACNA1C-E1115K with overlapping phenotypes of long QT syndrome, Brugada syndrome, and mild cardiac dysfunction. Electrophysiological properties were investigated utilizing iPSC-CMs. We used iPSCs from a healthy subject and an isogenic iPSC line corrected using CRISPR-Cas9-mediated gene editing as controls. The mathematical E1115K-CM model was developed using a human ventricular cell model.
Results
Patch-clamp analysis revealed that E1115K-iPSC-CMs exhibited reduced peak Ca2+ current density and impaired Ca2+ selectivity, with an increased permeability to monovalent cations. Consequently, E1115K-iPSC-CMs showed decreased action potential plateau amplitude (APAplateau), longer action potential duration (APD), and a higher frequency of early afterdepolarization compared with controls. In optical recordings examining the anti-arrhythmic drug effect, late Na+ channel current (INaL) inhibitors (mexiletine, GS-458967) shortened APDs specifically in E1115K-iPSC-CMs. AP-clamp using a voltage command obtained from E1115K-iPSC-CMs with lower APAplateau and longer APD confirmed the upregulation of INaL. An in silico study recapitulated the in vitro electrophysiological properties.
Conclusions
Our iPSC-based analysis in CACNA1C-E1115K with disrupted Cav1.2 selectivity demonstrated that the aberrant currents through the mutant channels carried by monovalent cations resulted in specific action potential changes, which increased endogenous INaL; thereby synergistically contributing to the arrhythmogenic phenotype.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 22 Aug 2022; epub ahead of print
Kashiwa A, Makiyama T, Kohjitani H, Maurissen TL, ... Makita N, Kimura T
Heart Rhythm: 22 Aug 2022; epub ahead of print | PMID: 36007726
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Abstract

Atrial fibrillation in the presence and absence of heart failure enhances expression of genes involved in cardiomyocyte structure, conduction properties, fibrosis, inflammation, and endothelial dysfunction.

Zeemering S, Isaacs A, Winters J, Maesen B, ... Stoll M, Schotten U
Background
Little is known about genome-wide changes in the atrial transcriptome as a cause or consequence of atrial fibrillation (AF), and the effect of its common and clinically relevant comorbidity, heart failure (HF).
Objective
To explore candidate disease processes for atrial fibrillation, we investigated gene expression changes in atrial tissue samples from patients with and without AF, stratified by HF.
Methods
RNA sequencing was performed in right and left atrial appendage tissue in 195 patients undergoing open-heart surgery from centers participating in the CATCH-ME consortium (no history of AF (n=91), paroxysmal AF (n=53) and persistent/permanent AF (n=51)). Analyses were stratified into patients with and without HF (n=75/120), and adjusted for age, sex, atrial side, and a combination of clinical characteristics.
Results
We identified 35 genes associated with persistent AF compared to patients without a history of AF, both in the presence or absence of HF (false discovery rate<0.05). These were mostly novel associations, including 13 long non-coding RNAs. Genes were involved in regulation of cardiomyocyte structure, conduction properties, fibrosis, inflammation, and endothelial dysfunction. Gene set enrichment analysis identified mainly inflammatory gene sets to be enriched in AF patients without HF, and gene sets involved in cellular respiration in AF patients with HF.
Conclusions
Analysis of atrial gene expression profiles identified numerous novel genes associated with persistent AF, in presence or absence of HF. Interestingly, no consistent transcriptional changes were associated with paroxysmal AF, suggesting that AF-induced changes in gene expression predominate other changes.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 22 Aug 2022; epub ahead of print
Zeemering S, Isaacs A, Winters J, Maesen B, ... Stoll M, Schotten U
Heart Rhythm: 22 Aug 2022; epub ahead of print | PMID: 36007727
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Abstract

Differences in Mode of Death between Men and Women Receiving Implantable Cardioverter Defibrillators or Cardiac Resynchronization Therapy in the MADIT Trials.

Tompkins CM, Zareba W, Greenberg H, Goldstein R, ... Brown M, Kutyifa V
Background
Studies report sex differences in outcomes following ICD and CRT-D. However, little is known about sex differences in mode of death or device efficacy following ICD or CRT-D implantation.
Objectives
We investigated whether sex influenced mode of death or device efficacy in ICD and CRT-D subjects enrolled in the MADIT trials (MADIT-II, MADIT-CRT, and MADIT-RIT).
Methods
The combined MADIT cohort consisted of 3038 men and 1000 women with ischemic (ICM) or non-ischemic cardiomyopathy (NICM), LVEF ≤ 30%; NYHA Class I-III heart failure who received ICD or CRT-D. Mode of death was divided into cardiac and non-cardiac causes, reviewed by independent adjudication committees.
Results
295 men and 66 women died (9.7% vs. 6.6%; p=0.003) during 26 months. The most common cause of death was non-arrhythmic cardiac death in men (n=121; 41%), and non-cardiac death in women (n=22; 33%). All-cause mortality and cardiac deaths were 1.5 to 2.0-fold higher in men vs. women with ICM, but similar in NICM after adjustment for covariates. ICD efficacy was similar in men and women, resulting in a 50% reduction in all-cause mortality. CRT-D was more effective at reducing all-cause and cardiac death in women than men.
Conclusions
Mode of death differs between sex and is dependent on the underlying cardiac substrate. Compared to women, cardiac death is higher in men with ICM, but similar with NICM. ICDs are equally effective at reducing mortality in both men and women. However, CRT-D may be more effective at reducing mortality in women.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 22 Aug 2022; epub ahead of print
Tompkins CM, Zareba W, Greenberg H, Goldstein R, ... Brown M, Kutyifa V
Heart Rhythm: 22 Aug 2022; epub ahead of print | PMID: 36007729
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Abstract

Sympathetic toggled sinus rate acceleration as a mechanism of sustained sinus tachycardia in chronic orthostatic intolerance syndrome.

Hwang D, Liu X, Rosenberg C, Lee A, ... Bairey Merz CN, Chen PS
Background
The role of sympathetic nerve activity to maintain sinus rate acceleration remains unclear.
Objective
To test the hypothesis that sustained (> 30 s) sinus rate acceleration can be associated with either sympathetic driven or sympathetic toggled mechanism.
Methods
We used a patch monitor to record skin sympathetic nerve activity (SKNA) and ECG over 24 hours. Study 1 included chronic orthostatic intolerance (OI) (N=18), atrial fibrillation (N=7), and asymptomatic reference control (N=19) groups. Study 2 included 17 chronic OI participants not treated with ivabradine, pyridostigmine, or beta-blockers.
Results
While a majority of sinus rate acceleration was driven by persistent SKNA in Study 1, some episodes were toggled on and off by SKNA bursts without persistent SKNA elevation. The sympathetic toggled sinus rate accelerations were found in 7 of 18 (39%) chronic OI, 2 of 7 (29%) AF, and 6 of 19 (32%) reference control participants (p=0.847) and were faster and longer in chronic OI than in other groups. In Study 2, there were a total of 11 episodes of sinus rate acceleration that persisted for > 200 s. Among them, 6 (35%) episodes were toggled on and off by SKNA bursts.
Conclusion
Sustained sinus rate acceleration (may be toggled on or off) is associated with bursts of SKNA in participants with chronic OI, AF, and normal controls. OI patients had more frequent and longer episodes when compared to other groups.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 19 Aug 2022; epub ahead of print
Hwang D, Liu X, Rosenberg C, Lee A, ... Bairey Merz CN, Chen PS
Heart Rhythm: 19 Aug 2022; epub ahead of print | PMID: 35995322
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Abstract

Neuromodulation Therapy for Atrial Fibrillation.

