Journal: J Cardiovasc Electrophysiol

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Abstract

Closing gigantic left atrial appendage using a LAmbre Closure System: first implant experience in North America.

Inohara T, Tsang MY, Lee C, Saw J

Despite maturing experience and growing procedural familiarity, there remain challenges in percutaneous left atrial appendage (LAA) closure due to anatomical complexities. We report a complex and extremely large LAA that was successfully closed percutaneously using a LAmbre Closure System (Lifetech Scientific Corp., Shenzhen, China). Cardiac computed tomography angiography demonstrated a gigantic multi-lobed LAA measuring 48 by 45.3mm at the level of the ostium, that can not be occluded by the currently approved LAA closure devices in Canada. A LAmbre Closure System 30/50mm (lobe/disc) was then successfully deployed under fluoroscopy and transesophageal echocardiogram guidance without procedure-related complications. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Inohara T, Tsang MY, Lee C, Saw J
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179356
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Abstract

The coronary artery calcium score correlates with left atrial low-voltage area: Sex differences.

Hojo R, Fukamizu S, Tokioka S, Inagaki D, ... Sakurada H, Hiraoka M
Introduction
In patients with coronary artery disease, a high coronary artery calcium score (CACS) correlates with atrial fibrillation (AF); however, the association between left atrial (LA) remodeling progression and coronary arteriosclerosis is unclear. This study aimed to evaluate the relationship between LA remodeling progression and the CACS.
Methods
This retrospective study enrolled 148 patients with AF (paroxysmal AF, n=94) who underwent catheter ablation. Voltage mapping for the left atrium and coronary computed tomography for CACS calculations were performed. The ratio of the LA low-voltage area (LA-LVA), defined by values <0.5 mV divided by the total LA surface without pulmonary veins, was calculated. Patients with LA-LVA (<0.5 mV) >5% and ≤5% were classified as the LVA (n=30) and non-LVA (n=118) groups, respectively. Patient characteristics and CACS values were compared between the two groups.
Results
LA volume, age, CHA DS VASc score, and percentage of female patients were significantly higher, and the estimated glomerular filtration rate was lower in the LVA group than in the non-LVA group. The CACS was significantly higher in the LVA group (248.4 vs 13.2, p=0.001). Multivariate analysis identified the LA volume index and CACS as independent predictors of LA-LVA (<0.5 mV) >5%. The areas under the receiver operating characteristic curves for predicting LA-LVA (<0.5 mV) >5% with CACS were 0.695 in the entire population, 0.782 in men, and 0.587 in women.
Conclusion
Progression of LA remodeling and coronary artery calcification may occur in parallel. A high CACS may indicate advanced LA remodeling, especially in men. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Nov 2020; epub ahead of print
Hojo R, Fukamizu S, Tokioka S, Inagaki D, ... Sakurada H, Hiraoka M
J Cardiovasc Electrophysiol: 17 Nov 2020; epub ahead of print | PMID: 33206418
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Abstract

Electrophysiological Identification of Superior Vena Cava: Novel Insight into Slow Conduction or Conduction Block.

Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, ... Nishino M, Tanouchi J
Introduction
It has not been clarified how to identify the electrophysiological junction between right atrium (RA) and superior vena cava (SVC). The aim of this study was to identify the electrophysiological RA-SVC junction according to slow conduction or conduction bock and to examine the electrophysiological SVC isolation procedure.
Methods
Seventy-three consecutive atrial fibrillation patients who underwent SVC mapping using a CARTO 3 system were enrolled in this study. Slow conduction or conduction block between the RA and SVC was identified by adjusting the lower threshold criteria of the early meets late function and was described as a white line. The SVC isolation was performed along the white line and with pacing maneuvers to confirm direct SVC capture.
Results
Activation mapping (1296±631 points) was obtained in 66 patients (90%) in 4.6±1.8 min. Slow conduction or conduction block was observed in all patients. The threshold for detecting slow conduction or conduction block was 24±8 ms. The location of the electrophysiological RA-SVC junction was higher in the anterior portion (anterior-septal, anterior, and anterior-lateral) than in the posterior portion (posterior-septal, posterior, and posterior-lateral) (-2.3±6.2 mm vs. 7.1±6.3 mm, p<0.001). The SVC isolation at the electrophysiological RA-SVC junction was successful in all patients without any injury to the sinus node function. Asymptomatic phrenic nerve injury was observed in 3 patients (4.5%).
Conclusion
In all patients, the electrophysiological RA-SVC junction determined by slow conduction or conduction block was identified and the electrophysiological SVC isolation was performed successfully and safely. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 Nov 2020; epub ahead of print
Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, ... Nishino M, Tanouchi J
J Cardiovasc Electrophysiol: 18 Nov 2020; epub ahead of print | PMID: 33210777
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Abstract

The Impact of the COVID-19 Pandemic on Cardiac Electrophysiology Training: A Survey Study.

Singla VK, Jain S, Ganeshan R, Rosenfeld LE, Enriquez AD
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has resulted in a significant decrease in volume of electrophysiology (EP) procedures. There has been concern that trainees may not achieve the procedural numbers required to graduate as independent electrophysiologists within the usual timeline. We sought to determine the impact of the COVID-19 pandemic on the percentage of clinical cardiac EP (CCEP) fellows in jeopardy of not meeting procedural volume requirements and overall sentiments regarding preparedness of fellows for independent practice.
Methods
We surveyed CCEP fellows and program directors about baseline procedural volumes, curriculum changes due to the pandemic, and attitudes about preparedness for board examinations and independent practice.
Results
Ninety-nine fellows and 27 program directors responded to the survey. Ninety-eight percent of responding fellows reported a decrease in procedural volume as a result of the pandemic. Program directors reported an overall decrease in annual number of ablations and device procedures performed by each fellow during the 2019-2020 academic year compared to the preceding year. Despite this, a minority of fellows and program directors reported concerns about meeting Accreditation Council for Graduate Medical Education procedural requirements for devices (9% and 4%, respectively) and ablation (19% and 9%) or preparedness for independent practice after a 2-year fellowship.
Conclusions
The COVID-19 pandemic has resulted in a decrease in procedural volume for CCEP trainees, but the majority of fellows and program directors do not anticipate major barriers to timely graduation. This may change with COVID-19 resurgence and further interruptions in training.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 03 Nov 2020; epub ahead of print
Singla VK, Jain S, Ganeshan R, Rosenfeld LE, Enriquez AD
J Cardiovasc Electrophysiol: 03 Nov 2020; epub ahead of print | PMID: 33146938
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Abstract

