Journal: J Cardiovasc Electrophysiol

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Abstract

Electromagnetic Interference from Left Ventricular Assist Devices detected in Patients with Implantable Cardioverter-Defibrillators.

Sheldon SH, Jazayeri MA, Pierpoline M, Mohammed M, ... Sauer AJ, Madhu Reddy Y
Introduction
Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter-defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD-related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs.
Methods
Single-center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal-to-noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events.
Results
Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months [2.3, 11.4 months]. LVAD subtypes included: HeartWare (n=22, 55%), Heartmate II (n=10, 25%), and Heartmate III (n=8, 20%). Over a follow-up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n=2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow-up. The SNR was similar between IB and DB sensing (50 [29-67] and 57 [41-69], p=0.89).
Conclusion
ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R-wave SNR with IB versus DB ICD leads. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 26 Nov 2021; epub ahead of print
Sheldon SH, Jazayeri MA, Pierpoline M, Mohammed M, ... Sauer AJ, Madhu Reddy Y
J Cardiovasc Electrophysiol: 26 Nov 2021; epub ahead of print | PMID: 34837431
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Abstract

Direction-Aware Mapping Algorithms Have Minimal Impact on Bipolar Voltage Maps Created Using High-Resolution Multielectrode Catheters.

Yavin HD, Sroubek J, Yarnitsky J, Buba ZP, ... Basu S, Anter E
Introduction
Direction-aware mapping algorithms improve the accuracy of voltage mapping by measuring the maximal voltage amplitude recorded in the direction of wavefront propagation. While beneficial for stationary catheters, its utility for roving catheters collecting electrograms at multiple angles is unknown.
Objective
To compare the directional dependency of bipolar voltage amplitude between stationary and roving catheters.
Methods
In 10 swine, a transcaval ablation line with gap was created. The gap was mapped using an array catheter (Optrell™, Biosense Webster). In step 1, the array was kept stationary over the gap, and 4 voltage maps were created during activation of the gap from superior, inferior, septal, and lateral directions. In step 2, 4 additional maps were created, however the catheter was allowed to move with points acquired at multiple angles. In step 3, the gap was re-mapped, however bipoles were computed using a direction-aware mapping algorithm.
Results
In a stationary catheter position, bipolar voltage distribution was influenced by the direction of activation with maximal differences obtained between orthogonal directions 32% (13-53%). However, roving the catheter produced similar bipolar voltage maps irrespective of the direction of activation 11% (5-18%). A direction-aware mapping algorithm was beneficial for reducing the directional dependency of voltage maps created by stationary catheters but not by roving catheters.
Conclusions
The directional dependency of bipolar voltage amplitude is greatest when the catheter is stationary. However, when the catheter is allowed to rove and collect electrograms at multiple angles as occurs clinically, the directional dependency of bipolar voltage is minimal. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 24 Nov 2021; epub ahead of print
Yavin HD, Sroubek J, Yarnitsky J, Buba ZP, ... Basu S, Anter E
J Cardiovasc Electrophysiol: 24 Nov 2021; epub ahead of print | PMID: 34822200
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Abstract

Ablation Index-guided point-by-point ablation versus Grid annotation-guided dragging for pulmonary vein isolation: A randomized controlled trial.

Mulder MJ, Kemme MJB, Hopman LHGA, Hagen AMD, ... van Rossum AC, Allaart CP
Introduction
Radiofrequency (RF) atrial fibrillation (AF) ablation using a catheter dragging technique may shorten procedural duration and improve durability of pulmonary vein isolation (PVI) by creating uninterrupted linear ablation lesions. We compared a novel AF ablation approach guided by Grid annotation allowing for \"drag lesions\" with a standard point-by-point ablation approach in a single-center randomized study.
Methods
Eighty-eight paroxysmal or persistent AF patients were randomized 1:1 to undergo RF-PVI with either a catheter dragging ablation technique guided by Grid annotation or point-by-point ablation guided by Ablation Index (AI) annotation. In the Grid annotation arm, ablation was visualized using 1 mm³ grid points coloring red after meeting predefined stability and contact force criteria. In the AI annotation arm, ablation lesions were created in a point-by-point fashion with AI target values set at 380 and 500 for posterior/inferior and anterior/roof segments, respectively. Patients were followed up for 12 months after PVI using ECGs, 24-h Holter monitoring and a mobile-based one-lead ECG device.
Results
Procedure time was not different between the two randomization arms (Grid annotation 71 ± 19 min, AI annotation 72 ± 26 min, p = .765). RF time was significantly longer in the Grid annotation arm compared with the AI annotation arm (49 ± 8 min vs. 37 ± 8 min, respectively, p < .001). Atrial tachyarrhythmia recurrence was documented in 10 patients (23%) in the Grid annotation arm compared with 19 patients (42%) in the AI annotation arm with time to recurrence not reaching statistical significance (p = .074).
Conclusions
This study shows that a Grid annotation-guided dragging approach provides an alternative to point-by-point RF-PVI using AI annotation.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 Nov 2021; epub ahead of print
Mulder MJ, Kemme MJB, Hopman LHGA, Hagen AMD, ... van Rossum AC, Allaart CP
J Cardiovasc Electrophysiol: 23 Nov 2021; epub ahead of print | PMID: 34820931
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Abstract

Hourly variability in outflow tract ectopy as a predictor of its site of origin.

Waight MC, Li AC, Leung LW, Wiles BM, ... Restrepo AJ, Saba MM
Introduction
Before ablation, predicting the site of origin (SOO) of outflow tract ventricular arrhythmia (OTVA), can inform patient consent and facilitate appropriate procedural planning. We set out to determine if OTVA variability can accurately predict SOO.
Methods
Consecutive patients with a clear SOO identified at OTVA ablation had their prior 24-h ambulatory ECGs retrospectively analysed (derivation cohort). Percentage ventricular ectopic (VE) burden, hourly VE values, episodes of trigeminy/bigeminy, and the variability in these parameters were evaluated for their ability to distinguish right from left-sided SOO. Effective parameters were then prospectively tested on a validation cohort of consecutive patients undergoing their first OTVA ablation.
Results
High VE variability (coefficient of variation ≥0.7) and the presence of any hour with <50 VE, were found to accurately predict RVOT SOO in a derivation cohort of 40 patients. In a validation cohort of 29 patients, the correct SOO was prospectively identified in 23/29 patients (79.3%) using CoV, and 26/29 patients (89.7%) using VE < 50. Including current ECG algorithms, VE < 50 had the highest Youden Index (78), the highest positive predictive value (95.0%) and the highest negative predictive value (77.8%).
Conclusion
VE variability and the presence of a single hour where VE < 50 can be used to accurately predict SOO in patients with OTVA. Accuracy of these parameters compares favorably to existing ECG algorithms.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Nov 2021; epub ahead of print
Waight MC, Li AC, Leung LW, Wiles BM, ... Restrepo AJ, Saba MM
J Cardiovasc Electrophysiol: 18 Nov 2021; epub ahead of print | PMID: 34797600
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Abstract

Patient acceptance of subcutaneous versus transvenous defibrillator systems: a multi-center experience.

Vicentini A, Bisignani G, Vivo S, Viani S, ... Rordorf R, “S-ICD Rhythm Detect” Investigators
Background
The subcutaneous ICD (S-ICD) is an effective alternative to the transvenous ICD. No study has yet compared S-ICD and transvenous ICD by assessing patient acceptance as a patient-centered outcome.
Objective
To evaluate patient acceptance of the S-ICD and to investigate its association with clinical and implantation variables. In patients with symptomatic heart failure and reduced ejection fraction (HFrEF), the acceptance of the S-ICD was compared with a control group of patients who received a transvenous ICD.
Methods
Patient acceptance was calculated with the Florida Patient Acceptance Survey (FPAS) which measures four factors: return to function (RTF), device-related distress (DRD), positive appraisal (PA), and body image concerns (BIC). The survey was administered 12 months after implantation.
Results
176 patients underwent S-ICD implantation. The total FPAS and the single factors did not differ according to gender, body habitus, or generator positioning. Patients with HFrEF had lower FPAS and RTF. Younger patients showed better RTF (75 [56-94] versus 56 [50-81], p=0.029). Patients who experienced device complications or device therapies showed higher DRD (40 [35-60] versus 25 [10-50], p=0.019). Patients with HFrEF receiving the S-ICD had comparable FPAS, RTF, DRD, and BIC to HFrEF patients implanted with the transvenous ICD while exhibited significantly better PA (88 [75-100] versus 81 [63-94], p=0.02).
Conclusions
Our analysis revealed positive patient acceptance of the S-ICD, even in groups at risk of more distress such as women or patients with thinner body habitus, and regardless of the generator positioning. Among patients receiving ICDs for HFrEF, S-ICD was associated with better PA versus transvenous ICD. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 Nov 2021; epub ahead of print
Vicentini A, Bisignani G, Vivo S, Viani S, ... Rordorf R, “S-ICD Rhythm Detect” Investigators
J Cardiovasc Electrophysiol: 18 Nov 2021; epub ahead of print | PMID: 34797012
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Abstract

Persistent left superior vena cava transvenous lead extraction: A European experience.

Akhtar Z, Sohal M, Starck CT, Mazzone P, ... Zaidi A, Gallagher MM
Background
Transvenous lead extraction (TLE) is rising in parallel to cardiac implantable electronic device implantations. Persistent left side superior vena cava (PLSVC) is a relatively common anatomical variant in the healthy population; TLE in patients with a PLSVC is rare.
Method
Data were collated from 6 European TLE institutes of 10 patients who had undergone lead extraction with a PLSVC. Patient demographics, procedural challenges and outcomes were reported.
Results
Ten patients aged 73.4 ± 7.8 years (60% male) underwent TLE of 20 leads (3 left ventricle, 10 right ventricle, 7 right atrium) with dwell time of 82.95 ± 39.1 months. Of the 10 cases, 4 had an infection indication and 5 were biventricular system extractions; 25% of the extracted leads were defibrillator leads. The majority of the procedures were completed in the cardiac catheterization suite (80%) under general anaesthesia (60%) by cardiologists (80%) using a rotational powered sheath (65%). The Tandem approach was used successfully in 3 cases. Complete procedural success was obtained in 100% of cases in the absence of complications within 127.4 ± 74.7 min. There was no 30-day mortality.
Conclusion
TLE in PLSVC is feasible albeit rare. Standard extraction techniques in experienced hands are associated with favorable outcomes; the Tandem procedure may be an additional technique to improve the safety and efficacy of TLE in PLSVC.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 14 Nov 2021; epub ahead of print
Akhtar Z, Sohal M, Starck CT, Mazzone P, ... Zaidi A, Gallagher MM
J Cardiovasc Electrophysiol: 14 Nov 2021; epub ahead of print | PMID: 34783107
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Abstract

The established and the challenger: A direct comparison of current cryoballoon technologies for pulmonary vein isolation.