Karatela MF, Fudim M, Mathew JP, Piccini JP
Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are pro-fibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 18 Aug 2022; epub ahead of print
Karatela MF, Fudim M, Mathew JP, Piccini JP
Heart Rhythm: 18 Aug 2022; epub ahead of print | PMID: 35988908
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Abstract

SIGNIFICANCE OF ABNORMAL AND LATE VENTRICULAR SIGNATURES IN VENTRICULAR TACHYCARDIA ABLATION OF ISCHAEMIC AND NON-ISCHAEMIC CARDIOMYOPATHIES.

Zachariah D, Nakajima K, Limite LR, Zweiker D, ... Della Bella P, Frontera A
Background
Abnormal ventricular signals(AVS) are the cornerstone of substrate-based ventricular tachycardia(VT) ablation in sinus rhythm. Signal characterization of AVS amongst ischaemic and non-ischaemic cardiomyopathies has never been performed.
Objective
To describe ventricular signal abnormalities in three different pathologies and study their association with the diastolic component of VT circuits.
Methods
45{15 ischaemic(ICM),15 arrhythmogenic(ACM),15 dilated(DCM) cardiomyopathy}patients who underwent VT ablation with more than 50% of the diastolic pathway of the VT circuit recorded, were studied. AVS were classified into late potentials (LP) and continuous fractionated ventricular signals (CFVS) and their characteristics and correlation with the diastolic pathway of VT circuits analysed.
Results
75 VT circuits were analysed. Bipolar scars were greatest in ICM endocardially (53cm2vs36cm2vs25cm2 in ICM,ACM,DCM respectively,p=0.010) and in ACM epicardially (98cm2vs25cm2 in ICM,24cm2 in DCM,p=0.005). Location of VT diastolic interval coincided with AVS location in 54% of VTs in ICM,89% in ACM and 72% in DCM(p=0.036). There was a trend to greater association of diastolic intervals coinciding with LPs rather than CFVS(78%vs57%, p=0.052).[69% diastolic intervals in ICM coincided with LPs,33% with CFVS(p=0.063)]. 100% patients with CFVS in ACM had VT diastolic components arising from CFVS (33% ICM,64% DCM,p=0.049). Positive predictive value for LPs vs CFVS was 77.8%vs56.7% and sensitivity 67.3%vs32.7% respectively.
Conclusions
The nature of abnormal signals in different cardiomyopathies reflect underlying pathology. LPs rather than continuous fractionated ventricular signals, appear to be more linked to diastolic components of VT circuits, especially in ICM. LPs have higher sensitivity and specificity for VT, however continuous fractionated ventricular signals may be of more relevance in ACM.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 11 Aug 2022; epub ahead of print
Zachariah D, Nakajima K, Limite LR, Zweiker D, ... Della Bella P, Frontera A
Heart Rhythm: 11 Aug 2022; epub ahead of print | PMID: 35964871
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Impact:
Abstract

Confirmation of the achievement of linear lesions using \'Activation Vectors\' based on omnipolar technology.

Takigawa M, Goya M, Ikenouchi T, Shimizu Y, ... Miyazaki S, Sasano T
Background
Although differential pacing has been conventionally used to confirm the achievement of block across linear lesion sets, high-resolution mapping demonstrates that pseudo-block is observed in 20-30% of cases.
Objectives
We examined the reliability and versatility of a method using \'Activation Vectors\' based on the omnipolar technology to confirm the block line.
Methods
Linear ablation was performed during pacing, with the HD Grid catheter placed beside the linear lesion opposite to the pacing site. The endpoint of complete linear lesion was when the activation vectors entirely inverted to the opposite direction. When inversion of the activation vectors was not observed after 10 minutes of RF-application, high-resolution mapping was performed to assess whether complete block was achieved or not.
Results
In 33 patients, 24 cavo-tricupid-isthmus (CTI)-lines, 11 mitral isthmus (MI)-lines, 16 posterior lines, and 2 intercaval lines were performed using this method. Out of a total of 53 lines, 10 (18.9%) lines required intermediate evaluation of the block line with high-resolution mapping because of the absence of the inversion of activation vectors despite 10 minutes of RF-application, resulting in incomplete block with endocardial gaps or epicardial conductions. Additional RF-applications finally achieved the inversion in direction of activation vectors in these 10 lines. In total, the present method can diagnose the achievement of the complete block line with 100% accuracy, while conventional differential pacing mis-diagnosed the incomplete block with epicardial conduction in 3 cases in posterior lines and 2 cases in MI-lines.
Conclusion
Confirmation of complete linear lesions using \'Activation vectors\' based on omnipolar technology is a reliable and versatile method.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 09 Aug 2022; epub ahead of print
Takigawa M, Goya M, Ikenouchi T, Shimizu Y, ... Miyazaki S, Sasano T
Heart Rhythm: 09 Aug 2022; epub ahead of print | PMID: 35961492
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Impact:
Abstract

Optimizing atrial sensing parameters in leadless pacemakers: atrioventricular synchrony achievement in real world.

Briongos-Figuero S, Estévez Paniagua Á, Hernández AS, Jiménez S, ... Motos AA, Muñoz-Aguilera R
Background
Performance of the leadless pacemaker capable of atrioventricular (AV) synchronous pacing on de novo patients warrants further investigation.
Objective
To assess what programming changes are needed to achieve proper atrial tracking and to study the percentage of AV synchrony (AVS) the device can provide under real-world conditions.
Methods
Consecutive patients undergoing Micra AV implant between June 2020 and November 2021 were studied. Reprogramming of atrial sensing parameters during the follow-up was performed by following device counters. AVS was studied with an ambulatory 24-h Holter monitor, automatically analyzed by an ECG delineation system. The primary endpoint was AVS≥85% of total cardiac cycles during the 24-h Holter-ECG monitor.
Results
Thirty one patients who remained in VDD mode were studied and all of them required manual reprogramming. Automatic A3 window end was deactivated and a fixed and short value was set in all patients through the follow-up. AVS significantly increased from 68.7±14.7% at 24-h follow-up to 83.9±7.4 % at 1-month visit (p=0.001). At 1-month, shorter A3 window end time (p=0.019), higher A4 threshold (p=0.011) and deactivation of the automatic A3 window (p=0.054) were independently related to higher AVS. A total of 2,291,953 Holter-recorded cardiac cycles were analyzed. Median AVS during 24-h of daily activities was 87.6% (interquartile range: 84.5%-90.6%). Twenty out of 26 patients (79.6%) reached an AVS≥85% of cardiac cycles.
Conclusions
High rates of AVS can be achieved in real-world patients undergoing leadless pacing. Manual reprogramming of the atrial sensing parameters is essential to optimize mechanically sensed atrial tracking.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 08 Aug 2022; epub ahead of print
Briongos-Figuero S, Estévez Paniagua Á, Hernández AS, Jiménez S, ... Motos AA, Muñoz-Aguilera R
Heart Rhythm: 08 Aug 2022; epub ahead of print | PMID: 35952980
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Impact:
Abstract

Incidence and clinical impact of tachyarrhythmic events following transcatheter aortic valve replacement: A review.