Endocardial versus epicardial left atrial appendage exclusion for stroke prevention in patients with atrial fibrillation: Midterm follow-up.

Litwinowicz R, Burysz M, Mazur P, Kapelak B, ... Malec-Litwinowicz M, Bartus K
Background
Left atrial appendage closure (LAAC) became an alternative method for stroke prevention in patients with non-valvular atrial fibrillation (AF) intolerant to long term oral anticoagulation therapy. This study aimed to compare endocardial (Amulet and LAmbere occluders) and epicardial (Lariat) LAAC techniques.
Methods
A retrospective, observational case-control study included 223 consecutive CHA DS -VAS score-matched patients with AF who underwent LAAC in two centers.
Results
There were 55 matched cases with the mean CHA2DS2-VASs score 4.4 ± 1.22 (p = 1). Overall follow-up was 308.2 patient-years. The Endocardial group patients were older and more often females with congestive heart failure and peripheral vascular disease. The epicardial group more frequently had a stroke/transient ischemic attack history. There were no differences in hypertension, diabetes mellitus, and indications for procedure between both groups. The mean HAS-BLED score was significantly higher in the endocardial group than in the epicardial group (4.3 ± 0.9 vs. 3.7 ± 1.3, p = .011). There were no differences in annual rates of thromboembolic events (2.6% vs 0.5%) and annual stroke (0.87% vs. 0%) between the endocardial and epicardial groups.
Conclusion
Endocardial and Epicardial LAAC techniques show comparable implantation outcomes and safety profile and stroke prevention in patients with AF. Future randomized studies are needed to corroborate these initial results and assess long term mortality.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 03 Nov 2020; epub ahead of print
Litwinowicz R, Burysz M, Mazur P, Kapelak B, ... Malec-Litwinowicz M, Bartus K
J Cardiovasc Electrophysiol: 03 Nov 2020; epub ahead of print | PMID: 33146462
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Abstract

Evaluation of image quality of wideband single-shot late gadolinium-enhancement MRI in patients with a cardiac implantable electronic device.

Schwartz SM, Pathrose A, Serhal AM, Ragin AB, ... Avery RJ, Kim D
Introduction
While wideband segmented, breath-hold late gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) has been shown to suppress image artifacts associated with cardiac-implanted electronic devices (CIEDs), it may produce image artifacts in patients with arrhythmia and/or dyspnea. Single-shot LGE is capable of suppressing said artifacts. We sought to compare the performance of wideband single-shot free-breathing LGE against the standard and wideband-segmented LGEs in CIED patients.
Methods and results
We retrospectively identified all 54 consecutive patients (mean age: 61 ± 15 years; 31% females) with CIED who had undergone CMR with standard segmented, wideband segmented, and/or wideband single-shot LGE sequences as part of quality assurance for determining best clinical practice at 1.5 T. Two raters independently graded the conspicuity of myocardial scar or normal myocardium and the presence of device artifact level on a 5-point Likert scale (1: worst; 3: acceptable; 5: best). Summed visual score (SVS) was calculated as the sum of conspicuity and artifact scores (SVS ≥ 6 defined as diagnostically interpretable). Median conspicuity and artifact scores were significantly better for wideband single-shot LGE (F = 24.2, p < .001) and wideband-segmented LGE (F = 20.6, p < .001) compared to standard-segmented LGE. Among evaluated myocardial segments, 72% were deemed diagnostically interpretable-defined as SVS ≥ 6-for standard-segmented LGE, 89% were deemed diagnostically interpretable for wideband-segmented LGE, and 94% segments were deemed diagnostically interpretable for wideband single-shot LGE.
Conclusions
Wideband single-shot LGE and wideband-segmented LGE produced similarly improved image quality compared to standard LGE.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 03 Nov 2020; epub ahead of print
Schwartz SM, Pathrose A, Serhal AM, Ragin AB, ... Avery RJ, Kim D
J Cardiovasc Electrophysiol: 03 Nov 2020; epub ahead of print | PMID: 33146422
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Abstract

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States.

Munir MB, Khan MZ, Darden D, Pasupula DK, ... Reeves R, Hsu JC
Objective
To determine trends in real-world utilization and in-hospital adverse events from Watchman implantation since its approval by the Food and Drug Administration in 2015.
Background
The risk of embolic stroke caused by atrial fibrillation is reduced by oral anticoagulants, but not all patients can tolerate long-term anticoagulation. Left atrial appendage occlusion with the Watchman device has emerged as an alternative therapy.
Methods
This was a retrospective cohort study utilizing data from National Inpatient Sample for calendar years 2015-2017. The outcomes assessed in this study were associated complications, in-hospital mortality, and resource utilization trends after Watchman implantation. Trends analysis were performed using analysis of variance. Multivariable adjusted logistic regression analysis was performed to determine predictors of mortality.
Results
A total of 17 700 patients underwent Watchman implantation during the study period. There was a significantly increased trend in the number of Watchman procedures performed over the study years (from 1195 in 2015 to 11 165 devices in 2017, p < .01). A significant decline in the rate of complications (from 26.4% in 2015% to 7.9% in 2017, p < .01) and inpatient mortality (from 1.3% in 2015% to 0.1% in 2017, p < .01) were noted. Predictors of in-hospital mortality included a higher CHA DS -VASc score (odds ratio [OR]: 2.61 per 1-point increase, 95% confidence interval [CI]: 1.91-3.57), chronic blood loss anemia (OR: 3.63, 95% CI: 1.37-9.61) and coagulopathy (OR: 4.90, 95% CI: 2.32-10.35).
Conclusion
In contemporary United States clinical practice, Watchman utilization has increased significantly since approval in 2015, while complications and in-patient mortality have declined.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Munir MB, Khan MZ, Darden D, Pasupula DK, ... Reeves R, Hsu JC
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155356
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Abstract