Moser F, Rottner L, Moser J, Schleberger R, ... Rillig A, Metzner A
Introduction
Cryoballoon (CB) ablation for pulmonary vein isolation (PVI) is an effective treatment of atrial fibrillation (AF). Recently, a novel cryoablation system was introduced. The aim of the study was to compare the safety, efficacy and biophysical characteristics of a novel cryoablation system (POLARx™; Boston Scientific) to a commonly used and clinically well characterized system (Arctic Front Advance Pro™, AFA; Medtronic).
Methods and results
Fifty consecutive patients with symptomatic AF, who underwent CB-based ablation with the POLARx were compared to 50 consecutive patients treated with the AFA. Acute PVI was achieved in 99.8% (POLARx 99.5%, AFA 100%, p = 1.00). Time to isolation (TTI) was comparable in both groups (POLARx 35 [27, 48] s, AFA 30 [21, 43] s, p = 0.165). The POLARx showed a lower balloon temperature at TTI (POLARx -44 [-50, -36] °C, AFA -31 [-38, -21] °C, p < 0.001) and lower nadir temperature (POLARx -60 [-65, -55] °C, AFA -48 [-54, -45] °C, p < 0.001). Procedure time (POLARx 80 [60, 105] min, AFA 62 [42, 80] min, p < 0.001), fluoroscopy time (POLARx 17 [13, 22] min, AFA 11 [7, 16] min, p < 0.001) and freeze cycles per patient (POLARx 5 [4, 6], AFA 4.5 [4, 5], p = 0.002) were higher in the POLARx group. Two cerebral ischemic events occurred in the POLARx group, two patients in each group had phrenic nerve injury.
Conclusion
Both systems enable effective isolation of pulmonary veins. The POLARx required longer procedure and fluoroscopy times. Larger, prospective and randomized studies are needed to assess long-term efficacy and safety of this technology.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2021; epub ahead of print
Moser F, Rottner L, Moser J, Schleberger R, ... Rillig A, Metzner A
J Cardiovasc Electrophysiol: 10 Nov 2021; epub ahead of print | PMID: 34766404
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Abstract

Adverse events related to AtriCure EPi-Sense Coagulation Device-Analysis of the FDA MAUDE database.

Sheth AR, Al Yafeai Z, Dominic P
Introduction
The AtriCure EPi-Sense Device is used for the hybrid convergent procedure, an emerging treatment for persistent atrial fibrillation (AF) and long-standing persistent AF. However, data on the AE related to the EPi-Sense device are scarce.
Methods
Keyword \"EPI-SENSE\" was searched on the MAUDE database. There were 80 device reports from 2016 to 2020. After excluding reports when the device was not returned for evaluation, 79 device reports were included for final analysis.
Results
The adverse events (AE) were broadly classified into 11 categories. The most common complications were pericardial effusion (25.3%), stroke (17.7%), and atrioesophageal fistula (AEF) (8.9%). Death was reported in 15 (19%) cases, 3 of which were due to pulmonary embolism, 6 due to AEF, 3 due to unknown cause, 1 due to sepsis, 2 due to events related to acute renal failure.
Discussion
Pericardial effusion is a common AE reported in patients with convergence procedures and is well documented in the CONVERGE trial. The convergent procedure is unique in that the epicardial ablations are performed on the posterior wall with the radiofrequency probe directed towards the heart and away from the esophagus which in theory should reduce esophageal injuries. Despite that, a high number of AEF were noticed. Finally, there were also some reports of saline perfusion malfunction which can lead to injuries due to overheating.
Conclusion
This analysis of the AE related to the EPi-Sense device highlights several major AE that are previously unreported.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 Nov 2021; epub ahead of print
Sheth AR, Al Yafeai Z, Dominic P
J Cardiovasc Electrophysiol: 08 Nov 2021; epub ahead of print | PMID: 34750929
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Abstract

A histological study of the atria in patients with isolated rheumatic mitral regurgitation with and without atrial fibrillation.

Kalpana SR, Shenthar J, Padmanabhan D, Rai MK, ... Kalyani RN, Kamalapurkar G
Background
There is a high incidence of atrial fibrillation (AF) in patients with isolated rheumatic mitral regurgitation (MR). The histopathologic changes in the atria of patients with isolated rheumatic MR with and without AF are unknown.
Objectives
We aimed to determine the histological findings in patients with isolated severe rheumatic MR with and without AF.
Methods
Patients with severe isolated rheumatic MR undergoing valve replacement surgeries underwent endocardial biopsies from right atrial appendage, left atrial appendage, right free wall, left free wall, left posterior wall, and mitral valve. Group I consisted of patients in sinus rhythm (SR), and Group II included patients with AF. We analyzed and compared these 10 histological features in the biopsies of patients in Groups I and II.
Results
Of the 25 patients, 12 were in Group I and 13 in Group II. In Group I, patients had severe myocyte hypertrophy (60% vs. 18%, p = .04) that was significantly more in the right atrium (22.7% vs. 11.4%, p = .059). Interstitial adipose tissue deposition was more common in Group I (30% vs. 25%, p = .06). Interstitial fibrosis was evenly distributed at all sites without significant difference between the two groups. Group II patients had a higher prevalence and severity of vacuolar degeneration (91% vs. 60%, p = .09).
Conclusions
Patients with isolated severe rheumatic MR and AF have more vacuolar degeneration in the atrial tissue. Patients with SR have myocyte hypertrophy and interstitial adipose tissue deposition. Interstitial fibrosis is uniformly distributed in patients in SR and AF.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 05 Nov 2021; epub ahead of print
Kalpana SR, Shenthar J, Padmanabhan D, Rai MK, ... Kalyani RN, Kamalapurkar G
J Cardiovasc Electrophysiol: 05 Nov 2021; epub ahead of print | PMID: 34741568
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Abstract

Device interaction between cardiac contractility modulation (CCM) and subcutaneous defibrillator (S-ICD).

Trolese L, Faber T, Gressler A, Steinfurt J, ... Zehender M, Hilgendorf I
Combined implantation of cardiac contractility modulation (CCM) with subcutaneous implantable cardioverter-defibrillator (S-ICD) appears a suitable option to reduce the amount of intracardiac leads and complications for patients. Here we report on a patient with ischemic cardiomyopathy carrying an S-ICD in which a CCM device was implanted. During crosstalk testing post-CCM implantation, the S-ICD misannotated QRS complexes and T waves. The problem was solved through reprogramming the CCM, while preserving S-ICD functionality and improving heart failure symptoms. In conclusion, S-ICD combined with CCM seems to be a good and safe option for patients when device interference is being ruled out.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3095-3098
Trolese L, Faber T, Gressler A, Steinfurt J, ... Zehender M, Hilgendorf I
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3095-3098 | PMID: 34379359
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Abstract

Sodium channel blockers in the management of long QT syndrome types 3 and 2: A system review and meta-analysis.

Yang Y, Lv TT, Li SY, Zhang P
Background
β-Blockers are first-line therapy in patients with long QT syndrome (LQTS). However, β-blockers had genotype dependent efficacy (LQT1>LQT2>LQT3). Sodium channel blockers have been recommended as add-on therapy for LQT3 patients. However, the pooled effect of sodium channel blockers in all LQTS patients remains unknown.
Methods
We conducted a systematic electronic search of PubMed, Embase, and the Cochrane Library. Fixed effects model was used to assess the effect of sodium channel blockers on QTc, cardiac events (CEs), and the proportion of QTc ≥ 500 ms and QTc ≤ 460 ms in LQTS patients.
Results
Pooled analysis of 14 studies with 213 LQTS (9 LQT1 + 63 LQT2 + 135 LQT3 + 6 others) patients showed that sodium channel blockers significantly shortened QTc by nearly 50 ms (mean difference [MD], -49.43; 95% confidence interval [CI], -57.80 to -41.05, p < .001), reduced the incidence of CEs (risk ratio [RR], 0.23; 95% CI, 0.11-0.47; p < .001) and the proportion of QTc ≥ 500 ms (RR, 0.33; 95% CI, 0.24-0.47; p < .001), and increased the proportion of QTc ≤ 460 ms (RR, 10.33; 95% CI, 4.62-23.09; p < .001). Sodium channel blockers significantly shortened QTc both in LQT3 and LQT2 patients, while the QTc shortening effect in LQT3 was superior to that in LQT2 (57.39 vs. 36.61 ms). Mexiletine, flecainide, and ranolazine all significantly shortened QTc, and the QTc shortening effect by mexiletine was the best (60.70 vs. 49.08 vs. 50.10 ms).
Conclusions
Sodium channel blockers can be useful both in LQT3 and LQT2 patients. Mexiletine, flecainide and ranolazine significantly shortened QTc in LQTS patients, and the QTc shortening effect by mexiletine was the best.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3057-3067
Yang Y, Lv TT, Li SY, Zhang P
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3057-3067 | PMID: 34427958
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Abstract

The long-term efficacy and safety of combining ablation and left atrial appendage closure: A systematic review and meta-analysis.

Li F, Sun JY, Wu LD, Hao JF, Wang RX
Background
Combined ablation and left atrial appendage closure (LAAC) is an alternative for atrial fibrillation patients with a high risk of stroke. However, the long-term outcomes of this combined procedure remain elusive.
Methods
PubMed, Embase, Cochrane Library, and Web of Science were systematically searched from the establishment of databases to 1 January 2021. Studies on the long-term (defined as a mean follow-up of approximately 12 months or longer) efficacy and safety outcomes of combined ablation and LAAC were included.
Results
A total of 16 studies comprising 1428 patients were enrolled. The pooled long-term freedom rate from atrial arrhythmia was 0.66 (95% confidence interval [CI]: 0.59-0.71), long-term successful rate sealing of LAAC was 1.00 (95% CI: 1.00-1.00), and ischemic stroke/transient ischemic attack/systemic embolism during follow-up was 0.01 (95% CI: 0.00-0.02). Meanwhile, of the periprocedural adverse events, phrenic nerve palsy, intracoronary air embolus, device embolization, and periprocedural death had a rate of 0.00 (95% CI: 0.00-0.00), procedure-related bleeding events of 0.03 (95% CI: 0.02-0.04), and pericardial effusion requiring or not requiring intervention of 0.00 (95% CI: 0.00-0.01). Moreover, for the long-term adverse events, device dislocation, intracranial bleeding, pericardial effusion requiring or not requiring intervention, and all-cause mortality had a rate of 0.00 (95% CI: 0.00-0.00), device embolization of 0.01 (95% CI: 0.00-0.01), and other bleeding events of 0.01 (95% CI: 0.00-0.03).
Conclusion
This meta-analysis suggests that the combined atrial ablation and LAAC is an effective and safe strategy with long-term benefits.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3068-3081
Li F, Sun JY, Wu LD, Hao JF, Wang RX
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3068-3081 | PMID: 34453379
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Abstract

Outcome of transvenous lead extraction of leads older than 20 years.

Issa ZF
Background
In patients undergoing transvenous lead extraction (TLE), lead dwell time has been recognized as a risk factor for extraction failure and procedure-related complications.
Objectives
The aim of this study was to evaluate the safety and effectiveness of TLE in patients with pacemaker or ICD leads with a dwell time of ≥20 years.
Methods
This is a single-center retrospective study of all patients who underwent TLE of at least 1 pacemaker or ICD leads a dwell time of ≥20 years.
Results
During the study period, 124 patients were included in this analysis (50.8% female, mean age: 74.6 ± 10.7 years). Device-related infection was the most common (92.7%) indication for TLE. Extraction was attempted for a total 313 leads, of which 182 leads had dwell times ≥20 years (median: 276 months; interquartile range: 255-300 months). Complete procedural success was achieved in 112/124 patients (90.3%), and clinical success in 119/124 patients (96.0%). Complete removal was achieved for 294 leads (93.9%), partial removal in 10 leads, and failure in 9 leads. Clinical success (combined complete and partial success) rates were higher for leads with dwell times <20 years compared to older leads (99.2% vs. 95.6%, p = .017). Major procedural complications (including 1 death) occurred in 7/124 patients (5.6%). Minor complications were observed in 8 patients (6.5%).
Conclusions
TLE of very old (≥20 years) leads can be performed with reasonable success and safety when conducted at centers with expertise in lead management.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3042-3048
Issa ZF
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3042-3048 | PMID: 34453369
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Abstract

Purkinje triggers of ventricular fibrillation in patients with hypertrophic cardiomyopathy.