Nuche J, Panagides V, Nault I, Mesnier J, ... Philippon F, Rodés-Cabau J
Transcatheter aortic valve replacement (TAVR) is well-established for treating severe symptomatic aortic stenosis. Whereas broad information exists about the epidemiology, clinical implications and management of bradyarrhythmias after TAVR, data about tachyarrhythmic events remains scarce. Despite the progressively lower risk profile of TAVR patients and the improvement in device characteristics and operators\' skills, approximately 10% of patients develop new-onset atrial fibrillation (NOAF) after TAVR. The proportion of patients in whom NOAF actually corresponds to previously undiagnosed silent AF has not been properly determined. The transapical approach, the need for pre- or post-balloon dilatation and the presence of peri-procedural complications have been associated with a higher risk of NOAF. Older age, left atrial volume or worse functional class are patient-derived risk factors shared with pre-procedural atrial fibrillation (AF). NOAF after TAVR has been associated with poorer survival and a higher incidence of cerebrovascular events. However, patients\' management markedly differs between different centers, especially for anticoagulation in patients with short-duration AF episodes detected in the periprocedural setting and in cases of silent NOAF detected during continuous ECG-monitoring. Evidence about ventricular arrhythmias is even more scarce than for AF. Some case reports of sudden cardiac death after TAVR in patients with a pacemaker described the identification of ventricular tachycardia or ventricular fibrillation in the device interrogation. It has been shown that TAVR reduces the arrhythmic burden, but a significant proportion of patients (16%) present complex premature ventricular complex arrhythmias within the year after TAVR. Whether these events are related to poorer outcomes is unknown. Continuous ECG-monitoring after TAVR may help describe the frequency, risk factors and prognostic implications of tachyarrhythmias in this population.

Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 08 Aug 2022; epub ahead of print
Nuche J, Panagides V, Nault I, Mesnier J, ... Philippon F, Rodés-Cabau J
Heart Rhythm: 08 Aug 2022; epub ahead of print | PMID: 35952981
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Impact:
Abstract

Outcomes in Patients with Electrocardiographic Left Ventricular Dyssynchrony following Transcatheter Aortic Valve Replacement.

Ananwattanasuk T, Atreya AR, Teerawongsakul P, Ghannam M, ... Oral H, Jongnarangsin K
Background
Left bundle branch block (LBBB) and atrioventricular (AV) conduction abnormalities, requiring permanent pacemaker implantation (PPM), occur frequently following transcatheter aortic valve replacement (TAVR). The resultant left ventricular (LV) dyssynchrony may be associated with adverse clinical events.
Objectives
To assess the adverse outcomes associated with LV dyssynchrony due to high-burden right ventricular (RV) pacing or permanent LBBB following TAVR in preserved LV ejection fraction (LVEF) patients.
Methods
Consecutive TAVR patients at the University of Michigan from January 2012 to June 2017 are included. Preexisting cardiac implantable electronic device, prior LBBB, LVEF<50%, or follow-up period <1 year were excluded. The primary outcome was all-cause mortality. Secondary outcomes included cardiomyopathy (defined as LVEF<45%), a composite endpoint of cardiomyopathy or all-cause mortality, and the change in LVEF at one-year follow-up.
Results
A total of 362 patients were analyzed (mean age 77 years). LV dyssynchrony group (n=91, 25.1%) included 56 permanent LBBB patients, 12 permanent LBBB patients with PPM, and 23 non-LBBB patients with PPM and high-burden RV pacing. Remaining patients served as control (n=271, 74.9%). After adjusted analysis, LV dyssynchrony had significantly higher all-cause mortality (adjusted HR 2.16; 95%CI 1.07-4.37) and cardiomyopathy (adjusted HR 14.80; 95%CI 6.31-14.69). The LV dyssynchrony group had a mean LVEF decline of 10.5±10.2% compared to a small increase (0.5±7.7%) in control.
Conclusion
Among TAVR patients with preserved LVEF and normal AV conduction, development of post-procedural LV dyssynchrony secondary to high-burden RV pacing or permanent LBBB was associated with significantly higher risk of death and cardiomyopathy at one-year follow-up.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 07 Aug 2022; epub ahead of print
Ananwattanasuk T, Atreya AR, Teerawongsakul P, Ghannam M, ... Oral H, Jongnarangsin K
Heart Rhythm: 07 Aug 2022; epub ahead of print | PMID: 35948202
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Impact:
Abstract

Ultrasound-guided injection of botulinum toxin type A blocks cardiac sympathetic ganglion to improve cardiac remodeling in a large animal model of chronic myocardial infarction.

Zhang S, Wang M, Jiao L, Liu C, ... Yu L, Jiang H
Background
Strategies to improve various cardiovascular diseases by blocking cardiac sympathetic ganglion have been increasingly available currently. Botulinum toxin type A (BTA), a typical neurotoxin, has been shown to block neural transmission in a safe and long-lasting manner.
Objective
The aim of the current preclinical study was to assess efficacy of BTA microinjection to alleviate cardiac remodeling after chronic myocardial infarction (MI) by blocking cardiac sympathetic ganglion in a canine model.
Methods
Beagles were randomly divided into a control group (saline microinjection with sham surgery), MI group (saline microinjection with MI) and MI+BTA group (BTA microinjection with MI). Ultrasound-guided percutaneous BTA or saline injection into the left stellate ganglion (LSG) was performed followed by MI induction via left anterior descending artery occlusion (LADO) or sham surgery. After 30 days, electrocardiogram, Doppler echocardiography, LSG function, neural activity and ventricular electrophysiological detection were performed in all experimental dogs. At the end, LSG and ventricular tissues were collected for further detection.
Results
BTA treatment significantly inhibited LSG function and neural activity and improved heart rate variability. Additionally, BTA application alleviated ventricle remodeling, ameliorated cardiac function and prevented ventricular arrhythmias after 30-day chronic LADO-induced MI.
Conclusion
Ultrasound-guided percutaneous microinjection of BTA can block cardiac sympathetic ganglion to improve cardiac remodeling in a large animal model of chronic LADO-induced MI. Ultrasound-guided BTA microinjection has potential for clinical application as a novel cardiac sympathetic ganglion blockade strategy for MI.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 07 Aug 2022; epub ahead of print
Zhang S, Wang M, Jiao L, Liu C, ... Yu L, Jiang H
Heart Rhythm: 07 Aug 2022; epub ahead of print | PMID: 35948203
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Impact:
Abstract

Strategies and Outcomes of Patients with Severely Reduced Ejection Fraction (≤15%) Undergoing Transvenous Lead Extraction: A Single Center Experience.