Sequential ultrahigh-density contact mapping of persistent atrial fibrillation: An efficient technique for driver identification.

Lațcu DG, Enache B, Hasni K, Wedn AM, ... Pathak A, Saoudi N
Introduction
Literature supports the existence of drivers as maintainers of atrial fibrillation (AF). Whether ultrahigh density (UHD) contact mapping may detect them is unknown.
Methods
We sequentially mapped the left atrial (LA) activation during spontaneous persistent AF and performed circumferential pulmonary vein isolation (CPVI), followed by remapping and ablation of potential drivers (rotational and focal propagation sites) with Rhythmia™ in 90 patients. The time reference was an LA appendage (LAA) electrogram (EGM). Regions with uniform color were defined as \"organized.\" Only patients (51) with no previous ablation were considered for acute results and follow-up reporting.
Results
LA maps (175 ± 28 ml, 43578 ± 18013 EGM) were acquired in 23 ± 7 min. In all post-CPVI maps potential drivers (7.3 ± 3.2/patient) were visualized: 85% with rotational propagation and continuous low voltage in the center; the remaining with focal propagation and an organized EGM at the site of earliest activation. The RF delivery time for extra-PV driver ablation was 12.2 ± 7.9 min. There was a progressive increase of AF organization: the LAA cycle length prolonged, the number of potential drivers decreased, and the organized LA surface in AF increased from 14 ± 6% to 28 ± 16% (p = .0007). Termination of AF without cardioversion was obtained in 67%. AF recurrence rate at 15 ± 7.3 months was 17.6% after the first procedure.
Conclusions
Sequential UHD contact activation mapping of persistent AF allows visualization of potential drivers. A sequential strategy of CPVI followed by ablation of potential drivers with limited RF time resulted in an increasing organization of AF and good acute and long-term results.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Lațcu DG, Enache B, Hasni K, Wedn AM, ... Pathak A, Saoudi N
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155347
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Abstract

Esophageal deviation with vacuum suction and mechanical deflection during ablation of atrial fibrillation: First in man evaluation.

Aguinaga L, Palazzo A, Bravo A, Lizarraga G, ... Daoud EG, Weiss R

Deviation of the esophagus during atrial fibrillation (AF) ablation can reduce esophageal injury. This study reports upon a novel esophageal retractor that utilizes vacuum suction and mechanical deflection to deviate the esophagus. The device was used in seven patients undergoing cryoballoon AF ablation. The esophagus was deviated 31.9 ± 4.4 mm to the right and 28.2 ± 5.9 mm to the left. Endoscopy at 4.4 ± 1.5 days postablation showed no esophageal injury. This study demonstrates the safe and effective deviation of the esophagus without a trailing edge with an esophageal retractor utilizing vacuum suction and mechanical deflection.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Aguinaga L, Palazzo A, Bravo A, Lizarraga G, ... Daoud EG, Weiss R
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155334
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Abstract

High-power short duration and low-power long duration in atrial fibrillation ablation: A meta-analysis.

Kewcharoen J, Techorueangwiwat C, Kanitsoraphan C, Leesutipornchai T, ... Bunch TJ, Navaravong L
Background
Multiple strategies have advocation for power titration and catheter movement during atrial fibrillation (AF) ablation. Comparative favoring evidence regarding the efficacy, logistics, and safety of a higher-power, shorter duration (HPSD) ablation strategy compared to a lower-power, longer duration (LPLD) ablation strategy is insubstantial. We performed a meta-analysis to compare arrhythmia-free survival, procedure times, and complication rates between the two strategies.
Methods
We searched MEDLINE, EMBASE, and Cochrane Library from inception to September 2020. We included studies comparing patients who underwent HPSD and LPLD strategies for AF ablation and reporting either of the following outcomes: Freedom from atrial tachyarrhythmia (AT) including AF and atrial flutter, procedure time, or periprocedural complications. We combined data using the random-effects model to calculate the odds ratio (OR) and weight mean difference (WMD) with a 95% confidence interval (CI).
Results
Ten studies from 2006 to 2020 involving 2274 patients were included (1393 patients underwent HPSD strategy and 881 patients underwent LPLD strategy). HPSD strategy was not associated with increased freedom from AT at 12-month follow-up (OR = 1.54, 95% CI: 0.99 to 2.40, p = .054). In the subgroup analysis of the randomized controlled trial, the HPSD strategy was associated with increased freedom from AT compared to the LPLD strategy (OR = 3.12, 95% CI: 1.18 to 8.20, p = .02). There was a significant reduction in the HPSD group for the total procedure (WMD = 49.60, 95% CI: 29.76 to 69.44) and ablation (WMD = 17.92, 95% CI: 13.63 to 22.22) times, but not for fluoroscopy time (WMD = 1.15, 95% CI: -0.67 to 2.97). HPSD was not associated with a reduction in esophageal ulcer/atrioesophageal fistula (OR = 0.35, 95% CI: 0.12 to 1.06) or pericardial effusion/cardiac tamponade rates (OR = 1.16, 95% CI: 0.35 to 3.81).
Conclusions
When compared to the LPLD strategy, the HPSD strategy does not improve recurrent AT nor reduce periprocedural complication risks. However, subgroup analysis of the randomized controlled trial showed that HPSD significantly reduces AT recurrence. An HPSD strategy can significantly reduce total procedure and ablation times.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print
Kewcharoen J, Techorueangwiwat C, Kanitsoraphan C, Leesutipornchai T, ... Bunch TJ, Navaravong L
J Cardiovasc Electrophysiol: 04 Nov 2020; epub ahead of print | PMID: 33155303
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Abstract

Atrio-ventricular synchronous pacing with a single chamber leadless pacemaker: Programming and trouble shooting for common clinical scenarios.