Hocini M, Ramirez FD, Szumowski Ł, Maury P, ... Jaïs P, Haïssaguerre M
Introduction
Ventricular fibrillation (VF) is the main mechanism of sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). The origin of VF and the success of catheter ablation to eliminate recurrent episodes in this population are poorly understood.
Methods and results
From 2010 to 2014, five patients with HCM (age 21 ± 9 years, three female) underwent invasive electrophysiological studies and ablation at our center after resuscitation from recurrent (9 ± 7) episodes of VF. Ventricular premature beats (VPBs), seen to initiate VF in certain cases, were recorded noninvasively before the ablation procedure. Postprocedural computed tomography (CT) was performed to correlate ablation sites with myocardial hypertrophy in three patients. Outcomes were assessed by clinical follow-up and implantable cardioverter-defibrillator interrogations. VPB triggers were localized invasively to the distal left Purkinje conduction system (left posterior fascicle [2], left anterior fascicle [1], and both fascicles [2]). All targeted VF triggers were successfully eliminated by radiofrequency ablation in the left ventricle. Among patients with postablation CT imaging, 93 ± 12% of ablation sites corresponded to hypertrophied segments. Over 50 ± 38 months, four of five patients were free from primary VF without antiarrhythmic drug therapy. One patient who had 13 episodes of VF before ablation had a single recurrence.
Conclusion
In our study of patients with HCM and recurrent VF, VF was not initiated from the myocardium but rather from Purkinje arborization. These sources colocalized with the hypertrophic substrate, suggesting electromechanical interaction. Focal ablation at these sites was associated with a marked reduction in VF burden.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2987-2994
Hocini M, Ramirez FD, Szumowski Ł, Maury P, ... Jaïs P, Haïssaguerre M
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2987-2994 | PMID: 34453363
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Abstract

Adenosine revives catheter-induced mechanical blocks in radiofrequency ablation.

Tsukahara K, Oginosawa Y, Yagyu K, Miyamoto T, ... Kataoka M, Abe H
Adenosine can hyperpolarize the atrial action potential, which helps rapidly re-establish the membrane potential in ablated sites and unmask \"dormant conduction.\" It has been reported that pharmacological agents, including adenosine, were unable to revive traumatized tissues. We present the first case of the catheter-induced mechanical block (\"bump\" phenomenon) that was unmasked with adenosine administration in the working myocardium of the superior vena cava. This result may be because, unlike before, we could determine the force of contact between the tip of the ablation catheter and the myocardial tissue. This case suggests the clinical usefulness of adenosine for unmasking bumped sites.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3103-3106
Tsukahara K, Oginosawa Y, Yagyu K, Miyamoto T, ... Kataoka M, Abe H
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3103-3106 | PMID: 34460986
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Abstract

Mechanism of ventricular tachycardia in a patient with double-outlet left ventricle.

Benali K, Hammache N, Guenancia C, de Chillou C
We report the case of ventricular tachycardia (VT) ablation procedure in a patient with history of surgically repaired double-outlet left ventricle. The electrophysiology procedure revealed a re-entry pattern between the right-ventricle to main-pulmonary-artery conduit and the tricuspid annulus. The re-entrant mechanism was most likely promoted by a fibrous remodeling of this area, related to the surgical repair. This case is the first to describe a re-entry mechanism between fixed anatomical barriers in a repaired right ventricle of a double-outlet left ventricle. A pace mapping technique was used to highlight the VT isthmus.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3099-3102
Benali K, Hammache N, Guenancia C, de Chillou C
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3099-3102 | PMID: 34455656
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Abstract

Distance between the descending aorta and the left inferior pulmonary vein as a determinant of biophysical parameters during paroxysmal atrial fibrillation cryoablation.

Benali K, Da Costa A, Macle L, Hammache N, ... Pavin D, Martins R
Introduction
The distance from the descending aorta (DA) to the posterior wall of the left atrium (LA) is variable. We aimed to determine whether the proximity between the DA and the left inferior pulmonary vein (LIPV) ostium has an impact on biophysical parameters and cryoballoon (CB) ablation efficacy during LIPV freezing.
Methods
Patients referred for CB-ablation of atrial fibrillation (AF) in two high-volume centers were included. Cryoablation data were collected prospectively for each patient. The anatomical relationships between the LIPV and the DA (distance LIPV ostium-DA, presence of an aortic imprint on the posterior aspect of the LIPV) were then retrospectively analysed on the LA computed tomography scans realized before AF ablation.
Results
A total of 350 patients were included (70% men, 59.7 ± 11.5 years). The decrease in the Ostium-DA distance was significantly correlated to the increase in the time-to-isolation (TTI) (r = -.31; p = .036), with less negative temperature (r = -.11; p = .045). Similarly, the presence of an aortic imprint on the LIPV was associated with a longer TTI (p < .001). The analysis of redo procedures data shows a trend toward the presence of shorter ostium-DA distances (15.3 ± 3.29 vs. 18.1 ± 4.99, p = .15) and more frequent aortic imprints (63.6% vs. 47.5%, p = .34) in patients with LIPV reconnection as opposed to patients without reconnection in the LIPV.
Conclusion
Our findings indicated that the DA seems to have a \"radiator\" effect influencing LIPV cryoablation parameters during CB-ablation. Additional studies will be needed to elucidate whether this biophysical influence has a clinical impact in LIPVs reconnections.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2943-2952
Benali K, Da Costa A, Macle L, Hammache N, ... Pavin D, Martins R
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2943-2952 | PMID: 34455655
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Impact:
Abstract

Novel approach to diagnosis of His bundle capture using individualized left ventricular lateral wall activation time as reference.

Jastrzębski M, Moskal P, Kukla P, Bednarek A, ... Curila K, Vijayaraman P
Background
During nonselective His bundle (HB) pacing, it is clinically important to confirm His bundle capture versus right ventricular septal (RVS) capture. The present study aimed to validate the hypothesis that during HB capture, left ventricular lateral wall activation time, approximated by the V6 R-wave peak time (V6 RWPT), will not be longer than the corresponding activation time during native conduction.
Methods
Consecutive patients with permanent HB pacing were recruited; cases with abnormal His-ventricle interval or left bundle branch block were excluded. Two corresponding intervals were compared: stimulus-V6 RWPT and native HB potential-V6 RWPT. The difference between these two intervals (delta V6 RWPT), which was diagnostic of lack of HB capture, was identified using receiver operating characteristic (ROC) curve analysis.
Results
A total of 723 electrocardiograms (ECGs) (219 with native rhythm, 172 with selective HB, 215 with nonselective HB, and 117 with RVS capture) were obtained from 219 patients. The native HB-V6 RWPT, nonselective-, and selective-HB paced V6 RWPT were nearly equal, while RVS V6 RWPT was 32.0 (±9.5) ms longer. The ROC curve analysis indicated delta V6 RWPT > 12 ms as diagnostic of lack of HB capture (specificity of 99.1% and sensitivity of 100%). A blinded observer correctly diagnosed 96.7% (321/332) of ECGs using this criterion.
Conclusions
We validated a novel criterion for HB capture that is based on the physiological left ventricular activation time as an individualized reference. HB capture can be diagnosed when paced V6 RWPT does not exceed the value obtained during native conduction by more than 12 ms, while longer paced V6 RWPT indicates RVS capture.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3010-3018
Jastrzębski M, Moskal P, Kukla P, Bednarek A, ... Curila K, Vijayaraman P
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3010-3018 | PMID: 34455648
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Impact:
Abstract

Outcomes of temporary pacing using active fixation leads and externalized permanent pacemakers in patients with cardiovascular implantable electronic device infection and pacemaker dependency.

Zhou X, Ze F, Li D, Li X, Wang B
Introduction
The incidence of cardiac implantable electronic device (CIED) infections is increasing. Complete device and lead removal are recommended for all patients with definite CIED system infection. In patients with pacemaker dependency, temporary pacing before reimplantation is necessary. In this study, temporary pacing using active fixation leads (TPAFL) was evaluated.
Methods
We reviewed data from consecutive patients implanted with TPAFL after transvenous lead extraction at our center between November 2014 and October 2020.
Results
TPAFL were placed in 334 patients. The mean age was 64.5 ± 16.4 years and 76.3% were males. Two hundred and forty (72%) were treated due to local pocket infection and 94 (28%) systemic infection. The indication for temporary pacing was sick sinus syndrome in 135 (40.4%) patients and complete or high-grade atrioventricular (AV) block in 199 (59.6%) patients. The most common access site for lead implantation was the ipsilateral subclavian or axillary vein (78.9%). A new permanent CIED was reimplanted at 10.3 ± 9.2 days (median 10, range: 2-70) after implantation of the temporary pacing. There were five (1.5%) adverse events related to the temporary pacing during hospitalization. The median follow-up duration was 23.1 months (interquartile range [IQR], 7.2-43.4 months). Only one patient (0.3%) developed recurrent CIED infection.
Conclusion
TPAFL is safe and effective in pacemaker-dependent patients after infected CIED removal. The rate of temporary pacing-related complications, including lead dislodgment and reinfection of CIED is relatively low.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3051-3056
Zhou X, Ze F, Li D, Li X, Wang B
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3051-3056 | PMID: 34487387
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Impact:
Abstract

Timing of syncope in ictal asystole as a guide when considering pacemaker implantation.

van Westrhenen A, Shmuely S, Surges R, Diehl B, ... van Dijk JG, Thijs RD
Introduction
In patients with ictal asystole (IA) both cardioinhibition and vasodepression may contribute to syncopal loss of consciousness. We investigated the temporal relationship between onset of asystole and development of syncope in IA, to estimate the frequency with which pacemaker therapy, by preventing severe bradycardia, may diminish syncope risk.
Methods
In this retrospective cohort study, we searched video-EEG databases for individuals with focal seizures and IA (asystole ≥ 3 s preceded by heart rate deceleration) and assessed the durations of asystole and syncope and their temporal relationship. Syncope was evaluated using both video observations (loss of muscle tone) and EEG (generalized slowing/flattening). We assumed that asystole starting ≤3 s before syncope onset, or after syncope began, could not have been the dominant cause.
Results
We identified 38 seizures with IA from 29 individuals (17 males; median age: 41 years). Syncope occurred in 22/38 seizures with IA and was more frequent in those with longer IA duration (median duration: 20 [range: 5-32] vs. 5 [range: 3-9] s; p < .001) and those with the patient seated vs. supine (79% vs. 46%; p = .049). IA onset always preceded syncope. In 20/22 seizures (91%), IA preceded syncope by >3 s. Thus, in only two instances was vasodepression rather than cardioinhibition the dominant presumptive syncope triggering mechanism.
Conclusions
In IA, cardioinhibition played an important role in most seizure-induced syncopal events, thereby favoring the potential utility of pacemaker implantation in patients with difficult to suppress IA.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3019-3026
van Westrhenen A, Shmuely S, Surges R, Diehl B, ... van Dijk JG, Thijs RD
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3019-3026 | PMID: 34510639
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Impact:
Abstract

Outcomes and predictors of readmission after implantation of a percutaneous left atrial appendage occlusion device in the United States: A propensity score-matched analysis from The National Readmission Database.