Arora Y, Llaneras N, Carrillo R
Background
Patients with severely reduced EF (SREF≤15%) are deferred from transvenous lead extraction (TLE) due to fears of intraoperative hemodynamic collapse. When these patients require lead extraction, their management options are limited, and they suffer high morbidity and mortality. Left ventricular assist devices provide intraoperative hemodynamic support and facilitate TLE, enabling life-saving interventions.
Objective
We present our experience performing TLE in 245 patients with SREF. Additionally, we report outcomes of 8 patients who received left ventricular support during TLE.
Methods
Between January 2008-January 2022, we performed TLE on 245 patients with Stage D heart failure, SREF, and Class I or II indications for extraction. Primary (clinical success and in-hospital mortality) and secondary outcomes (length of stay [LOS] and procedure-associated complications) were compared between SREF patients and control. A subgroup analysis was performed in the SREF group to evaluate outcomes of eight patients who underwent extraction with LV assist devices.
Results
In patients with SREF clinical success was high (97.6%), and mortality was low (5.3%). There were no statistically significant differences in primary outcomes between groups. Similarly, there were no significant differences in procedural complications between groups. In the SREF group, there were no significant differences in outcomes between the eight patients undergoing TLE with LV assist devices and cases that did use LV assist devices.
Conclusion
Lead extraction in patients with SREF can be performed safely and effectively. Adopting a few simple steps, including the early initiation of LV support, can overcome myocardial impairment in patients who decompensate.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 07 Aug 2022; epub ahead of print
Arora Y, Llaneras N, Carrillo R
Heart Rhythm: 07 Aug 2022; epub ahead of print | PMID: 35948204
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Impact:
Abstract

Infection in Subcutaneous Implantable Cardioverter Defibrillator Patients: Results from the S-ICD Post-Approval study.

Gold MR, Aasbo JD, Weiss R, Burke MC, ... Brisben AJ, El-Chami MF
Background
Early subcutaneous defibrillator (S-ICD) studies included atypical cohorts who were younger with fewer co-morbidities. Recent S-ICD studies included patient populations with more co-morbidities.
Objective
To determine the incidence and predictors of S-ICD-related infection over a 3-year follow-up period and to use these results to develop an infection risk score.
Methods
PAS is a US prospective registry of 1637 patients. Baseline demographics and outcomes with 3-year post-implant follow-up were compared between patients with and without device-related infection. A risk score was derived from multivariate proportional hazard analysis of 22 variables.
Results
Infection was observed in 55 patients (3.3%), with 69% occurring within 90 days and a vast majority (92.7%) within 1 year post implant. Late infections more likely involved device erosion; no infections took place after year 2. Annualized mortality rate post infection was 0.6%/year. No lead extraction complications or bacteremia related to device infection were observed. An infection risk score was created with diabetes, age, prior transvenous ICD implant, and ejection fraction as predictors. Patients with a risk score ≥3 had an 8.8 hazard ratio (95% CI: 2.8-16.3) of infection compared with a 0 risk score.
Conclusion
Infection rates in the S-ICD Post Approval Study were similar to other S-ICD populations and not associated with systemic blood-borne infections. Late infection (>1 year) is very uncommon and associated with system erosion. A high-risk infection cohort can be identified that may facilitate preventive measures.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 06 Aug 2022; epub ahead of print
Gold MR, Aasbo JD, Weiss R, Burke MC, ... Brisben AJ, El-Chami MF
Heart Rhythm: 06 Aug 2022; epub ahead of print | PMID: 35944889
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Impact:
Abstract

Cardiac Resynchronization Therapy Optimization in Nonresponders and Incomplete Responders Using Electrical Dyssynchrony Mapping.

Brown CD, Burns KV, Harbin MM, Espinosa EA, Olson MD, Bank AJ
Background
Nonresponse to cardiac resynchronization therapy (CRT) occurs in ∼30-50% of patients. There are no well-accepted clinical approaches for optimizing CRT in nonresponders.
Objective
To demonstrate the results of CRT optimization using electrical dyssychrony mapping (EDM) on left ventricular (LV) function, size and dyssynchrony in selected patients with nonresponse/ incomplete response to CRT.
Methods
We studied 39 patients with underlying left bundle branch block or interventricular conduction delay who had an LV ejection fraction (LVEF) <40% after receiving CRT and had significant electrical dyssynchrony. Electrical dyssynchrony was measured at multiple AVDs and VVDs. The QRS area between combinations of 9 anterior and 9 posterior electrograms (AUC) was calculated and cardiac resynchronization index (CRI) defined as the percent change in AUC compared to native. EDM depicted CRI over the wide range of settings tested. Patients were programmed to optimal device setting and echocardiograms were performed 5.9±3.7 months post-optimization.
Results
CRI increased from 49.4±24.0% to 90.8±10.5%. CRT optimization significantly improved LVEF from 31.8±4.7% to 36.3±5.9% (p<0.001) and LV end-systolic volume (LVESV) from 108.5±37.6 to 98.0±37.5mL (p=0.009). Speckle-tracking measures of LV strain significantly improved by 2.4±4.5% (transverse, p=0.002) and 1.0±2.6% (longitudinal, p=0.017). Aortic to pulmonic valve opening time, a measure of interventricular dyssynchrony, significantly (p=0.040) decreased by 14.9±39.4ms.
Conclusion
CRT optimization of electrical dyssynchrony using a novel EDM technology significantly improves LV systolic function, LVESV and mechanical dyssynchrony. This methodology offers a non-invasive, practical clinical approach to treating nonresponders and incomplete responders to CRT.

Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 05 Aug 2022; epub ahead of print
Brown CD, Burns KV, Harbin MM, Espinosa EA, Olson MD, Bank AJ
Heart Rhythm: 05 Aug 2022; epub ahead of print | PMID: 35940458
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Impact:
Abstract

Feasibility of leadless left ventricular septal pacing with the WiSE-CRT system to target the left bundle branch area: a porcine model and multi-center patient experience.

Elliott MK, Vergara P, Wijesuriya N, Mehta VS, ... Shute A, Rinaldi CA
Background
The WiSE-CRT system delivers leadless endocardial left ventricular (LV) pacing to achieve cardiac resynchronization therapy. The electrode is conventionally placed on the lateral wall, but implanting on the LV septum may have advantages, including capture of the left bundle branch, and improved battery longevity due to reduced distance from the transmitter.
Objective
To assess the feasibility of leadless LV septal pacing via the WiSE-CRT system.
Methods
Two pigs underwent electrode implantation on the LV septum with subsequent anatomical and histological examination. Eight patients underwent implantation of the WiSE-CRT system with deployment of the electrode on the LV septum via an inter-atrial transseptal approach.
Results
Deployment of the electrode on the LV septum was successful in both animals. Histological examination demonstrated electrode tines in close proximity to Purkinje tissue. WiSE-CRT implantation with an LV septal electrode was successful in all patients. Biventricular capture was confirmed, with significant reduction in QRS duration (187.1±33.8ms vs 149.5±15.7ms, P=0.009). Temporary LV pacing achieved further QRS reduction (139.8±12.4ms), and in four patients the time to peak left ventricular activation time in lead V5/6 was <90ms, suggesting left bundle branch capture. At early follow-up, median LV pacing percentage was 98.5% and 62.5% of patients improved symptomatically. Transmitter-to-electrode distance was lower than the distance to the lateral wall during acoustic window screening (8.8±1.6cm vs 11.9±1.5cm; P=0.002).
Conclusion
Leadless LV septal pacing with the WiSE-CRT system to target the left bundle branch appears feasible. Further study is required to assess the efficacy and safety of this technique.

Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 05 Aug 2022; epub ahead of print
Elliott MK, Vergara P, Wijesuriya N, Mehta VS, ... Shute A, Rinaldi CA
Heart Rhythm: 05 Aug 2022; epub ahead of print | PMID: 35940464
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Impact:
Abstract

Unsupervised Machine Learning Reveals Epicardial Adipose Tissue Subtypes with Distinct Atrial Fibrosis Profiles in Patients with Persistent Atrial fibrillation: a prospective two-center cohort study.