El-Chami MF, Bhatia NK, Merchant FM

Micra leadless pacemaker has progressed from a single chamber pacemaker that can deliver VVIR pacing to a pacing device that can provide atrio-ventricular (AV) synchrony via a unique pacing algorithm that relies on identifying mechanical atrial contraction. This novel algorithm has its own limitations and intricacies. In this paper, we review this algorithm, suggest steps for troubleshooting and programming these devices and provide clinical examples of Micra AV cases that required changes in programming for adequate tracking of atrial activity.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
El-Chami MF, Bhatia NK, Merchant FM
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179814
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Abstract

Occurrence of persistent atrial fibrillation during pacing for sinus node disease: The influence of His bundle pacing versus managed ventricular pacing.

Pastore G, Marcantoni L, Lanza D, Maines M, ... Roncon L, Zanon F
Introduction
In patients with sinus node disease (SND), the dual-chamber pacemaker (PM) is programmed in DDDR mode with an algorithm to avoid unnecessary right ventricular (RV) pacing. This pacing mode may prolong PR interval with consequently atrioventricular (AV) asynchrony which is associated with a higher risk of atrial fibrillation (AF). We evaluate whether preserving AV synchrony by setting a fixed AV delay during physiological RV pacing, that is, His bundle pacing (HBP), could reduce the risk of AF occurrence in comparison with a standard pacing mode with an algorithm to avoid unnecessary RV pacing (DDD-VPA).
Methods and results
We collected retrospective data from 313 consecutive patients who had undergone PM for SND. The first occurrence of persistent AF (>7 consecutive days) as a function of the pacing mode was evaluated. HBP and DDD-VPA were implemented in 82 and 231 patients, respectively. Persistent AF occurred in 128 (40.9%) patients over a median follow-up of 70 months (67-105). The DDD-VPA pacing mode was significantly correlated with the occurrence of persistent AF only when the basal PR was long (>180 ms). The risk of persistent AF was significantly lower in patients on HBP than in those on DDD-VPA, adjusted HR = .57 (95% CI, .36- .89, p=.014). Other independent predictors of persistent AF occurrence were: A history of AF (HR = 3.91; 95% CI, 2.48-6.19, p = .001), age, and long PR interval (HR = 2.98; 95% CI, 2.00-4.43, p=.001).
Conclusion
In SND patients and long basal PR interval, the HBP may reduce the risk of persistent AF in comparison with the DDD-VPA.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Pastore G, Marcantoni L, Lanza D, Maines M, ... Roncon L, Zanon F
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179400
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Abstract

Focal and pseudo/rotational activations in human atrial fibrillation defined with automated periodicity mapping.

Nayyar S, Ha ACT, Timmerman N, Suszko A, Ragot D, Chauhan VS
Introduction
Defining atrial fibrillation (AF) wave propagation is challenging unless local signal features are discrete or periodic. Periodic focal or rotational activity may identify AF drivers. Our objective was to characterize AF propagation at sites with periodic activation to evaluate the prevalence and relationship between focal and rotational activation.
Methods
We included 80 patients (61 ± 10 years, persistent AF 49%) from the FaST randomized trial that compared the efficacy of adjunctive focal site ablation versus pulmonary vein isolation. Patients underwent left atrial (LA) activation mapping with a 20-pole circular catheter during spontaneous or induced AF. Five-second bipolar and unipolar electrograms in AF were analyzed. Periodic sites were identified by spectral analysis of the bipolar electrogram. Activation maps of periodic sites were constructed using an automated, validated tracking algorithm, and classified into three patterns: focal sites (FS), rotation (RO), or pseudo-rotation (pRO).
Results
The most common propagation pattern at periodic sites was FS for 5-s in all patients (4.9 ± 1.9 per patient). RO and pRO were observed in two and seven patients, respectively, but were all transient (3-5 cycles). Activation from a FS evolved into transient RO/pRO in five patients. No patient had autonomous RO/pRO activations. Patients with RO/pRO had greater LA surface area with periodicity (78 ± 7 vs. 63 ± 16%, p = .0002) and shorter LA periodicity CL (166 ± 10 vs. 190±28 ms, p = .0001) than the rest.
Conclusion
Using automated, regional AF periodicity mapping, FS is more prevalent and temporally stable than RO/pRO. Most RO/pRO evolve from neighboring FS. These findings and their implications for AF maintenance require verification with global, panoramic mapping.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Nayyar S, Ha ACT, Timmerman N, Suszko A, Ragot D, Chauhan VS
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179399
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Abstract

Acute coronary artery occlusion and ischemia-related ventricular tachycardia during catheter ablation in the right ventricular outflow tract.

Nakatani Y, Vlachos K, Ramirez FD, Nakashima T, ... Sacher F, Romain T

Coronary artery injury is a rare complication of catheter ablation in the right ventricular outflow tract (RVOT). Furthermore, acute myocardial ischemia usually causes polymorphic ventricular tachycardia (VT) or ventricular fibrillation. We herein describe a case in which catheter ablation for VT originating from the RVOT provoked ischemia-related VTs due to acute occlusion of the left anterior descending artery.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Nakatani Y, Vlachos K, Ramirez FD, Nakashima T, ... Sacher F, Romain T
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179375
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Abstract

An irregular narrow complex tachycardia.