Pasupula DK, Munir MB, Bhat AG, Siddappa Malleshappa SK, ... Hirji S, Hsu JC
Background
Left atrial appendage occlusion (LAAO) devices have become a favorable alternative option among nonvalvular atrial fibrillation (AF) patients with long-term contraindication to anticoagulation. Real-world experience with postprocedural readmission rates and predictors of readmission in LAAO patients is limited.
Objective
To assess all-cause 30-day readmission rate and predictors of readmission after LAAO procedure in the United States.
Method
This retrospective observational study included all AF patients undergoing percutaneous LAAO procedures in the United States from January 1, 2016, and December 31, 2017, in the National Readmission Database. The primary outcome measure was all-cause 30-day readmission. A propensity score-matched analysis compared outcomes with a non-LAAO AF cohort.
Result
Among 14 024 LAAO procedures (age: 76 ± 8 years; 60.5% males), 9.4% were readmitted within 30-days and, 0.2% died during their index hospitalization. The most frequent primary diagnosis during readmission among LAAO was gastrointestinal bleeding (12%). The incidence of LAAO procedures increased by 102%. In the multivariate model, gender and CHA2 DS2 -VASc failed to predict readmission. Age 55-64 years had lower odds (adjusted odds ratios [aOR]: 0.41; 95% confidence interval [CI]: 0.18-0.94), while drug abuse (aOR: 4.1; 95% CI: 1.34-12.54), and deficiency anemia (aOR: 1.88; 95% CI: 1.12-3.18) had higher odds of readmission. In propensity-matched cohort, compared to non-LAAO AF, LAAO patients had lower 30-day readmission (9.4% vs. 10.98%, p = .002) and all-cause in-hospital mortality (0.19% vs. 0.57%, p < .001).
Conclusion
The readmission rate following the LAAO procedure is substantial (approximately 10%), and largely attributable to gastrointestinal bleeding. Factors such as drug abuse and anemia must be explored further to minimize readmission risk.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2961-2970
Pasupula DK, Munir MB, Bhat AG, Siddappa Malleshappa SK, ... Hirji S, Hsu JC
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2961-2970 | PMID: 34535939
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Impact:
Abstract

Earliest pulmonary vein potential-guided cryoballoon ablation is associated with better clinical outcomes than conventional cryoballoon ablation: A result from two randomized clinical studies.

Mizutani Y, Yanagisawa S, Kanashiro M, Yamashita D, ... Inden Y, Murohara T
Introduction
With regard to short-term outcome in atrial fibrillation (AF), the benefit of cryoballoon ablation (CBA) by pressing a balloon against the earliest pulmonary vein (PV) potential site during PV isolation (earliest potential [EP]-guided CBA) has been previously demonstrated. The present study aimed to evaluate the long-term outcome of the EP-guided CBA.
Methods and results
This study included 136 patients from two randomized studies, who underwent CBA for paroxysmal AF for the first time. Patients were randomly assigned to the EP-guided and conventional CBA groups in each study. In the EP-guided CBA group, we pressed a balloon against the EP site when the time-to-isolation (TTI) after cryoapplication exceeded 60 and 45 s in the first and second studies, respectively. We compared the clinical outcomes for 1 year after the procedure between the EP-guided CBA group (68 patients) and the conventional CBA group (68 patients). The primary endpoint was the recurrence of atrial arrhythmia after ablation. No significant differences in baseline characteristics were observed between the two groups. Compared with the conventional CBA group, the EP-guided CBA group had a significantly higher success rate at TTI ≤ 90 s (98.5% vs. 90.0%, p < .001); lower touch-up rate and total cryoapplication; and shorter procedure time, and fluoroscopy time. The recurrence at 1 year after ablation was significantly lower in the EP-guided CBA group than in the conventional CBA group (6.0% vs. 19.4%; p = .019).
Conclusions
The EP-guided CBA approach can facilitate the ablation procedure and achieve low recurrence at 1 year after ablation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2933-2942
Mizutani Y, Yanagisawa S, Kanashiro M, Yamashita D, ... Inden Y, Murohara T
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2933-2942 | PMID: 34535938
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Impact:
Abstract

Low incidence of major complications after the first six hours post atrial fibrillation ablation: Is same-day discharge safe and feasible in most patients?

Paul Nordin A, Drca N, Insulander P, Bastani H, ... Åkerström F, Jensen-Urstad M
Aims
This study evaluates the incidence of procedural complications related to catheter ablation of atrial fibrillation (AF) to assess the potential feasibility and safety of same-day discharge in a large cohort.
Methods
We performed an analysis of prospectively collected data of complications of all patients staying overnight after undergoing AF ablation between 2001 and 2020 at a tertiary center. Using medical records, we analyzed complications occurring intraprocedurally until 6 h postablation and between 6 h postablation and discharge the day after the ablation procedure.
Results
In 5414 AF ablations, we identified a total of 108 (2.0%) major complications occurring intraprocedural or before discharge. Most major complications occurred intraprocedurally or within 6 h after the procedure (n = 96, 1.8%). Twelve (0.2%) major complications occurred between 6 h Postablation and discharge. The most common of these major complications were congestive heart failure (n = 6) and transient ischemic attack (TIA, n = 4). During this time span, 61 (1.1%) minor complications occurred. Factors independently associated with major complications intraprocedurally and until discharge were body mass index (BMI) ≥ 30 kg/m2 (p = .009), significant valvular disease (p = .001), cardiomyopathy (p < .001), prior stroke or TIA (p = .014), first-time procedure versus repeat procedure (p = .013), cryoablation versus radiofrequency (p < .001), and procedure duration (p < .001).
Conclusion
After AF ablation, very few complications occurred between 6 h postprocedure and discharge the next day. Therefore, same-day discharge is a safe option for a majority of patients.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2953-2960
Paul Nordin A, Drca N, Insulander P, Bastani H, ... Åkerström F, Jensen-Urstad M
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2953-2960 | PMID: 34535936
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Impact:
Abstract

Pacing site- and rate-dependent shortening of retrograde conduction time over the slow pathway after atrial entrainment of fast-slow atrioventricular nodal reentrant tachycardia.

Kaneko Y, Nakajima T, Tamura S, Hasegawa H, Kobari T, Ishii H
Introduction
We tested our hypothesis that atrial entrainment pacing (EP) of a) the common-type (com-) fast-slow (F/S-) atypical atrioventricular nodal reentrant tachycardia (AVNRT) using a typical slow pathway (SP), or b) the superior-type (sup-) F/S-AVNRT using a superior SP, both modify the retrograde conduction time across the SP immediately after termination of EP (retro-SP-time).
Methods
We measured the difference in the His-atrial interval (HA difference) immediately after cessation of EP, performed at 2 ± 2 rates from the high right atrium (HA[1]-HRA) versus from the proximal coronary sinus (HA[1]-CS) in 17 patients with com-F/S-AVNRT and 11 patients with sup-F/S-AVNRT. We also measured the atrial-His and HA intervals of the first and second cycles immediately after cessation of EP and during stable tachycardia.
Results
Unequal responses, defined as a ≥ 20-ms HA difference at ≥1 EP rates, were observed in 16 patients (57%), including 7 with com- and 9 with sup-F/S-AVNRT. Irrespective of the EP rate, all unequal responses of com-F/S-AVNRT were due to a shorter HA[1]-CS than HA[1]-HRA, with a mean 34 ± 11 ms HA difference, whereas all unequal responses of sup-F/S-AVNRT were due to a longer HA[1]-CS than HA[1]-HRA, with a mean 49 ± 25 ms HA difference. The unequal responses resolved within two cycles after the cessation of EP.
Conclusions
We have identified a little-known pacing site- and pacing rate-dependent shortening of the retro-SP-time.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2979-2986
Kaneko Y, Nakajima T, Tamura S, Hasegawa H, Kobari T, Ishii H
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2979-2986 | PMID: 34535933
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Impact:
Abstract

Cryoablation of atypical atrioventricular nodal reentry tachycardia.

von Olshausen G, Jemtrén A, Schwieler J, Tapanainen J, ... Braunschweig F, Drca N
Aim
Data on ablation for atypical recurrent atrioventricular nodal reentry tachycardia (AVNRT) and long-term follow-up are generally sparse. Furthermore, the rate of recurrence and safety of cryoablation for atypical AVNRT has not been established. We compared patients cryoablated for atypical AVNRT and typical AVNRT during long-term follow-up.
Methods
All patients (n = 2612) who underwent catheter ablation for AVNRT at the Karolinska University Hospital between January 2009 and August 2019 were analyzed. A total of 91 patients undergoing first-time cryoablation for atypical AVNRT were included. A control group with first-time cryoablation for typical AVNRT was matched in a 1:1 ratio. Patients were followed-up for recurrences for a median of 5.0 years (interquartile range: 3.1-7.5 years).
Results
After 5 years, AVNRT recurrence occurred in 10 patients (11.0%) in the atypical AVNRT group and in 8 patients (8.8%) in the typical AVNRT group (hazard ratio: 1.31 [95% confidence interval: 0.52-3.32]; p = 0.568). The duration of the index procedure was significantly longer for atypical compared to typical AVNRT ablation (132.1 ± 49.2 min vs. 110.1 ± 38.8 min; p = 0.001). Transient AV blocks occurred in a similar fashion in the atypical compared to typical group (11 [12.1%] vs. 4 [4.9%]; p = 0.103). However, no ablation induced persistent AV block developed in either group.
Conclusion
Cryoablation for atypical AVNRT showed similar rate of recurrences and safety compared to typical AVNRT during long-term follow-up.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2971-2978
von Olshausen G, Jemtrén A, Schwieler J, Tapanainen J, ... Braunschweig F, Drca N
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2971-2978 | PMID: 34535930
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Impact:
Abstract

Single-sweep pulmonary vein isolation using the new third-generation laser balloon-Evolution in ablation style using endoscopic ablation system.

Tohoku S, Bordignon S, Chen S, Zanchi S, ... Chun KRJ, Schmidt B
Background
The endoscopic ablation system (EAS) is an established ablation device for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). The novel X3 EAS is now equipped with a contiguous circumferential ablation mode (RAPID mode).
Aim
To determine the feasibility of single-shot fashioned ablation using X3.
Methods
Consecutive patients who underwent AF ablation using X3 were enrolled. We assessed the acute procedural data focusing on \"Single-sweep PVI\" defined as successful PVI with a single RAPID mode energy application, and on \"first-pass isolation\" defined as successful PVI after initial circular lesion set.
Results
One hundred AF patients (56% male, age: 68 ± 10 years, 66% paroxysmal AF) were analyzed. A total of 379 of 383 PVs (99%) were isolated with X3. Single-sweep PVI and first-pass-isolation were achieved in 214 PVs (56%) and in 362 PVs (95%), respectively. Single-sweep PVI rates varied across PVs with higher rates at the superior PVs (61.2% vs. inferior PVs: 49.5%, p = .0239) and at PVs with maximal ostial diameter <24 mm (57.6% vs. >24 mm: 36.8%, p = .0151). The mean total procedure and fluoroscopy times were 43.0 ± 10 and 4.0 ± 2 min, respectively. In none of the patients an acute thromboembolic event (stroke or transient ischemic attack) or a pericardial effusion/tamponade occurred. A single transient phrenic nerve palsy was observed.
Conclusion
The new X3 EAS allows for single-shot fashioned ablation in terms of single-sweep PVI in half or more of PVs. The new RAPID ablation mode leads to an improved rate of first-pass isolation associated with very short procedure times without compromising safety.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2923-2932
Tohoku S, Bordignon S, Chen S, Zanchi S, ... Chun KRJ, Schmidt B
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2923-2932 | PMID: 34535929
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Impact:
Abstract

Cardiac stereotactic body radiation therapy for ventricular tachycardia: Current experience and technical gaps.