Cui C, Qin H, Zhu X, Lu X, ... Wang D, Chen M
Background
Epicardial adipose tissue (EAT) accumulation is associated with the progression of atrial fibrillation. However, the histological features of EATs are poorly defined, and their correlation with atrial fibrosis is unclear.
Objective
To identify and characterize EAT subgroups in the PeAF cohorts.
Methods
EATs and corresponding left atrial appendage (LAA) samples were obtained from patients with persistent atrial fibrillation (PeAF) via surgical intervention. Adipocyte markers, i.e., UCP1, TCF21, and CD137, were examined. Based on the expressions of adipocyte markers, PeAF patients were categorized into subgroups using unsupervised clustering analysis. Clinical characteristics, histological analyses, and outcomes were subsequently compared across the clusters. External validation was performed in a validation cohort.
Results
The ranking of feature importance revealed that the three adipocyte markers were the most relevant factors for atrial fibrosis comparing with other clinical indicators. On the k-medoids analysis, the PeAF patients could be categorized into three clusters in the discovery cohort. The histological studies revealed that patients in Cluster 1 exhibited statistically larger size of adipocytes in EATs and severe atrial fibrosis in LAAs. Findings were replicated in the validation cohort, where severe atrial fibrosis was noted in Cluster 1. Moreover, in the validation cohort, there was a high degree of overlap between the supervised classification results and the unsupervised cluster results from the k-medoids method.
Conclusion
Machine learning-based cluster analysis could identify subtypes of PeAF patients with distinct atrial fibrosis profiles. Additionally, EAT whitening (increased proportion of white adipocytes) may be involved in the process of atrial fibrosis.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 04 Aug 2022; epub ahead of print
Cui C, Qin H, Zhu X, Lu X, ... Wang D, Chen M
Heart Rhythm: 04 Aug 2022; epub ahead of print | PMID: 35934243
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Impact:
Abstract

The Genetic Basis of Sudden Death after Covid-19 Vaccination in Thailand.

Ittiwut C, Mahasirimongkol S, Srisont S, Ittiwut R, ... Kerr SJ, Shotelersuk V
Background
SAR-CoV2 vaccination reduces morbidity and mortality associated with Covid-19 disease; unfortunately, it is associated with serious adverse events, including sudden unexplained death (SUD).
Objective
We aimed to study the genetic basis of SUD after Covid-19 vaccination in Thailand.
Methods
From April to December 2021, cases with natural but unexplained death within seven days after Covid-19 vaccination were enrolled for whole exome sequencing.
Results
Thirteen were recruited, aged between 23 and 72 years, 10 (77%) were males, 12 were Thai and one was Australian. Eight (61%) died after receiving the first dose of vaccine and seven (54%) died after ChAdOx1 nCoV-19; however, there were no significant correlations between SUD and either the number or type of vaccine. Fever was self-reported in three cases. Ten (77%) and 11 (85%) died within 24 hours and 3 days after vaccination, respectively. WES analysis revealed five cases harbored SCN5A variants which had previously been identified in patients with Brugada syndrome (BrS), giving an SCN5A variant frequency of 38% (5/13). This is a significantly higher rate than observed in Thai SUD cases occurring 8 - 30 days after Covid-19 vaccination during the same period (10% (1/10)), in a Thai SUD cohort studied before the Covid-19 pandemic (12% (3/25)), and in our in-house exome database (12% (386/3231)).
Conclusions
These findings suggest that SCN5A variants may be associated with SUD within seven days after Covid-19 vaccination, regardless of vaccine type, number of vaccine dose, and presence of underlying diseases or postvaccine fever.

Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Heart Rhythm: 04 Aug 2022; epub ahead of print
Ittiwut C, Mahasirimongkol S, Srisont S, Ittiwut R, ... Kerr SJ, Shotelersuk V
Heart Rhythm: 04 Aug 2022; epub ahead of print | PMID: 35934244
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Impact:
Abstract

A new criterion to determine left bundle branch capture based on individualized His bundle or right ventricular septal pacing.

Qian Z, Xue S, Zou F, Qin C, ... Hou X, Zou J
Background
Left bundle branch pacing (LBBP) is an emerging physiological pacing modality. How to differentiate LBBP from left ventricular septal pacing (LVSP) remains challenging.
Objective
We aimed to develop a new personalized intra-operative criterion to confirm left bundle branch (LBB) capture in patients with or without heart failure (HF).
Methods
Patients were enrolled if surface 12-lead ECGs of LBBP, LVSP, temporary His bundle pacing (HBP) and right ventricular septal pacing (RVSP) were recorded during the procedure with the leads placed in basal midseptal region. Left ventricular activation time (LVAT) was measured during different pacing modalities. ΔLVAT1 was defined as the difference of LVAT between HBP and LBBP/LVSP. ΔLVAT2 was estimated by the difference of LVAT between RVSP and LBBP/LVSP. ΔLVAT1% and ΔLVAT2% were calculated as the percent reduction of ΔLVAT1 and ΔLVAT2 respectively.
Results
A total of 105 consecutive patients were included, among whom 80 had normal cardiac function (65 LBBP and 15 LVSP) and 25 had HF. Patients with LBBP showed significantly shorter LVAT than those with LVSP. In patients with normal cardiac function, a cut-off value of ΔLVAT1 > 12.5 ms showed 73.9% sensitivity and 93.3% specificity to confirm LBB capture. In patients with HF, a cut-off value of ΔLVAT1% > 9.8% exhibited great accuracy for LBB capture (sensitivity 92.0% and specificity 92.3%). The optimal value of ΔLVAT2% for differentiating LBBP from LVSP was 21.2%.
Conclusion
Temporary HBP and RVSP can serve as references to confirm LBB capture in an individualized fashion in patients with or without HF.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 03 Aug 2022; epub ahead of print
Qian Z, Xue S, Zou F, Qin C, ... Hou X, Zou J
Heart Rhythm: 03 Aug 2022; epub ahead of print | PMID: 35932987
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Impact:
Abstract

Detection of inflammation using cardiac positron emission tomography (PET) for evaluation of ventricular arrhythmias: an institutional experience.

Hayase J, Do DH, Liang JJ, Kim M, ... Shivkumar K, Bradfield JS
Background
The use of cardiac PET-CT is increasingly used for detection of underlying inflammation in patients with ventricular arrhythmias (VT/VF), but the role of PET-CT remains undefined, particularly for patients who do not meet task force criteria for sarcoidosis.
Objective
To determine the utility of PET-CT for clinical evaluation of VT/VF in patients with non-ischemic cardiomyopathy (NICM).
Methods
Consecutive patients with NICM and VT/VF who underwent cardiac PET-CT to detect inflammation between 2012 and 2019 were analyzed for baseline demographics, imaging results, and outcomes. Patients with known sarcoidosis or other conditions requiring immunosuppressive therapy were excluded.
Results
PET-CT was performed in 133 patients with mean age 56.3 ± 13.5 years and left ventricular ejection fraction 43 ± 16.1%, with evidence of myocardial inflammation detected in 32 (23.5%). Patients with myocardial inflammation were managed conservatively with medical therapy including immunosuppressive agents. Ten patients with myocardial inflammation ultimately required catheter ablation for ongoing arrhythmias. There was no significant difference in arrhythmia recurrence between PET-positive and PET-negative groups (37.5% vs 32.4%; p = 0.43) or time to recurrence (p = 0.26), in spite of the disparate management strategies. Gadolinium-enhanced cardiac MRI was obtained in 96 (72%) of patients; however, MRI did not detect 31% of cases with active inflammation that were otherwise detected on PET-CT.
Conclusion
The use of PET-CT significantly improves detection of underlying myocardial inflammation contributing to ventricular arrhythmias. Management of these patients with immunosuppressive medical therapy is effective for arrhythmia control and may obviate the need for invasive ablation procedures in some patients.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 03 Aug 2022; epub ahead of print
Hayase J, Do DH, Liang JJ, Kim M, ... Shivkumar K, Bradfield JS
Heart Rhythm: 03 Aug 2022; epub ahead of print | PMID: 35932988
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Impact:
Abstract

Postural Orthostatic Tachycardia Syndrome as a Sequela of COVID-19.