Zhang X, Yang R, Di Biase L

A 53 year-old gentleman with hypertension presented to the emergence room with sudden chest pain, associated with shortness of breath and dizziness. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print
Zhang X, Yang R, Di Biase L
J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print | PMID: 33205527
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Abstract

Pause-dependent mitral isthmus conduction block during ablation of the mitral isthmus: What is the mechanism?

Kamakura T, Chauvel R, Duchateau J, Derval N, Pambrun T

Mitral isthmus (MI) ablation is commonly performed as an adjunct therapy to pulmonary isolation during the treatment for persistent atrial fibrillation. Confirmation of complete MI block is essential because an incomplete MI block may result in iatrogenic atrial tachycardia. However, there are several pitfalls in the diagnosis of an MI line block. We herein report a case of transient pause-dependent MI block during MI ablation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Nov 2020; epub ahead of print
Kamakura T, Chauvel R, Duchateau J, Derval N, Pambrun T
J Cardiovasc Electrophysiol: 17 Nov 2020; epub ahead of print | PMID: 33206428
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Abstract

Incidence of pacing-induced cardiomyopathy in pacemaker-dependent patients is lower with leadless pacemakers compared to transvenous pacemakers.

Sanchez R, Nadkarni A, Buck B, Daoud G, ... Daoud EG, Afzal MR
Introduction
Frequent right AQ4ventricular pacing (≥40%) with a transvenous pacemaker (TVP) is associated with the risk of pacing-induced cardiomyopathy (PICM). Leadless pacemakers (LPs) have distinct physical and mechanical differences from TVP. The risk of PICM with LP is not known. To identify incidence, predictors, and long-term outcomes of PICM in LP and TVP patients.
Methods
The study comprised all pacemaker-dependent patients with LP or TVP who had left ventricular ejection fraction (LVEF) of ≥50 from 2014 to 2019. The incidence of PICM (≥10% LVEF drop) was assessed with an echocardiogram. Predictors for PICM were identified using multivariate analysis. Long-term outcomes after cardiac resynchronization (CRT) were assessed in both groups.
Results
A total of 131 patients with TVP and 67 with LP comprised the study. All patients in the TVP group and the majority in the LP group underwent atrioventricular node ablation. The mean follow-up duration in TVP and LP groups was 592 ± 549 and 817 ± 600 days, respectively. A total of 18 (13.7%) patients in TVP and 2 (3%) in LP developed PICM after a median duration of 254 (interquartile range: 470) days. The incidence of PICM was significantly higher with TVP compared with LP (p = .02). TVP as pacing modality was a positive (odds ratio [OR]: 1.07) while age was negative (OR: 0.94) predictor for PICM on multivariable analysis. Both patients in LP and all except two in the TVP group responded to CRT.
Conclusion
Incidence of PICM is significantly lower with LP compared with TVP in pacemaker-dependent patients. Age and TVP as pacing modality were predictors for PICM.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print
Sanchez R, Nadkarni A, Buck B, Daoud G, ... Daoud EG, Afzal MR
J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print | PMID: 33205561
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Abstract

Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation.

Nakamura K, Sasaki T, Take Y, Minami K, ... Funabashi N, Naito S
Introduction
The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific).
Methods and results
Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537).
Conclusions
Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 02 Nov 2020; epub ahead of print
Nakamura K, Sasaki T, Take Y, Minami K, ... Funabashi N, Naito S
J Cardiovasc Electrophysiol: 02 Nov 2020; epub ahead of print | PMID: 33141496
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Impact:
Abstract

High-density mapping validation of antral pulmonary vein isolation and posterior wall isolation created with a new cryoballoon ablation system: The first reported case.

Moltrasio M, Kochi AN, Fassini G, Riva S, Tundo F, Tondo C

Cryoballoon ablation is a recognized and widespread method for pulmonary vein isolation. For many years the impossibility of using it to create additional lines was considered a drawback of this approach. However, recently, the technique was adapted to allow the creation of rooflines, and potentially also inferior lines. In this article, we present the first reported case of a patient submitted to pulmonary vein isolation plus posterior wall isolation using the novel Boston POLAR X™ cryoballoon exclusively. To confirm the quality of the lesions, the patient underwent pre and postablation high-density mapping.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 Sep 2020; epub ahead of print
Moltrasio M, Kochi AN, Fassini G, Riva S, Tundo F, Tondo C
J Cardiovasc Electrophysiol: 08 Sep 2020; epub ahead of print | PMID: 32905654
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Impact:
Abstract

Double ventricular tachycardias associated with an anatomical isthmus identified by a computed tomography-derived channel.

Takigawa M, Martin R, Kitamura T, Cochet H, Jais P, Sacher F

We describe a 47-year-old woman with ischemic ventricular tachycardia (VT) with repetitive implantable cardioverter-defibrillator shocks, requiring ablation. Preprocedural computed tomography (CT) demonstrated a single anatomical channel on the inferior-basal infarcted area between less than a 3-mm wall-thinning area and the mitral annulus, which suggested the circuit of two VTs observed. In addition, distribution of less than 2 mm and less than 3 mm wall-thinning area can explain the mechanism of the variation of the QRS morphology and S-QRS interval during entrainment. Ablation in this region resulted in no VT inducibility and the absence of any VTs for 2 years. CT wall thinning data may allow us to understand the mechanism and circuit of VT and aid VT ablation procedures.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Sep 2020; epub ahead of print
Takigawa M, Martin R, Kitamura T, Cochet H, Jais P, Sacher F
J Cardiovasc Electrophysiol: 04 Sep 2020; epub ahead of print | PMID: 32889746
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Impact:
Abstract

Prognostic significance of extensive versus limited induction protocol during catheter ablation of scar-related ventricular tachycardia.