Wei C, Qian PC, Boeck M, Bredfeldt JS, ... Mak R, Zei PC
Introduction
Despite advances in drug and catheter ablation therapy, long-term recurrence rates for ventricular tachycardia remain suboptimal. Cardiac stereotactic body radiotherapy (SBRT) is a novel treatment that has demonstrated reduction of arrhythmia episodes and favorable short-term safety profile in treatment-refractory patients. Nevertheless, the current clinical experience is early and limited. Recent studies have highlighted variable duration of treatment effect and substantial recurrence rates several months postradiation. Contributing to these differential outcomes are disparate approaches groups have taken in planning and delivering radiation, owing to both technical and knowledge gaps limiting optimization and standardization of cardiac SBRT.
Methods and findings
In this report, we review the historical basis for cardiac SBRT and existing clinical data. We then elucidate the current technical gaps in cardiac radioablation, incorporating the current clinical experience, and summarize the ongoing and needed efforts to resolve them.
Conclusion
Cardiac SBRT is an emerging therapy that holds promise for the treatment of ventricular tachycardia. Technical gaps remain, to be addressed by ongoing research and growing clincial experience.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2901-2914
Wei C, Qian PC, Boeck M, Bredfeldt JS, ... Mak R, Zei PC
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2901-2914 | PMID: 34587335
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Impact:
Abstract

Evaluation of a novel cardiac signal processing system for electrophysiology procedures: The PURE EP 2.0 study.

Al-Ahmad A, Knight B, Tzou W, Schaller R, ... McLeod C, Natale A
Background
Intracardiac electrogram data remain one of the primary diagnostic inputs guiding complex ablation procedures. However, the technology to collect, process, and display intracardiac signals has known shortcomings and has not advanced in several decades.
Objective
The purpose of this study was to evaluate a new signal processing platform, the PURE EP™ system (PURE), in a multi-center, prospective study.
Methods
Intracardiac signal data of clinical interest were collected from 51 patients undergoing ablation procedures with PURE, the signal recording system, and the 3D mapping system at the same time stamps. The samples were randomized and subjected to blinded, controlled evaluation by three independent electrophysiologists to determine the overall quality and clinical utility of PURE signals when compared to conventional sources. Each reviewer assessed the same (92) signal sample sets and responded to (235) questions using a 10-point rating scale. If two or more reviewers rated the PURE signal higher than the control, it was deemed superior.
Results
A total of 93% of question responses showed consensus amongst the blinded reviewers. Based on the ratings for each pair of signals, a cumulative total of 164 PURE signals out of 218 (75.2%) were statistically rated as Superior for this data set (p < .001). Only 14 PURE signals out of 218 were rated as Inferior (6.4%).
Conclusion
The PURE intracardiac signals were statistically rated as superior when compared to conventional systems.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2915-2922
Al-Ahmad A, Knight B, Tzou W, Schaller R, ... McLeod C, Natale A
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2915-2922 | PMID: 34554634
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Impact:
Abstract

A 10 J shock impedance in sinus rhythm correlates with a 65 J defibrillation impedance during subcutaneous defibrillator implantation using an intermuscular technique.

Okabe T, Savona SJ, Matto F, Ward C, ... Hummel JD, Daoud EG
Introduction
Defibrillation testing (DT) is recommended during the subcutaneous defibrillator (S-ICD) placement. We sought to compare 10 J shock impedance in sinus rhythm (SR) with 65 J defibrillation impedance and evaluate device position on a postimplant chest X-ray (CXR) using an intermuscular (IM) technique.
Methods
Consecutive S-ICD implantations between 12/2019 and 12/2020 at The Ohio State University were reviewed. All implantations were performed using a two-incision IM technique. Standard DT with 65 J shock and 10 J shock in SR were performed unless contraindicated. The PRAETORIAN score was calculated based on CXR.
Results
A total of 37 patients (age: 47.2 ± 15.8 years old, male: n = 26 [70.3%], body mass index: 30.1 ± 6.7 kg/m2 ) underwent IM S-ICD implantation, and of those, 27 (73%) underwent both 65 J shock and 10 J shock in SR. The coefficient of determination (R2 ) between 10 J shock impedance and 65 J shock impedance was 0.84. The mean of an impedance difference was 1.6 ± 4.8 Ω (minimum - 11 and maximum 8). Postimplant CXR was available for 33 out of 37 patients (89.2%). The PRAETORIAN score was less than 90 in all patients and the mean score was 32.7 ± 8.8.
Conclusion
We demonstrated that 10 J shock impedance in SR correlated well with 65 J defibrillation impedance during IM S-ICD implantation. An IM implantation technique provides excellent generator location on postimplant CXR. The IM technique combined with 10 J shock in SR may be sufficient to predict and ensure the defibrillation efficacy of the S-ICD.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3027-3034
Okabe T, Savona SJ, Matto F, Ward C, ... Hummel JD, Daoud EG
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3027-3034 | PMID: 34554620
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Impact:
Abstract

Etiology and device therapy in complete atrioventricular block in pediatric and young adult population: Contemporary review and new perspectives.

Cioffi GM, Gasperetti A, Tersalvi G, Schiavone M, ... Dello Russo A, Forleo GB
Complete atrioventricular block (CAVB) is a total dissociation between the atrial and ventricular activity, in the absence of atrioventricular conduction. Several diseases may result in CAVB in the pediatric and young-adult population. Permanent right ventricular (RV) pacing is required in permanent CAVB, when the cause is neither transient nor reversible. Continuous RV apical pacing has been associated with unfavorable outcomes in several studies due to the associated ventricular dyssynchrony. This study aims to summarize the current literature regarding CAVB in the pediatric and young adult population and to explore future treatment perspectives.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3082-3094
Cioffi GM, Gasperetti A, Tersalvi G, Schiavone M, ... Dello Russo A, Forleo GB
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3082-3094 | PMID: 34570400
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Impact:
Abstract

Intraprocedural PRAETORIAN score for early assessment of S-ICD implantation: A proof-of-concept study.

Gasperetti A, Schiavone M, Biffi M, Casella M, ... Tilz RR, Forleo GB
Introduction
The PRAETORIAN score (PS) was developed to assess the implant position and predict defibrillation success of the subcutaneous implantable cardioverter defibrillators (S-ICD). The main critique moved to the routine use of PS has been its postprocedural timing, that limits its usefulness on procedure guidance. The aim of this proof-of-concept study was to assess the feasibility of an intraprocedural use of PS.
Methods
Forty consecutive patients undergoing S-ICD implantation were enrolled. Intraprocedural PS (IP-PS) obtained with fluoroscopy before closure of the pocket and postprocedural PS (PP-PS) obtained with two-views chest X-ray were compared. Intraprocedural data and PS were compared with the historic cohorts of the involved institutions.
Results
When assessing IP-PS and PP-PS, a complete overall agreement was observed (100%, 1.00-κ; p < .001). When assessing a per-step agreement, a very high-degree of concordance in evaluating Step 1 of the PS was observed (95%, 0.81-κ; p < .001). A complete agreement in Step 2-3 (100%, 1.00-κ; p < .001) of the PS was reported. In comparison with our historical cohort, procedural time in the IP-PS cohort did not increase (45 [41-52] vs. 45 [39-49] min; p = .351) while the expected increase in fluoroscopy time resulted scarce (15 [10-15] s).
Conclusion
An IP-PS can be reliably obtained using fluoroscopy guidance during S-ICD implantation, without a significant increase in procedural duration and may serve as guidance for implanting physicians, to avoid postprocedural S-ICD repositioning, leading to patient discomfort and significantly enhancing infective risks. IP-PS showed a very high agreement with the PP-PS obtained from two-views chest X-ray.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3035-3041
Gasperetti A, Schiavone M, Biffi M, Casella M, ... Tilz RR, Forleo GB
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:3035-3041 | PMID: 34582055
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Impact:
Abstract

Right ventricular outflow tract electroanatomical abnormalities in asymptomatic and high-risk symptomatic patients with Brugada syndrome: Evidence for a new risk stratification tool?

Letsas KP, Vlachos K, Conte G, Efremidis M, ... Haissaguerre M, Hocini M
Introduction
Microstructural abnormalities at the epicardium of the right ventricular outflow tract (RVOT) may provide the arrhythmia substrate in Brugada syndrome (BrS). Endocardial unipolar electroanatomical mapping allows the identification of epicardial abnormalities. We evaluated the clinical implications of an abnormal endocardial substrate as perceived by high-density electroanatomical mapping (HDEAM) in patients with BrS.
Methods
Fourteen high-risk BrS patients with aborted sudden cardiac death (SCD) (12 males, mean age: 41.9 ± 11.8 years) underwent combined endocardial-epicardial HDEAM of the right ventricle/RVOT, while 40 asymptomatic patients (33 males, mean age: 42 ± 10.7 years) underwent endocardial HDEAM. Based on combined endocardial-epicardial procedures, endocardial HDEAM was considered abnormal in the presence of low voltage areas (LVAs) more than 1 cm2 with bipolar signals less than 1 mV and unipolar signals less than 5.3 mV. Programmed ventricular stimulation (PVS) was performed in all patients.
Results
The endocardial unipolar LVAs were colocalized with epicardial bipolar LVAs (p = .0027). Patients with aborted SCD exhibited significantly wider endocardial unipolar (p < .01) and bipolar LVAs (p < .01) compared with asymptomatic individuals. A substrate size of unipolar LVAs more than 14.5 cm2 (area under the curve [AUC]: 0.92, p < .001] and bipolar LVAs more than 3.68 cm2 (AUC: 0.82, p = .001) distinguished symptomatic from asymptomatic patients. Patients with ventricular fibrillation inducibility (23/54) demonstrated broader endocardial unipolar (p < .001) and bipolar LVAs (p < .001) than noninducible patients. The presence of unipolar LVAs more than 13.5 cm2 (AUC: 0.95, p < .001) and bipolar LVAs more than 2.97 cm2 (AUC: 0.78, p < .001) predicted a positive PVS.
Conclusion
Extensive endocardial electroanatomical abnormalities identify high-risk patients with BrS. Endocardial HDEAM may allow risk stratification of asymptomatic patients referred for PVS.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2997-3007
Letsas KP, Vlachos K, Conte G, Efremidis M, ... Haissaguerre M, Hocini M
J Cardiovasc Electrophysiol: 30 Oct 2021; 32:2997-3007 | PMID: 34596938
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Abstract

Epicardial atrial pacing after the extracardiac Fontan operation: Feasibility of an entirely transvenous approach.

Hoyt WJ, Moore JP, Shannon KM, Kannankeril PJ, Fish FA
This series describes an innovative technique for pacing in patients with sinus node dysfunction after extracardiac Fontan surgery. This transpulmonary approach to the left atrial epi-myocardium has been successfully applied to three patients at two centers and resulted in excellent acute and midterm pacing characteristics without known complications. The principal advantage of this procedure in comparison to prior iterations is the absence of pacing material within the pulmonary venous atrium, so that future systemic thromboembolism risk is minimized. The transpulmonary approach for permanent atrial pacing offers a novel solution to the unique challenges for patients after extracardiac Fontan operation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Oct 2021; epub ahead of print
Hoyt WJ, Moore JP, Shannon KM, Kannankeril PJ, Fish FA
J Cardiovasc Electrophysiol: 29 Oct 2021; epub ahead of print | PMID: 34716972
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Abstract

Actual tissue temperature during ablation index-guided high-power short-duration ablation versus standard ablation: Implications in terms of the efficacy and safety of atrial fibrillation ablation.

Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, ... Takahashi R, Taniguchi Y
Background
Actual in vivo tissue temperatures and the safety profile during high-power short-duration (HPSD) ablation of atrial fibrillation have not been clarified.
Methods
We conducted an animal study in which, after a right thoracotomy, we implanted 6-8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We recorded tissue temperatures during a 50 W-HPSD ablation and 30 W-standard ablation targeting an ablation index (AI) of 400 (5-15 g contact force).
Results
Maximum tissue temperatures reached with HSPD ablation were significantly higher than that reached with standard ablation (62.7 ± 12.5 vs. 52.7 ± 11.4°C, p = 0.033) and correlated inversely with the distance between the catheter tip and thermocouple, regardless of the power settings (HPSD: r = -0.71; standard: r = -0.64). Achievement of lethal temperatures (≥50°C) was within 7.6 ± 3.6 and 12.1 ± 4.1 s after HPSD and standard ablation, respectively (p = 0.003), and was best predicted at cutoff points of 5.2 and 4.4 mm, respectively. All HPSD ablation lesions were transmural, but 19.2% of the standard ablation lesions were not (p = 0.011). There was no difference between HPSD and standard ablation regarding the esophageal injury rate (30% vs. 33.3%, p > 0.99), with the injury appearing to be related to the short distance from the catheter tip.
Conclusions
Actual tissue temperatures reached with AI-guided HPSD ablation appeared to be higher with a greater distance between the catheter tip and target tissue than those with standard ablation. HPSD ablation for <7 s may help prevent collateral tissue injury when ablating within a close distance.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 27 Oct 2021; epub ahead of print
Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, ... Takahashi R, Taniguchi Y
J Cardiovasc Electrophysiol: 27 Oct 2021; epub ahead of print | PMID: 34713525
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Impact:
Abstract

Safety and durability of cavo-tricuspid isthmus linear ablation in the current era: Single-center 9-year experience from 1078 procedures.

Kakehashi S, Miyazaki S, Hasegawa K, Nodera M, ... Uzui H, Tada H
Background
Cavo-tricuspid isthmus (CTI) linear ablation is performed not only for atrial flutter (AFL) but empirically during atrial fibrillation (AF) ablation in real-world practice. 
Purpose:
We sought to evaluate the safety and durability of the CTI ablation. 
Methods:
This retrospective study included 1078 consecutive patients who underwent a CTI ablation. AFL was documented before or during the procedure in 249 (23.1%) patients, and an empirical CTI and AF ablation were performed in 829 (76.9%) patients. 
Results:
CTI block was successfully created in 1051 (97.5%) patients with a 10.3 ± 6.6 min total radiofrequency time. Repeat procedures were performed for recurrent arrhythmias in 187 (17.3%) patients at a median of 11.0 (5.0-30.0) months postprocedure, and conduction resumption was identified in 68/174 (39.1%). Among those undergoing a CTI ablation with an AF ablation, the durability was significantly higher in those with than without documented AFL (78.1% vs. 58.2%, p = .031).  The total radiofrequency time was significantly shorter (9.0 ± 5.3 vs. 10.0 ± 6.4 [mins], p = .024) and durability significantly higher (78.1 vs. 58.7[%], p = .043) in the large-tip than irrigated-tip catheter group. Iatrogenic AFL was observed after the empiric CTI ablation in 11 (1.3%) patients. Procedure-related complications occurred in 15 (1.4%) patients. Eight patients experienced coronary artery spasms, including one with ventricular fibrillation following ST elevation on the ward. The other six patients experienced transient atrioventricular block and one experienced cardiac tamponade requiring drainage. 
Conclusions:
Despite a high acute CTI ablation success, the conduction block durability was relatively low after the empiric ablation. An empiric CTI ablation at the time of the AF ablation is not recommended.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 21 Oct 2021; epub ahead of print
Kakehashi S, Miyazaki S, Hasegawa K, Nodera M, ... Uzui H, Tada H
J Cardiovasc Electrophysiol: 21 Oct 2021; epub ahead of print | PMID: 34676946
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Abstract

Procedural and short-term results of electroanatomic-mapping-guided ganglionated plexus ablation by first-time operators: A multicenter study.

Aksu T, De Potter T, John L, Osorio J, ... Gupta D, Davila A
Introduction
Single-center observational studies have shown promising results with fragmented electrogram (FE)-guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE-guided GP ablation in patients with VMB performed by first-time operators and those of a single high-volume operator.
Methods and results
This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high-volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty-seven consecutive patients with VMB who underwent FE-guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p = .022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p < .001). Over a mean follow-up duration of 8.0 ± 3 months (range 2-24 months), none of the patients suffered from syncope.
Conclusion
This multi-center pilot study shows for the first time the feasibility of FE-guided GP ablation across a large group of procedure-naïve operators.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 20 Oct 2021; epub ahead of print
Aksu T, De Potter T, John L, Osorio J, ... Gupta D, Davila A
J Cardiovasc Electrophysiol: 20 Oct 2021; epub ahead of print | PMID: 34674347
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Abstract

Endothelial function and atrial fibrillation: A missing piece of the puzzle?

Black N, Mohammad F, Saraf K, Morris G
Endothelial dysfunction, a term used to describe both the physical damage and dysregulated physiology of this endothelial lining, is an increasingly recognized pathophysiological state shared by many cardiovascular diseases. Historically, the role of endothelial dysfunction in atrial fibrillation (AF) was thought to be limited to mediating atrial thromboembolism. However, there is emerging evidence that endothelial dysfunction both promotes and maintains atrial arrhythmic substrate, predicts adverse outcomes, and identifies patients at high risk of recurrence following cardioversion and ablation therapy. Treatments targeted at improving endothelial function also represent a promising new therapeutic paradigm in AF. This review summarizes the current understanding of endothelial function in AF.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 20 Oct 2021; epub ahead of print
Black N, Mohammad F, Saraf K, Morris G
J Cardiovasc Electrophysiol: 20 Oct 2021; epub ahead of print | PMID: 34674346
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Abstract

Pregnancy in women with Brugada syndrome: Is there an increased arrhythmia risk? A case-series report.

van der Crabben SN, Kowsoleea AIE, Clur SB, Wilde AAM
Introduction
In some rare arrhythmia syndromes, arrhythmia risk in female patients increases during pregnancy, necessitating extra controls. We wanted to evaluate if the increased risk for arrhythmia during pregnancy applies in women with Brugada syndrome and their potentially affected fetuses.
Methods
A comprehensive literature search was performed on PubMed (MeSH search terms \"Brugada syndrome,\" \"pregnancy,\" \"parturition,\" \"labor,\" \"delivery,\" \"fetal death,\" and \"stillbirth\").
Results
Overall, six case reports with a total of six patients were identified. Of these six patients (three carriers of an SCN5A variant, three not tested), two women (both with unknown SCN5A status), developed severe cardiac events during pregnancy. The first patient, with a previous history of aborted sudden cardiac arrest at the age of 12 years, developed ventricular fibrillation (VF), while the other was diagnosed with Brugada syndrome postpartum because of nocturnal agonal respiration during pregnancy.
Conclusion
These (limited, heterogenous) cases suggest that women with Brugada syndrome (and their possibly affected fetuses), might have an overall low tendency to develop arrhythmias during pregnancy, but important data on risk factors (SCN5A status) are lacking. Arrhythmia risk during pregnancy seems to increase in probands and those who have previously experienced cardiac events. We suggest the use of risk stratification in these women to improve patient care, lower the emotional stress and physical burden for the pregnant mother, and lower health costs. Furthermore, we plead for SCN5A analysis in all these women for use of risk stratification and to enable cascade screening especially for specialized care in children carrying an SCN5A mutation.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 20 Oct 2021; epub ahead of print
van der Crabben SN, Kowsoleea AIE, Clur SB, Wilde AAM
J Cardiovasc Electrophysiol: 20 Oct 2021; epub ahead of print | PMID: 34674339
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Abstract

Physiologic lead placement with electroanatomic mapping: A case series.

Baman JR, Garg V, Kalluri AG, Wasserlauf J, ... Sharma PS, Verma N
Introduction
His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as attractive alternatives to traditional biventricular pacing to achieve cardiac resynchronization therapy. Early reported results have been inconsistent, particularly amongst patients in whom initial placement with traditional approaches has been unsuccessful or those with complex anatomy or congenital abnormalities. In this report, we describe the use of three-dimensional electroanatomic mapping (EAM) in five selected cases.
Methods
Five patients from multiple clinical sites underwent EAM-guided HBP or LBBAP by highly trained electrophysiologists with significant experience with conduction system pacing. Each patient in this series underwent EAM-guided conduction system pacing due to complex anatomy and/or prior failed lead implantation.
Results
EAM-guided lead implantation was successful in all five cases. Capture thresholds were relatively low and patients continued to have evidence of successful lead implantation with minimum 1-month follow-up. The fluoroscopy time varied, likely owing to the variable complexity of the cases.
Conclusions
The use of EAM, in combination with traditional intracardiac electrograms with or without fluoroscopy, allows more targeted and precise placement of leads for HBP and LBBAP pacing. Further investigation is needed to determine this strategy\'s long-term performance and to optimize patient selection.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Baman JR, Garg V, Kalluri AG, Wasserlauf J, ... Sharma PS, Verma N
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34665491
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Abstract

Effect of DrOnedarone on atrial fibrosis progression and atrial fibrillation recurrence postablation: Design of the EDORA randomized clinical trial.

Marrouche NF, Dagher L, Wazni O, Akoum N, ... Hua H, EDORA Investigators
Background
Atrial fibrillation (AF) recurrence after catheter ablation is associated with worse outcomes and quality of life. Left atrial (LA) structural remodeling provides the essential substrate for AF perpetuation. Baseline extent and the progression of LA fibrosis after ablation are strong predictors of postprocedural AF recurrence. Dronedarone is an antiarrhythmic drug proven to efficiently maintain sinus rhythm.
Objective
We sought to investigate the effect of the antiarrhythmic drug Dronedarone in decreasing LA fibrosis progression and AF recurrence after ablation of AF patients.
Methods
EDORA (NCT04704050) is a multicenter, prospective, randomized controlled clinical trial. Patients with persistent or paroxysmal AF undergoing AF ablation will be randomized into Dronedarone versus placebo/standard of care. The co-primary outcomes are the recurrence of atrial arrhythmias (AA) within 13 months of follow-up after ablation and the progression of left atrial fibrosis postablation. All patients will receive a late-gadolinium enhancement magnetic resonance imaging at baseline, 3- and 12-month follow-up for the quantification of LA fibrosis and ablation-related scarring. AA recurrence and burden will be assessed using a 30-day ECG patch every 3 months with daily ECG recordings in between. Quality of life improvement is assessed using the AFEQT and AFSS questionnaires.
Conclusion
EDORA will be the first trial to assess the progression of LA structural remodeling after ablation and its association with Dronedarone treatment and ablation success in a randomized controlled fashion. The trial will provide insight into the pathophysiology of AF recurrence after ablation and may provide potential therapeutic targets to optimize procedural outcomes.

© 2021 The Authors. Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Marrouche NF, Dagher L, Wazni O, Akoum N, ... Hua H, EDORA Investigators
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664772
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Impact:
Abstract

Catheter ablation of ventricular tachycardia in patients with postinfarction left ventricular aneurysm.

Amin M, Farwati M, Hilaire E, Siontis KC, ... Asirvatham SJ, Killu AM
Background
While ventricular tachycardia (VT) in the setting of postmyocardial infarction left ventricular aneurysms (LVA) is not uncommonly encountered, there is a scarcity of data regarding the safety, efficacy, and outcomes of ablation of VT in this subset of patients.
Methods
Our study included consecutive patients aged 18 years or older with postmyocardial infarction LVA who presented to Mayo Clinic for catheter ablation of VT between 2002 and 2018.
Results
Of 34 patients, the mean age was 70.4 ± 9.1 years; 91% were male. Mean LVEF was 29 ± 9.7% and left ventricular end-diastolic dimension was 64.9 ± 6.6 mm. The site of the LVA was apical in 21 patients (62%). Fifteen patients (44%) presented with electrical storm or incessant VT. Nine patients (26%) had a history of intracardiac thrombus. All except for one patient had at least one VT originating from the aneurysm. The mean number of VTs was 2.9 ± 1.7. All patients underwent ablation at the site of the aneurysm. Ablation outside the aneurysm was performed in 13 patients (38%). Low-voltage fractionated potentials and/or late potentials at the aneurysmal site were present in all cases. Complete elimination of all VTs was achieved in 18 (53%), while the elimination of the clinical VT with continued inducibility of nonclinical VTs was achieved in a further 11 patients (32%). Two patients developed cardiac tamponade requiring pericardiocentesis. During a mean follow-up period of 2.3 ± 2.4 years, 11 patients (32%) experienced VT recurrence. Freedom from all-cause mortality at 1-year follow-up was 94%.
Conclusion
Radiofrequency catheter ablation targeting the aneurysmal site is a feasible and reasonably effective management strategy for clinical VTs in patients with postinfarction LVA.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Amin M, Farwati M, Hilaire E, Siontis KC, ... Asirvatham SJ, Killu AM
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664765
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Impact:
Abstract

His-Purkinje conduction system pacing: A systematic review and network meta-analysis in bradycardia and conduction disorders.