Ormiston CK, Świątkiewicz I, Taub PR
Postural Orthostatic Tachycardia Syndrome (POTS) is a complex, multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate 2-14% of COVID-19 survivors develop POTS and 9-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months following a SARS-CoV-2 infection. Pathophysiological mechanisms of Post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess for POTS in patients with post-acute COVID syndrome symptoms. Given symptoms of Post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or beta-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of Post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of Post-COVID-19 POTS.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 16 Jul 2022; epub ahead of print
Ormiston CK, Świątkiewicz I, Taub PR
Heart Rhythm: 16 Jul 2022; epub ahead of print | PMID: 35853576
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Abstract

Machine learning for distinguishing right from left premature ventricular contractions origin using surface electrocardiogram features.

Zhao W, Zhu R, Zhang J, Mao Y, ... Chen M, Zhang F
Background
The precise localization of the site of origin of a premature ventricular contraction (PVC) prior to ablation can facilitate the planning and execution of the electrophysiological procedure.
Objective
This study aims to develop a predictive model that can be used to differentiate PCs between the left ventricular outflow tract (LVOT) and right ventricular outflow tract (RVOT) using surface electrocardiogram characteristics.
Methods
A total of 851 patients undergoing radiofrequency ablation of premature ventricular beats from January 2015 to March 2022 were enrolled. 92 patients were excluded. The other 759 patients enrolled into development cohort (n = 605), external validation cohort (n = 104) and prospective cohort (n = 50). The development cohort consisted of training group (n = 423) and internal validation group (n = 182). Machine learning (ML) algorithms were used to construct predictive models for the origin of PVCs using body surface electrocardiogram features.
Results
In the development cohort, the Random Forest model showed a maximum ROC curve area of 0.96. In the external validation cohort, the Random Forest model surpasses 4 reported algorithms in predicting performance (accuracy: 94.23%, sensitivity: 97.10%, specificity: 88.57%). In prospective cohort, the Random Forest model showed good performance (accuracy: 94.00%, sensitivity: 85.71%, specificity: 97.22%).
Conclusions
Random Forest algorithm has improved the accuracy of distinuishing the origin of PVCs, which surpasses 4 previous standards, and would be used to identify the origin of PVCs before the interventional procedure.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 14 Jul 2022; epub ahead of print
Zhao W, Zhu R, Zhang J, Mao Y, ... Chen M, Zhang F
Heart Rhythm: 14 Jul 2022; epub ahead of print | PMID: 35843464
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Abstract

His Bundle Pacing vs Biventricular Pacing Following Atrioventricular Node Ablation in Patients with Atrial Fibrillation and Reduced Ejection Fraction: A Multicenter, Randomized, Crossover Study. The ALTERNATIVE-AF trial.

Huang W, Wang S, Su L, Fu G, ... Ellenbogen KA, Whinnett ZI
Background
Atrioventricular node ablation (AVNA) combined with biventricular pacing (BVP) improves outcomes in patients with persistent AF, adequate rate control and reduced left ventricular ejection fraction (LVEF). His bundle pacing (HBP) delivers physiological ventricular activation and is a promising alternative to BVP.
Objective
In this trial we compared HBP with BVP following AVNA.
Methods
In this multicenter, prospective, randomized crossover trial, we recruited patients with persistent AF and reduced LVEF (≤ 40%). All patients underwent AVNA and received both HBP and BVP. Patients were randomized to either HBP or BVP for 9 months (phase 1) after which they were switched to the alternative pacing modality for next 9 months (phase 2). The primary endpoint was change in LVEF.
Results
Fifty patients (64.3±10.3 years, ventricular rate 93.1±19.9 bpm, 72% male) were enrolled. Thirty-eight patients completed the two phases and were included in the crossover analysis. We observed a significant improvement in LVEF with HBP compared to BVP (In phase 1, ΔLVEFHBP 21.3% and ΔLVEFBVP 16.7%; In phase 2 ΔLVEFHBP 3.5% and ΔLVEFBVP -2.4%; Pgeneralized additive model=0.015). Significant improvements in left ventricular end-diastolic diameter, NYHA class and B-type natriuretic peptide were observed with both pacing modalities when compared with baseline whereas no significant differences were observed between HBP and BVP.
Conclusion
HBP delivers a modest but significant improvement in LVEF in patients with persistent AF, impaired ventricular function and narrow QRS duration post AVNA compared with BVP. Larger long-term trials are required to confirm the additional improvements in function with HBP.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 14 Jul 2022; epub ahead of print
Huang W, Wang S, Su L, Fu G, ... Ellenbogen KA, Whinnett ZI
Heart Rhythm: 14 Jul 2022; epub ahead of print | PMID: 35843465
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Abstract

Malignant Purkinje Ectopy induced by Sodium-channel Blocker.

Escande W, Gourraud JB, Haissaguerre M, Gandjbakhch E, ... Sacher F, Probst V
Background
Sodium-Channel Blocker (SCB) infusion is used to unmask the ECG pattern of Brugada syndrome. The test may also induce premature ventricular complexes (PVCs) in individuals without Brugada pattern, the clinical relevance of which is little known.
Objective
To describe the prevalence of short-coupled (Sc) PVCs induced by ajmaline or flecainide in patients with suspected or documented severe ventricular arrhythmias.
Methods
We reviewed the SCB tests performed in 335 patients with suspected ventricular arrhythmias and structurally normal hearts in 9 centers. ScPVCs were defined as frequent and repetitive PVCs with an R-on-T pattern on SCB tests. Repeated SCB tests were performed in seven patients and electrophysiological mapping of ScPVCs in nine.
Results
Sixteen patients (8 males, 36±11 years) showed ScPVCs and were included. ScPVCs appeared 229±118 sec after the start of the infusion and displayed coupling intervals of 288±28 ms. ScPVC patterns were monomorphic in 10 and polymorphic in 5 patients, originating from the Purkinje system in mapped patients. Repetitive PVCs were induced in 15 (94%) patients including polymorphic ventricular tachycardias in 9 (56%). SCB was repeated 45 (IQR 0.6-46) months later and induced identical ScPVC in all. SCB test was the only mean to reveal the malignant arrhythmia in six patients. Catheter ablation was performed in 9 patients, resulting in arrhythmia elimination in 8 with a follow-up of 6 (IQR 2-9) years.
Conclusion
SCB can induce ScPVC, mostly from Purkinje tissue, in a small subset of patients with idiopathic ventricular arrhythmias. Its high reproducibility suggests a distinct individual mechanism.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 11 Jul 2022; epub ahead of print
Escande W, Gourraud JB, Haissaguerre M, Gandjbakhch E, ... Sacher F, Probst V
Heart Rhythm: 11 Jul 2022; epub ahead of print | PMID: 35835363
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Abstract

Thirty-day readmission rate of same-day discharge protocol following left atrial appendage occlusion: a propensity score-matched analysis from National Readmission Database.