Campbell T, Bennett RG, Garikapati K, Turnbull S, ... De Silva K, Kumar S
Introduction
Testing for inducible ventricular tachycardia (VT) pre- and postablation forms the cornerstone of contemporary scar-related VT ablation procedures. There is significant heterogeneity in reported VT induction protocols. We examined the utility of an extensive induction protocol (up to 4 extra-stimuli [ES] ± burst ventricular pacing) compared to the current guideline-recommended protocol (up to 3ES, defined as limited induction protocol) in patients with scar-related VT.
Methods and results
Sixty-two patients (age: 64 ± 14 years; left ventricular ejection fraction: 37 ± 13%, ischemic cardiomyopathy: 31, nonischemic cardiomyopathy: 31) with at least one inducible VT were included. An extensive testing protocol induced 11%-17% more VTs, compared to the limited induction protocol before, and after the final ablation. VT recurred in 48% of patients during a mean follow up of 566 ± 428 days. Patients who were noninducible for any VT using the limited induction protocol had worse ventricular arrhythmia (VA)-free survival (12 months, 43% vs. 82%; p = .03) and worse survival free of VA, transplantation and mortality (12 months 46% vs. 82%; p = .02), compared to patients who were noninducible for any VT using the extensive induction protocol.
Conclusions
Between 11% and 17% of inducible VTs may be missed if 4ES and burst pacing are not performed in induction protocols before and after ablation. Noninducibility for any VT after an extensive induction protocol after the final ablation portends more favorable prognostic outcomes when compared with the current guideline-recommended induction protocol of up to 3ES. This data suggests that the adoption of an extensive induction protocol is of prognostic benefit after VT ablation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 Sep 2020; epub ahead of print
Campbell T, Bennett RG, Garikapati K, Turnbull S, ... De Silva K, Kumar S
J Cardiovasc Electrophysiol: 08 Sep 2020; epub ahead of print | PMID: 32905634
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Impact:
Abstract

Maternal focal atrial tachycardia during pregnancy: A systematic review.

Wang NC, Shen C, McLaughlin TJ, Li JZ, ... Kancharla K, Saba S
Introduction
The presentation and optimal management of maternal focal atrial tachycardia (AT) during pregnancy are unknown. The objective of this study is to conduct a comprehensive summary of the existing evidence.
Methods and results
A systematic review of all reported cases of maternal focal AT during pregnancy was performed. The primary search queried PubMed using the MeSH terms \"supraventricular tachycardia\" and \"pregnancy.\" A stepwise ancillary search included article bibliographies, citations listed by the Google internet search engine, and PubMed using the MeSH terms \"atrial tachycardia\" and \"pregnancy.\" In total, 28 citations that described 32 patients were retrieved. A case from our institution was added. Detailed information was available for 30 patients. Clinical characteristics at presentation included a mean ± standard deviation of 28.3 ± 5.7 years for maternal age and 24.6 ± 7.7 weeks for gestation age. Suspected tachycardia-induced cardiomyopathy was present in 20 of 30 (67%) patients and left ventricular ejection fraction improved in 15 of 15 (100%) patients with follow-up measurements. Medication failure was common. Focal AT resolved spontaneously after delivery in eight of nine (89%) patients treated with only medications. Automaticity was suggested by discrete electrograms at sites of origin and lack of reported inducibility and termination with programmed stimulation in all patients who underwent electrophysiology studies. There were nine cases of successful catheter ablation with zero fluoroscopy since 2010.
Conclusions
Automaticity is the dominant mechanism for patients with maternal focal AT during pregnancy. Catheter ablation with zero fluoroscopy is an emerging therapy for medically refractory cases.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Sep 2020; epub ahead of print
Wang NC, Shen C, McLaughlin TJ, Li JZ, ... Kancharla K, Saba S
J Cardiovasc Electrophysiol: 07 Sep 2020; epub ahead of print | PMID: 32897619
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Impact:
Abstract

Temporal trends of catheter ablation for patients with atrial fibrillation: A Korean nationwide population-based study.

Lee E, Lee SR, Choi EK, Han KD, ... Lip GYH, Oh S
Introduction
Catheter ablation (CA) for atrial fibrillation (AF) is used as a treatment to restore and maintain sinus rhythm in patients with AF. However, limited data exist regarding the temporal trends of AF ablation in Asia. This study aimed to describe the temporal trends of CA for AF in Korean over 11 years.
Methods
The nationwide claims database in Korea was utilized. Patients underwent CA for AF were identified using combinations of diagnostic codes, claims history, and procedure codes. Comorbidities and complications were also identified, and their temporal trends were evaluated.
Results
The numbers of patients underwent CA for AF were observed to gradually increased over 11 years (452 patients in 2007 vs. 3035 patients in 2017). Mean age of the study population increased (55.4 in 2007-2010 vs. 58.9 in 2015-2017); and mean CHA DS -VASc score also increased (1.9 in 2007-2010 vs. 2.2 in 2015-2017). Risks of complications decreased during the study period but risks of all-cause deaths did not changed significantly. Older age, women, hypertension, cerebrovascular accident, chronic obstructive pulmonary disease, chronic kidney disease, general anesthesia, and small procedure volume were independent predictors of complications but, only diabetes and occurrence of any complication were associated with mortality after CA.
Conclusion
CA for AF has become an increasingly important treatment option. Although the proportion of high-risk patients increased, risks of complications decreased over time. Performing procedure without complications and prompt managements are essential to improve the outcome of the patients with AF underwent CA.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Sep 2020; epub ahead of print
Lee E, Lee SR, Choi EK, Han KD, ... Lip GYH, Oh S
J Cardiovasc Electrophysiol: 07 Sep 2020; epub ahead of print | PMID: 32897567
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Impact:
Abstract

Is the abnormal conduction zone of the left atrium a precursor to a low voltage area in patients with atrial fibrillation?