Qu Q, Sun JY, Zhang ZY, Kan JY, ... Li F, Wang RX
Background
His-Purkinje conduction system pacing (HPCSP) has emerged as an effective alternative to overcome the limitations of right ventricular pacing (RVP) via physiological left ventricular activation, but there remains a paucity of comparative information for His bundle pacing (HBP) and left bundle branch pacing (LBBP).
Methods
A Bayesian random-effects network analysis was conducted to compare the relative effects of HBP, LBBP, and RVP in patients with bradycardia and conduction disorders. PubMed, Embase, Cochrane Library, and Web of Science were systematically searched from database inception until September 21, 2021.
Results
Twenty-eight studies involving 4160 patients were included in this meta-analysis. LBBP significantly improved success rate, pacing threshold, pacing impedance, and R-wave amplitude compared with HBP. LBBP also demonstrated a nonsignificant trend towards superior outcomes of lead complications, heart failure hospitalization, atrial fibrillation, and all-cause death. However, HBP was associated with significantly shorter paced QRS duration relative to LBBP. Despite higher success rates, shorter procedure/fluoroscopy duration, and fewer lead complications, patients receiving RVP were more likely to experience reduced left ventricular ejection fraction, longer paced QRS duration, and higher rates of heart failure hospitalization than those receiving HPCSP. No statistical differences were observed in the remaining outcome measures.
Conclusions
This network meta-analysis demonstrates the efficacy and safety of HPCSP for the treatment of bradycardia and conduction disorders, with differences in pacing parameters, electrophysiology characteristics, and clinical outcomes between HBP and LBBP. Larger-scale, long-term comparative studies are warranted for further verification.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Qu Q, Sun JY, Zhang ZY, Kan JY, ... Li F, Wang RX
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664764
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Impact:
Abstract

Characterization of the electrophysiological substrate in patients with Barlow\'s disease.

Vergara P, Scarfò I, Esposito A, Colantoni C, ... Della Bella P, La Canna G
Background
Myxomatous mitral valve prolapse (MVP) and mitral-annular disjunction (Barlow disease) are at-risk for ventricular arrhythmias (VA). Fibrosis involving the papillary muscles and/or the infero-basal left ventricular (LV) wall was reported at autopsy in sudden cardiac death (SCD) patients with MVP.
Objectives
We investigated the electrophysiological substrate subtending VA in MVP patients with Barlow disease phenotype.
Methods
Twenty-three patients with VA were enrolled, including five with syncope and four with a history of SCD. Unipolar (Uni < 8.3 mV) and bipolar (Bi < 1.5 mV) low-voltage areas were analyzed with electro-anatomical mapping (EAM), and VA inducibility was evaluated with programmed ventricular stimulation (PES). Electrophysiological parameters were correlated with VA patterns, electrocardiogram (ECG) inferior negative T wave (nTW), and late gadolinium enhancement (LGE) assessed by cardiac magnetic resonance.
Results
Premature ventricular complex (PVC) burden was 12 061.9 ± 12 994.6/24 h with a papillary-muscle type (PM-PVC) in 18 patients (68%). Twelve-lead ECG showed nTW in 12 patients (43.5%). A large Uni less than 8.3 mV area (62.4 ± 45.5 cm2 ) was detected in the basal infero-lateral LV region in 12 (73%) patients, and in the papillary muscles (2.2 ± 2.9 cm2 ) in 5 (30%) of 15 patients undergoing EAM. A concomitant Bi less than 1.5 mV area (5.0 ± 1.0 cm2 ) was identified in two patients. A history of SCD, and the presence of nTW, and LGE were associated with a greater Uni less than 8.3 mV extension: (32.8 ± 3.1 cm2 vs. 9.2 ± 8.7 cm2 ), nTW (20.1 ± 11.0 vs. 4.1 ± 3.8 cm2 ), and LGE (19.2 ± 11.7 cm2 vs. 1.0 ± 2.0 cm2 , p = .013), respectively. All patients with PM-PVC had a Uni less than 8.3 mV area. Sustained VA (ventricular tachycardia 2 and VF 2) were induced by PES only in four patients (one with resuscitated SCD).
Conclusions
Low unipolar low voltage areas can be identified with EAM in the basal inferolateral LV region and in the papillary muscles as a potential electrophysiological substrate for VA and SCD in patients with MVP and Barlow disease phenotype.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Vergara P, Scarfò I, Esposito A, Colantoni C, ... Della Bella P, La Canna G
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664762
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Impact:
Abstract

Electrocardiography of cardiac resynchronization therapy: Pitfalls and practical tips.

Manolis AS, Manolis AA, Manolis TA, Melita H
Cardiac resynchronization therapy (CRT) has been established as an effective mode of therapy in patients with heart failure and concurrent cardiac dyssynchrony, principally in the form of left bundle branch block (LBBB). The widespread use of CRT has ushered in a new landscape in 12-lead electrocardiography (ECG). ECG readings in these patients are most important to guide troubleshooting and also appropriate device programming, as well as discerning and managing nonresponders. A set of four ECG recordings need to accompany each patient with a CRT device, including a baseline ECG and recordings from monochamber (right and left ventricular) and biventricular pacing, which can be compared against a new recording to facilitate the evaluation of proper versus problematic biventricular pacing. Precordial ECG leads V1/2 acquired at the fourth intercostal space and limb leads, I and III, together with a quick assessment of perpendicular leads I and aVF to determine the quadrant of the QRS axis in the hexaxial diagram, may provide the framework for proper ECG interpretation in these patients. This important issue of 12-lead ECG in CRT patients is herein reviewed, pitfalls are pointed out and practical tips are provided for ECG reading to help recognize and manage problems with CRT device function. Furthermore, several pertinent ECG recordings and tabulated data are provided, and an algorithm is suggested that integrates prior algorithms and relevant information from current literature.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Manolis AS, Manolis AA, Manolis TA, Melita H
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664758
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Impact:
Abstract

Perimitral atrial tachycardias dependent on residual nonligament of Marshall conduction.

Sato Y, Kusa S, Hachiya H, Yamao K, ... Hirano H, Sasano T
Introduction
Catheter ablation for perimitral atrial tachycardia (PMAT) that persists despite lateral mitral isthmus (LMI) ablation is challenging. The aim of this study was to identify the role of the ligament of Marshall (LOM) in PMATs that persist after LMI conduction block has been created, and evaluate the validity of ethanol infusion into the vein of Marshall (VOM) as treatment.
Methods and results
Sixteen consecutive PMATs in 13 patients that persisted despite apparent LMI conduction block, which was confirmed by ultrahigh-resolution mapping and entrainment pacing along the mitral annulus, were analyzed. PMATs were classified into two types based on the location of the endocardial breakthrough site: those utilizing the LOM (n = 13), which had a breakthrough site along with the LOM, and those not utilizing the LOM (n = 3), which had a breakthrough site at an anterior or posterior side of the LOM. Of the 16 PMATs, 5 PMATs (31%) were not suitable for ethanol infusion into the VOM because the LOM was not involved in the tachycardia circuit or because of the anatomy of the VOM. Fourteen PMATs (88%) were successfully terminated solely by breakthrough site ablation. At a mean follow-up period of 12 ± 9 months, 10 (77%) patients have remained free from atrial tachyarrhythmias.
Conclusion
In cases of PMAT following LMI ablation, epicardial conduction over the LMI can occur independently of the LOM. Ethanol infusion into the VOM in such cases would not abolish residual epicardial conduction. The anatomy of the VOM can also preclude the use of this method.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Sato Y, Kusa S, Hachiya H, Yamao K, ... Hirano H, Sasano T
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664757
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Impact:
Abstract

A reliable fossa ovalis impedance mapping for safer transseptal puncture: A new vision beyond voltage.

Pentimalli F, Cornara S, Astuti M, Bacino L, ... Errigo D, Bellone P
Introduction
Transseptal puncture (TSP) is widely used in clinical practice but is negatively affected by a nonneglectable rate of complications and X-ray exposure. To address these problems, we investigated whether or not impedance mapping could correctly identify fossa ovalis (FO) and safely guide TSP.
Methods and results
Electroanatomic mapping was performed with CARTO 3 system version 7 and a ThermoCool® SmartTouch® mapping catheter was employed. In each patient, an impedance map and a bipolar voltage map of the whole interatrial septum were collected, acquiring at least 150 points with a contact force ≥2 g and using the pattern matching filter. Thirty-five patients were enrolled. A low impedance area was clearly identified in 34 of them. In 30 patients (88%), the FO was located in the low impedance area. The map was obtained in sinus rhythm in 17 cases (50%); in 15 of these (88%), the TSP site, the patent foramen ovale, or the FO tenting area fell inside the low impedance area. The same numbers were observed when mapping during atrial fibrillation.
Conclusion
To the best of our knowledge, this is the first study that provides the reliability and reproducibility of impedance mapping in identifying FO, an affordable and feasible tool that could be potentially introduced into clinical practice.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Pentimalli F, Cornara S, Astuti M, Bacino L, ... Errigo D, Bellone P
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664750
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Impact:
Abstract

Novel approach to intracardiac defibrillator placement in patients with atriopulmonary Fontan: Ventricular defibrillation with an atrial positioned ICD lead.

Padanilam MS, Ahmed AS, Clark BA, Mozes JI, Steinberg LA
Introduction
The Fontan procedure, used to palliate univentricular physiology, eliminates direct venous access to the ventricle and complicates implantable cardioverter-defibrillator (ICD) placement.
Methods and results
We describe two patients with Fontan palliation who underwent a novel transvenous approach to ICD placement. The approach uses a transvenous bipolar lead placed in a coronary sinus branch for ventricular sensing, and a defibrillation lead placed in the right atrium for atrial sensing and ventricular defibrillation.
Conclusion
Transvenous ICD implantation is possible in some patients with an atriopulmonary Fontan. This approach avoids a redo sternotomy for epicardial leads and excludes the need for lead placement in the systemic circulation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Padanilam MS, Ahmed AS, Clark BA, Mozes JI, Steinberg LA
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664746
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Abstract

Ventricular arrhythmia ablation in the presence of mechanical valve utilization and complications of catheter ablation for ventricular arrhythmia in patients with mechanical prosthetic valves.