Kawamura I, Kuno T, Sahashi Y, Tanaka Y, ... Briasoulis A, Malik AH
Background
Given the reduction in periprocedural complication rates, same-day discharge (SDD) following percutaneous left atrial appendage closure (LAAC) could be beneficial. To date, little data exists comparing the standard overnight stay (ONS) vs SDD following LAAC.
Objective
To investigate the safety and efficacy of SDD compared to ONS.
Methods
A retrospective cohort study of LAAC procedures performed in the US from 2015 to 2019 was performed using the US Nationwide Readmission Database (NRD). The primary outcome was all-cause 30-day readmission following discharge in patients receiving LAAC, and a secondary outcome was requiring total healthcare cost. A 1:1 propensity score matching was conducted for adjustment. A multivariate Cox proportional-hazards regression was also performed to estimate the hazard ratio for all-cause readmission within 30 days following LAAC.
Results
Among 48,953 patients (mean 76.0±7.9 years), 972 (1.99%) patients were discharged on the same day following LAAC (SDD group), and the remaining 47,981 patients stayed at least one night (ONS group). A propensity score analysis generated 961 matched pair in each group. The 30-day readmission following discharge was similar between the groups (SDD vs. ONS: 8.5% vs. 9.8%, p=0.31 hazard ratio: 1.13, 95% confidence interval: 0.78-1.63, p=0.53). Total requiring healthcare cost was significantly lower in the SDD group ($23,720 [18,075-29,416] vs $25,877 [19,906-32,748], p<0.01). Gastrointestinal bleeding was the major cause for the readmission (14.7% SDD vs. 15.1% ONS, p=0.95) but stroke and pericardial effusion were rare.
Conclusion
Among the patients without procedure-related complications, SDD is a safe and cost-effective protocol.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 11 Jul 2022; epub ahead of print
Kawamura I, Kuno T, Sahashi Y, Tanaka Y, ... Briasoulis A, Malik AH
Heart Rhythm: 11 Jul 2022; epub ahead of print | PMID: 35835364
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Abstract

Impact of early ventricular tachycardia ablation in patients with an implantable cardioverter defibrillator: An updated systematic review and meta-analysis of randomized control trials.

Prasitlumkum N, Navaravong L, Desai A, Desai D, ... Jongnarangsin K, Chokesuwattanaskul R
Background
There is limited information on whether early catheter ablation (CA) for ventricular tachycardia (VT) is associated with better outcomes compared with alternative strategies in patients with implantable cardioverter defibrillator (ICD).
Objective
To assess the efficacy of early VT CA in patients with ICD MethodsEMBASE, PubMed, and Cochrane were searched from inception to April 2022. Randomized control trials (RCTs) comparing the efficacy of early VT ablation strategies between controls and patients with ICD were included in the analysis. Data on effect estimates in individual studies were extracted and combined via random-effects meta-analysis using the DerSimonian and Laird method, a generic inverse-variance strategy.
Results
Nine RCTs, with 1,106 patients (92.1% with ischemic cardiomyopathy [ICM] and 7.9% with nonischemic cardiomyopathy [NICM]) were evaluated. VT CA was associated with reduced VT recurrences (odds ratio [OR]: 0.64, p value = 0.007), appropriate ICD shocks (OR: 0.53, p value = 0.002), ICD therapies (OR: 0.54, p value = 0.002), and cardiovascular hospitalization (OR: 0.67, p value = 0.004). However, no significant differences were observed in terms of mortality rate, heart failure hospitalization, and quality of life between the early VT CA and control groups.
Conclusion
Early CA was beneficial in reducing VT burdens and ICD therapies. However, it did not affect mortality rate and quality of life. Since most patients in the included studies presented with ICM, further studies on NICM should be conducted to validate if early CA has similar outcomes.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 09 Jul 2022; epub ahead of print
Prasitlumkum N, Navaravong L, Desai A, Desai D, ... Jongnarangsin K, Chokesuwattanaskul R
Heart Rhythm: 09 Jul 2022; epub ahead of print | PMID: 35820619
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Abstract

Dual Atrioventricular Nodal Non-Reentrant Tachycardia: Various Atrioventricular Conduction Responses to Atrioventricular Simultaneous Pacing.

Adachi T, Asakawa T, Yamauchi Y, Naito S, ... Ieda M, Aonuma K
Background
Specific pacing methods to unmask the existence of the dual atrioventricular (AV) nodal pathway in patients with dual AV nodal non-reentrant tachycardia remain to be established.
Objective
This study aimed to determine the electrophysiological characteristics of dual AV nodal non-reentrant tachycardia by its responses to specific pacing methods.
Methods
Five patients diagnosed as having dual AV nodal non-reentrant tachycardia were retrospectively investigated.
Results
Atrial pacing could not induce the clinical tachycardia as continuous double firing in any of the 5 patients but did induce sudden prolongation of the A-H interval as the linking phenomenon in 1 patient. A single atrial extrastimulation following sinus excitations was performed without interruption of the double firing in 1 patient, and it induced the double ventricular response phenomenon within the limited range of the extrastimuli intervals. The pacing method of AV simultaneous basic pacing preceding atrial programmed extrastimulation (AVSP-APS) did not allow interruptions of the double firing during the basic drive trains and induced the double ventricular response phenomenon within the limited range of the extrastimuli intervals in all 5 patients, even in 1 patient without inducibility of the clinical tachycardia in the catheterization laboratory. The double ventricular response phenomenon within the limited range of the extrastimuli intervals may be based on the existence of the dual AV nodal pathway with concealed retrograde penetration.
Conclusion
The AVSP-APS method consistently and reproducibly unmasked the existence of the dual AV nodal pathway as the double ventricular response phenomenon in patients with dual AV nodal non-reentrant tachycardia.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 08 Jul 2022; epub ahead of print
Adachi T, Asakawa T, Yamauchi Y, Naito S, ... Ieda M, Aonuma K
Heart Rhythm: 08 Jul 2022; epub ahead of print | PMID: 35817252
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Abstract

The need for a subsequent transvenous system in patients implanted with subcutaneous implantable cardioverter defibrillator.