Kishima H, Mine T, Fukuhara E, Takahashi S, Ishihara M
Background
The abnormal conduction zone (ACZ) in the left atrium (LA) has attracted attention as an arrhythmia source in atrial fibrillation (AF). We investigated the hypothesis that the ACZ is related to the low voltage area (LVA) or the LA anatomical contact areas (CoAs) with other organs.
Methods and results
We studied 100 patients (49 non-paroxysmal AF, 66 males, and 67.9 ± 9.9 years) who received catheter ablation for AF. High-density LA mapping during high right atrial pacing was constructed. Isochronal activation maps were created at 5-ms interval setting, and the ACZ was identified on the activation map by locating a site with isochronal crowding of ≥3 isochrones, which are calculated as ≤27 cm/s. The LVA was defined as the following; mild ( < 1.3 mV), moderate (<1.0 mV), and severe LVA (<0.5 mV). The CoAs (ascending aorta-anterior LA, descending aorta-posterior LA, and vertebrae-posterior LA) were assessed using computed tomography. The ACZ was linearly distributed, and observed in 95 patients (95%). The ACZ was most frequently observed in the anterior wall region (77%). A longer ACZ was significantly associated with a larger LA size and a prevalence of non-PAF. The 51.2 ± 36.2% of ACZ overlapped with mild LVA, 32.9 ± 32.8% of ACZ with moderate LVA, and 14.6 ± 22.0% of ACZ with severe LVA. In contrast, only 25.6 ± 28.0% of ACZ matched with the CoAs.
Conclusion
The ACZ reflects LA electrical remodeling and may be a precursor finding of the low voltage zone and not the LA CoAs in patients with atrial fibrillation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 15 Sep 2020; epub ahead of print
Kishima H, Mine T, Fukuhara E, Takahashi S, Ishihara M
J Cardiovasc Electrophysiol: 15 Sep 2020; epub ahead of print | PMID: 32936499
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Impact:
Abstract

A simple maneuver to determine if septal accessory pathway ablation requires a left atrial approach.

Kanawati J, Roberts JD, Rowe MK, Khan H, ... Skanes AC, Klein GJ
Introduction
Septal accessory pathway (AP) ablation can be challenging due to the complex anatomy of the septal region. The decision to access the left atrium (LA) is often made after failure of ablation from the right. We sought to establish whether the difference between ventriculo-atrial (VA) time during right ventricular (RV) apical pacing versus the VA during tachycardia would help establish the successful site for ablation of septal APs.
Methods
Intracardiac electrograms of patients with orthodromic reciprocating tachycardia (ORT) using a septal AP with successful catheter ablation were reviewed. The ∆VA was the difference between the VA interval during RV apical pacing and the VA interval during ORT. The difference in the VA interval during right ventricular entrainment and ORT (StimA-VA) was also measured.
Results
The median ∆VA time was significantly less in patients with a septal AP ablated on the right side compared with patients with a septal AP ablated on the left side (12 ± 19 vs. 56 ± 10 ms, p < .001). The StimA-VA was significantly different between the two groups (22 ± 14 vs. 53 ± 9 ms, p < .001). The ∆VA and StimA-VA were always40 ms in patients with non-decremental septal APs ablated from the right side and always greater than 40 ms in those with septal APs ablated from the left.
Conclusion
ΔVA and StimA-VA values identified with RV apical pacing in the setting of ORT involving a septal AP predict when left atrial access will be necessary for successful ablation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 15 Sep 2020; epub ahead of print
Kanawati J, Roberts JD, Rowe MK, Khan H, ... Skanes AC, Klein GJ
J Cardiovasc Electrophysiol: 15 Sep 2020; epub ahead of print | PMID: 32936492
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Impact:
Abstract

Reproducibility of clinical late gadolinium enhancement magnetic resonance imaging in detecting left atrial scar after atrial fibrillation ablation.

Kamali R, Schroeder J, DiBella E, Steinberg B, ... Macleod RS, Ranjan R
Introduction
Late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (MRI) can be used to detect postablation atrial scar (PAAS) but its reproducibility and reliability in clinical scans across different magnetic flux densities and scar detection methods are unknown.
Methods
Patients (n = 45) having undergone two consecutive MRIs (3 months apart) on 3T and 1.5T scanners were studied. We compared PAAS detection reproducibility using four methods of thresholding: simple thresholding, Otsu thresholding, 3.3 standard deviations (SD) above blood pool (BP) mean intensity, and image intensity ratio (IIR). We performed a texture study by dividing the left atrial wall intensity histogram into deciles and evaluated the correlation of the same decile of the two scans as well as to a randomized distribution of intensities, quantified using Dice Similarity Coefficient (DSC).
Results
The choice of scanner did not significantly affect the reproducibility. The scar detection performed by Otsu thresholding (DSC of 71.26 ± 8.34) resulted in a better correlation of the two scans compared with the methods of 3.3 SD above BP mean intensity (DSC of 57.78 ± 21.2, p < .001) and IIR above 1.61 (DSC of 45.76 ± 29.55, p <.001). Texture analysis showed that correlation only for voxels with intensities in deciles above the 70th percentile of wall intensity histogram was better than random distribution (p < .001).
Conclusions
Our results demonstrate that clinical LGE-MRI can be reliably used for visualizing PAAS across different magnetic flux densities if the threshold is greater than 70th percentile of the wall intensity distribution. Also, atrial wall-based thresholding is better than BP-based thresholding for reproducible PAAS detection.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 14 Sep 2020; epub ahead of print
Kamali R, Schroeder J, DiBella E, Steinberg B, ... Macleod RS, Ranjan R
J Cardiovasc Electrophysiol: 14 Sep 2020; epub ahead of print | PMID: 32931635
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Impact:
Abstract

Interventional device implantation, Part I: Basic techniques to avoid complications: A hands-on approach.