Rozen G, Elbaz-Greener G, Andria N, Heist EK, ... Amir O, Marai I
Background
Catheter ablation (CA) for ventricular arrhythmias (VAs) is increasingly utilized in recent years. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for VAs in patients with mechanical valve (MV) prosthesis.
Methods
We drew data from the US National Inpatient Sample database to identify cases of VA ablations, including premature ventricular contraction and ventricular tachycardia, in patients with MVs, between 2003 and 2015. Sociodemographic and clinical data were collected and the incidence of catheter ablation complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity-matched cohort of patients without prior valve surgery.
Results
The study population included a weighted total of 647 CA cases in patients with prior MVs. The annual number of ablations almost doubled, from 34 ablations on average during the \"early years\" (2003-2008) to 64 on average during the \"late years\" (2009-2015) of the study (p = .001). Length of stay at the hospital did not differ significantly between patients with MVs and 649 matched patients without prior MVs (5.4 ± 0.4, 4.7 ± 0.3 days, respectively, p = .12). The data revealed a trend toward a higher incidence of complications (12.6% vs. 7.5% respectively, p = .14) and mortality (3.7% vs. 0.7%, respectively, p = .087) among patients with MVs compared to the matched control group, not reaching statistical significance.
Conclusion
The data show increased utilization of VA ablations in patients with MVs and a trend toward a higher incidence of in-hospital mortality and complications compared to the propensity-matched control group without MVs.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print
Rozen G, Elbaz-Greener G, Andria N, Heist EK, ... Amir O, Marai I
J Cardiovasc Electrophysiol: 18 Oct 2021; epub ahead of print | PMID: 34664743
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Abstract

Cardioversion of recent-onset atrial fibrillation using intravenous antiarrhythmics: A European perspective.

Lévy S
Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent-onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real-life use.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Oct 2021; epub ahead of print
Lévy S
J Cardiovasc Electrophysiol: 17 Oct 2021; epub ahead of print | PMID: 34662471
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Abstract

HPSD ablation for AF high-power short-duration RF ablation for atrial fibrillation: A review.

Winkle RA
This manuscript reviews the literature for all in silico, ex vivo, in vitro, in vivo and clinical studies of high-power short-duration (HPSD) radiofrequency (RF) ablations. It reviews the biophysics of RF energy delivery applicable to HPSD and the use of surrogate endpoints to guide the duration of HPSD ablations. In silico modeling shows that a variety of settings in power, contact force and RF duration can result in the same surrogate endpoint value of ablation index and several HPSD combinations produce lesion volumes similar to a low-power long-duration (LPLD) RF application. HPSD lesions are broader with more endocardial effect and are slightly shallower but still transmural. The first 10 s of RF application is most important for lesion formation with diminishing effect beyond 20 s. The ideal contact force is 10-20 g with only a small effect beyond 30 g. In vitro and in vivo models confirm that HPSD makes transmural lesions that are often broader and shallower, and with proper settings, result in fewer steam pops than LPLD. One randomized trial shows better outcomes with HPSD and validates lesion size index as a surrogate endpoint. Clinical studies of HPSD using comparator groups of LPLD ablations uniformly show shorter procedure times and shorter total RF energy delivery for HPSD. HPSD generally has a higher first pass vein isolation rate and a lower acute vein reconnection rate than LPLD. Although not dramatically different from LPLD, long-term freedom from atrial fibrillation and complication rates seem slightly better with HPSD.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Sep 2021; 32:2813-2823
Winkle RA
J Cardiovasc Electrophysiol: 29 Sep 2021; 32:2813-2823 | PMID: 33382506
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Abstract

Efficacy and tolerability of quinidine as salvage therapy for monomorphic ventricular tachycardia in patients with structural heart disease.

Deshmukh A, Larson J, Ghannam M, Saeed M, ... Bogun F, Liang JJ
Introduction
Quinidine is an effective therapy for a subset of polymorphic ventricular tachycardia and ventricular fibrillation (VF) syndromes; however, the efficacy of quinidine in scar-related monomorphic ventricular tachycardia (MMVT) is unclear.
Methods and results
Between 2009 and 2020 a single VT referral center, a total of 23 patients with MMVT and structural heart disease (age 66.7 ± 10.9, 20 males, 15 with ischemic cardiomyopathy, mean LVEF 22.2 ± 12.3%, 9 with left ventricular assist device [LVAD]) were treated with quinidine (14 quinidine gluconate; 996 ± 321 mg, 8 quinidine sulfate; 1062 ± 588 mg). Quinidine was used in combination with other antiarrhythmics (AAD) in 19 (13 also on amiodarone). All patients previously failed >1 AAD (amiodarone 100%, mexiletine 73%, sotalol 32%, other 32%) and eight had prior ablations (median of 1.5). Quinidine was initiated in the setting of VT storm despite AADs (6), inability to tolerate other AADs (4), or recurrent VT(12). Ventricular arrhythmias recurred despite quinidine in 13 (59%) patients at a median of 26 (4-240) days after quinidine initiation. In patients with recurrent MMVT, VT cycle length increased from 359 to 434 ms (p = .02). Six (27.3%) patients remained on quinidine at 1 year with recurrence of ventricular arrhythmias in all. The following adverse effects were seen: gastrointestinal side effects (6), QT prolongation (2), rash (1), thrombocytopenia (1), neurologic side effects (1). One patient discontinued due to cost.
Conclusion
Quinidine therapy has limited tolerability and long-term efficacy when used in the management of amiodarone-refractory scar-related MMVT.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Sep 2021; epub ahead of print
Deshmukh A, Larson J, Ghannam M, Saeed M, ... Bogun F, Liang JJ
J Cardiovasc Electrophysiol: 28 Sep 2021; epub ahead of print | PMID: 34586686
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Abstract

Cryofreezing for slow-pathway modification in patients with slow-fast AVNRT: Efficacy, safety, and electroanatomical relation between sites of transient AV block and sites of successful cryoablation.

Fukuda R, Nakahara S, Wakamatsu Y, Hori Y, ... Ishikawa T, Taguchi I
Introduction
Cryoablation has emerged as an alternative to radiofrequency ablation for treating atrioventricular nodal reentrant tachycardia (AVNRT). The aim of this prospective study was to evaluate the efficacy and safety of cryoapplication at sites within the mid/high septal region of Koch\'s triangle and the relation between sites of transient AV block (AVB) and sites of successful cryoablation.
Methods and results
Included were 45 consecutive patients undergoing slow-fast AVNRT cryoablation. Initial delivery of cryoenergy was to the mid-septal to high septal region of Koch\'s triangle. Transient AVB occurred during cryoenergy delivery in 62% (28/45) of patients. Median distance between sites at which cryofreezing successfully eliminated slow pathway conduction and sites of AVB was 4.0 (3.25-5.0) mm. Sites of successful cryoablation tended to be to the left and inferior to the AVB sites. The atrial/ventricular electrogram ratio was significantly lower at sites of successful cryoablation than at AVB sites (0.25 [0.17-0.56] vs. 0.80 [0.36-1.25], p < .001). Delayed discrete or fractionated atrial electrograms were recorded more frequently at sites of successful cryoablation than at AVB sites (78% vs. 20%, p < .001). No persistent AV conduction disturbance occurred, and 96% (43/45) of patients showed absence of recurrence at a median follow-up time of 25.0 months.
Conclusion
Cryoablation of slow-fast AVNRT and targeting the mid/high septal region of Koch\'s triangle was highly successful. AVB frequently emerged near the site at which the slow pathway was eliminated but always resolved by regulating the energy delivery under careful monitoring, and it may be distinguishable by its local electrogram features.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 27 Sep 2021; epub ahead of print
Fukuda R, Nakahara S, Wakamatsu Y, Hori Y, ... Ishikawa T, Taguchi I
J Cardiovasc Electrophysiol: 27 Sep 2021; epub ahead of print | PMID: 34582058
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Abstract

Characteristics and optimal ablation settings of a novel, contact-force sensing and local impedance-enabled catheter in an ex vivo perfused swine ventricle model.

Tsutsui K, Kawano D, Mori H, Kato R, ... Muramatsu T, Matsumoto K
Background
Local impedance (LI) has emerged as a new technology that informs on electrical catheter-tissue coupling during radiofrequency (RF) ablation. Recently, IntellaNav StablePoint, a novel LI-enabled catheter that equips contact force (CF) sensing, has been introduced. Although StablePoint and its predecessor IntellaNav MiFi OI share the common technology that reports LI, distinct mechanics for LI sensing between the two products raise a concern that the LI-RF lesion formation relationship may differ.
Methods
In an ex vivo swine cardiac tissue model, we investigated the initial level and range of a reduction in LI during a 60-s RF ablation and the resultant lesion characteristics at nine combinations of three energy power (30, 40, and 50 W) and CF (10, 30, and 50 g) steps. Correlations and interactions between CF, LI, wattage, and formed lesions were analyzed. Incidence of achieving LI drop plateau and that of a steam pop were also determined.
Results
Positive correlations existed between CF and initial LI, CF and absolute/relative LI drop, CF and lesion volume, and LI drop and lesion volume. At the same LI drop, wattage-dependent gain in lesion volume was observed. Steam pops occurred in all CF steps and the prevalence was highest at 50 W. LI drop predicted a steam pop with a cutoff value at 89Ω.
Conclusion
In StablePoint, wattage crucially affects LI drop and lesion volume. Because 30 W ablation may by underpowered for intramural lesion formation and 50 W often resulted in a steam pop, 40 W appears to achieve the balance between the safety and efficacy.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 Sep 2021; epub ahead of print
Tsutsui K, Kawano D, Mori H, Kato R, ... Muramatsu T, Matsumoto K
J Cardiovasc Electrophysiol: 23 Sep 2021; epub ahead of print | PMID: 34559441
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Abstract

The surgical technique of the convergent procedure.

Yammine M, Puskas J, El Moheb M, Lattouf O
The convergent procedure is a newly developed hybrid ablation procedure that involves extensive epicardial ablation of the posterior left atrial wall followed by endocardial mapping and addition of pulmonary vein isolation. It is a team-based approach that provides a promising option for patients with persistent and permanent atrial fibrillation. In this manuscript, we present a detailed description of the surgical component of this procedure and include potential pitfalls based on our experience in performing it.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 Sep 2021; epub ahead of print
Yammine M, Puskas J, El Moheb M, Lattouf O
J Cardiovasc Electrophysiol: 23 Sep 2021; epub ahead of print | PMID: 34559431
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Abstract

Use of a novel 4D intracardiac echocardiography catheter to guide interventional electrophysiology procedures.

Kaplan RM, Narang A, Gay H, Gao X, ... Lin A, Knight BP
Introduction
Standard two-dimensional (2D), phased-array intracardiac echocardiography (ICE) is routinely used to guide interventional electrophysiology (EP) procedures. A novel four-dimensional (4D) ICE catheter (VeriSight Pro, Philips) can obtain 2D and three-dimensional (3D) volumetric images and cine-videos in real-time (4D). The purpose of this study was to determine the early feasibility and safety of this 4D ICE catheter during EP procedures.
Methods
The 4D ICE catheter was placed from the femoral vein in ten patients into various cardiac chambers to guide EP procedures requiring transseptal catheterization, including ablation for atrial fibrillation and left atrial appendage closure. 2D- and 3D-ICE images were acquired in real-time by the electrophysiologist. A dedicated imaging expert performed digital steering to optimize and postprocess 4D images.
Results
Eight patients underwent pulmonary vein isolation (cryoballoon in seven patients, pulsed field ablation in one, additional radiofrequency left atrial ablation in one). Two patients underwent left atrial appendage closure. High quality images of cardiac structures, transseptal catheterization equipment, guide sheaths, ablation tools, and closure devices were acquired with the ICE catheter tip positioned in the right atrium, left atrium, pulmonary vein, coronary sinus, right ventricle, and pulmonary artery. There were no complications.
Conclusion
This is the first experience of a novel deflectable 4D ICE catheter used to guide EP procedures. 4D ICE imaging is safe and allows for acquisition of high-quality 2D and 3D images in real-time. Further use of 4D ICE will be needed to determine its added value for each EP procedure type.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 22 Sep 2021; epub ahead of print
Kaplan RM, Narang A, Gay H, Gao X, ... Lin A, Knight BP
J Cardiovasc Electrophysiol: 22 Sep 2021; epub ahead of print | PMID: 34554627
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This program is still in alpha version.