Gasperetti A, Schiavone M, Vogler J, Laredo M, ... Forleo GB, Biffi M
Background
The absence of pacing capabilities may reduce the appeal of S-ICD devices for patients at risk of conduction disorders or with anti-tachycardia pacing/cardiac resynchronization (CRT) requirements. Reports of rates of S-ICD to TV-ICD system switch in real-world scenarios are limited.
Objective
To investigate the need for a subsequent transvenous (TV) device in patients implanted with subcutaneous implantable cardioverter defibrillator (S-ICD) and its predictors.
Methods
All patients implanted with an S-ICD were enrolled from the multicentered, real-world iSUSI registry. The need for a TV device and its clinical reason, alongside to appropriate and inappropriate device therapies were assessed. A logistic regression with Firth penalization was used to assess the association between baseline and procedural characteristics and the overall need for a subsequent TV device.
Results
A total of 1509 patients were enrolled (50.8±15.8 years; 76.9% male; 32.0% ischemic; LVEF 38 [30-60]%). Over 26.5 [13.4-42.9] months, 155 (10.3%) and 144 (9.3%) patients experienced appropriate and inappropriate device therapies. Forty-one (2.7%) patients required a TV device (n=13 bradycardia; n=10 need for CRT; n=10 inappropriate shocks). BMI >30 kg/m2 and CKD were associated with need for a TV device (OR 2.57 [1.37-4.81], p=0.003 and OR 2.67 [1.29-5.54], p=0.008).
Conclusion
A low rate (2.7%) of conversion from S-ICD to a TV device was observed at follow-up, with need for anti-bradycardia pacing, ATP or CRT being the main reasons. BMI >30 kg/m2 and CKD predicted all-cause need for a TV device.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 30 Jun 2022; epub ahead of print
Gasperetti A, Schiavone M, Vogler J, Laredo M, ... Forleo GB, Biffi M
Heart Rhythm: 30 Jun 2022; epub ahead of print | PMID: 35781042
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Abstract

Long-term Outcome of Repaired Tetralogy of Fallot: Survival, Tachyarrhythmia, and Impact of Pulmonary Valve Replacement.

Wu MH, Wang JK, Chiu SN, Lu CW, ... Chun-An C, Tseng WC
Background
Pulmonary valve replacement (PVR) is recommended for severe pulmonary regurgitation in repaired tetralogy of Fallot (rTOF).
Objective
We investigated the event rate and effectiveness.
Methods
A retrospective study on TOF patients who survived total repair from 1970 to 2020.
Results
We identified 1744 rTOF patients; 86.6% classical rTOF, 11.5% with pulmonary atresia, 0.8% with endocardial cushion defect, and 1.1% with absent pulmonary valve. Annual risks of tachyarrhythmia/sudden cardiac arrest (SCA) increased to 0.295% and 1.338% in patients aged 10-30 and 30-60 years, respectively, without sex predominance. PVR (223 surgical and 39 percutaneous) event rate was 34.7 (±2.1) % by 30 years after repair (annual risk: 1.57 % between 10 and 30 years after repair). The second PVR rate was 9.9(±4.1) % by 20 years after the first PVR. Tachyarrhythmia/SCA risk was higher in PVR patients than in NO PVR patients and was reduced in PVR patients without tachyarrhythmia/SCA before PVR. Even though, survival in patients with ventricular tachyarrhythmia/SCA was still better after PVR. At PVR, 13% of patients had tachyarrhythmia/SCA, which was the major predictor of events after PVR. Before PVR, while the ventricular tachyarrhythmia/SCA risks included QRS duration >160 ms and NYHA functional class III or IV, supraventricular tachyarrhythmia was associated with PVR age ≥28 years and NT-proBNP > 450 pg/mL.
Conclusion
Tachyarrhythmia/SCA occurrence and the need for PVR increased with age during young adulthood. PVR reduced subsequent arrhythmias only in those patients without arrhythmias prior to PVR.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 30 Jun 2022; epub ahead of print
Wu MH, Wang JK, Chiu SN, Lu CW, ... Chun-An C, Tseng WC
Heart Rhythm: 30 Jun 2022; epub ahead of print | PMID: 35781043
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Abstract

Renal Denervation prevents subclinical atrial fibrillation in patients with hypertensive heart disease: randomized, sham-controlled trial.

Heradien M, Mahfoud F, Greyling C, Lauder L, ... Böhm M, Brink PA
Background
Catheter-based renal denervation (RD), in addition to pulmonary vein isolation (PVI), reduced AF recurrence in hypertensive patients. It remains unknown if RD, without additional PVI, can prevent subclinical AF (SAF) in HHD patients.
Objective
To assess the efficacy of RD to prevent SAF in patients with hypertensive heart disease (HHD).
Methods
Single-center, randomized, sham-controlled pilot trial, including patients >55 years in sinus rhythm, but with a high risk of developing SAF. Patients had uncontrolled hypertension despite taking three antihypertensive drugs, including a diuretic. The primary endpoint was the first SAF episode lasting ≥6 minutes recorded via an implantable cardiac monitor scanned six-monthly for 24 months. A blinded independent monitoring committee assessed ECG rhythm recordings. Change in SAF burden (SAFB), office and 24-hour ambulatory blood pressure (BP) at six-month follow-up were secondary endpoints.
Results
Eighty patients were randomly assigned to RD (n=42) or sham groups (n=38). After 24 months of follow-up, SAF occurred in 8 RD patients (19%) and 15 sham patients (39.5%) (hazard ratio, 0.40; 95% CI, 0.17 to 0.96; P=0.031). Median (IQR) SAFB was low in both groups, but significantly lower in the RD vs sham group: 0% (0,0) vs 0% (0,0.3) P=0.043. Fast AF (>100 bpm) occurred less frequently in the RD than sham group (2% vs 26%; P=0.002). After adjusting for baseline values, there were no significant differences in office or 24-hour BP changes between treatment groups.
Conclusion
RD reduced incident SAF events, SAFB and fast AF in patients with HHD. The observed effects may occur independently of BP lowering.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 30 Jun 2022; epub ahead of print
Heradien M, Mahfoud F, Greyling C, Lauder L, ... Böhm M, Brink PA
Heart Rhythm: 30 Jun 2022; epub ahead of print | PMID: 35781044
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Abstract

Diagnostic Utility of Early Premature Ventricular Complexes in Differentiating Atrioventricular Reentry and Atrioventricular Node Reentry Tachycardias.

Shah AN, Field J, Clark BA, Olson JA, ... Patel PJ, Padanilam BJ
Background
His refractory premature ventricular complexes (HrPVC) perturbing a supraventricular tachycardia (SVT) establishes the presence of an accessory pathway (AP). Earlier PVCs (ErPVC) may perturb SVTs but are considered non-diagnostic.
Objective
We hypothesize that an ErPVC will always show a difference of >35 ms in its advancement of the next atrial activation during atrioventricular nodal reentrant tachycardia (AVNRT). During atrioventricular reentrant tachycardia (AVRT), a PVC delivered close to the circuit can result in greater advancement of atrial activation due to retrograde conduction via an AP. Thus, an AP response, defined as ErPVC (H1 S2 ) advancing the subsequent atrial activation (A1 -A2 ) more than this minimum difference (A1 A2 ≤ H1 S2 +35ms), establishes the presence of an AP.
Methods
Sixty-five consecutive patients with SVT were retrospectively evaluated. ErPVCs were defined when the ventricular pacing stimulus was >35 ms ahead of the His during tachycardia.
Results
Among the 65 cases, 43 were AVNRT and 22 AVRT. Fourteen AVRT cases had an AP response with a mean H1 S2 +35ms of 336 ± 58 ms and A1 A2 of 309 ± 51ms. No AVNRT cases had an AP response. The specificity of an AP response to ErPVC in predicting AVRT was 100%.
Conclusions
An AP response to PVCs (A1 A2 ≤ H1 S2 +35 ms) is 100% specific for the presence of an AP.

Copyright © 2022. Published by Elsevier Inc.

Heart Rhythm: 30 Jun 2022; epub ahead of print
Shah AN, Field J, Clark BA, Olson JA, ... Patel PJ, Padanilam BJ
Heart Rhythm: 30 Jun 2022; epub ahead of print | PMID: 35781045
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Impact:

This program is still in alpha version.