Zou F, Brar V, Worley SJ
Introduction
The essence of cardiac resynchronization therapy (CRT) is biventricular (BiV) pacing, which involves implanting pacing leads in both the right ventricle (RV) and left ventricle (LV). Unlike traditional RV pacing, many hurdles lie ahead of successful LV lead implantation.
Methods and results
In this review, we first highlight the importance of optimizing the patient and the tools. Next, we describe the CRT tools developed over several decades, to facilitate successful implantation. Thereafter, we provide a streamlined step-by-step summary of the basic BiV implantation procedure. Lastly, we discuss some commonly encountered challenges during implantation and the techniques to tackle them.
Conclusion
A systematic approach to every step of the implantation process can reduce procedure time, decrease patient exposure to radiation and contrast, and minimize complications. The use of right tools and techniques can enable all implanters to become more successful with BiV implantation.

© 2020 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print
Zou F, Brar V, Worley SJ
J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print | PMID: 32945053
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Impact:
Abstract

Modified snare technique improves left ventricular lead implant success for cardiac resynchronization therapy.

Marques P, Nunes-Ferreira A, António PS, Aguiar-Ricardo I, ... Pinto FJ, de Sousa J
Background
Left ventricular (LV) lead placement is the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate of up to 10% due to complex coronary anatomies. We describe a modified snare technique for LV lead placement and evaluate its safety and efficacy in cases when standard methods fail.
Methods and results
A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was employed. Patients were evaluated every 6 months. From 2015 to 2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%). There were no differences between the modified snare and standard techniques in the rates of 30-day postimplant CRT all-cause mortality (3.2% vs. 1.7%, p = .33), 4-year all-cause mortality (15.9% vs. 15.5%, p = .49), or major acute complications (7.4% vs. 3.8%, p = .12). However, the 4-year procedural reintervention rate was lower with the modified snare technique (3.2% vs. 10.2%, p < .05), specifically LV implant failure or dislodgement rates (0% vs. 5.3%, p < .05), improving the response rate (71.8% vs. 55.1%, p < .05).
Conclusions
For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was safe and effective, with comparable mortality and complications, but significantly lower procedural reintervention and higher response rates.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print
Marques P, Nunes-Ferreira A, António PS, Aguiar-Ricardo I, ... Pinto FJ, de Sousa J
J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print | PMID: 32945049
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Impact:
Abstract

Neglected lead tip erosion: An unusual case of S-ICD inappropriate shock.

Mitacchione G, Schiavone M, Gasperetti A, Viecca M, Curnis A, Forleo GB

A 52-year-old man experienced a subcutaneous implantable cardioverter-defibrillator (S-ICD) inappropriate shock due to electrode tip decubitus. The device, implanted two years before with a three-incision technique, was extracted, and a new electrode was implanted along the contralateral parasternal line with a two-incision technique, in a one-stage procedure. One-year follow-up was eventless. Early S-ICD electrode extraction and reimplantation during the same procedure is effective and should be considered as soon as initial signs of decubitus appear to avoid inappropriate shocks. A two-incision technique should be preferred to reduce the risk of electrode tip decubitus.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print
Mitacchione G, Schiavone M, Gasperetti A, Viecca M, Curnis A, Forleo GB
J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print | PMID: 32945022
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Impact:
Abstract

Incidence and clinical impact of early recurrence of atrial tachyarrhythmia after surgical ablation for atrial fibrillation.

Choi JH, Hwang KW, Jung SM, Lee SY, ... Lee SK, Chun KJ
Background
Atrial tachyarrhythmias (ATAs) are common within the 3-month blanking period after catheter ablation of atrial fibrillation (AF). However, little evidence is available regarding the current guidelines on the blanking period after surgical AF ablation. We investigate the incidence and significance of early recurrence of atrial tachyarrhythmia (ERAT) and evaluate the optimal blanking period after surgical AF ablation.
Methods
Data from 259 patients who underwent surgical AF ablation from 2009 to 2016 were collected. ERAT was defined as documented ATA episodes lasting for 30 s. A multivariate Cox proportional hazard model was constructed to evaluate the role of ERAT as a predictor of late recurrences (LR) for AF.
Results
In total, 127 patients (49.0%) experienced their last episodes of ERAT during the first (n = 65), second (n = 14), or third (n = 48) month of the 3-month blanking period (p < .001). One year freedom from ATAs was 97.8% in patients without ERAT compared with 95.4%, 64.3%, and 8.3% in patients with ERAT in the first, second, and third months after the index procedure, respectively (p < .001). Hazard ratios of LR according to the timing of the last episode of ERAT first, second, and third months after the procedure were 2.84, 16.70, and 119.75, respectively.
Conclusions
The ERAT occurred in 49.0% of patients within the first 3 months after surgical ablation. The occurrence of ERAT within 3 months after surgical AF ablation was a significant independent predictor of LR. Hence, the currently accepted 3-month blanking period may be considered for redefining in patients with AF surgical ablation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print
Choi JH, Hwang KW, Jung SM, Lee SY, ... Lee SK, Chun KJ
J Cardiovasc Electrophysiol: 17 Sep 2020; epub ahead of print | PMID: 32945008
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Impact:
Abstract

Trends in reported industry payments to physicians practicing cardiac electrophysiology from 2013 to 2018 in the United States.

Tseng AS, Hu TY, Lee JZ, Amin M, ... Asirvatham SJ, Mulpuru SK
Introduction
The need for transparency in financial relationships in the healthcare system, has culminated in Open Payments database, managed by the Center for Medicare and Medicaid Services (CMS). Since its inception in 2013, the trend in such payments to physicians practicing cardiac electrophysiology was not examined.
Methods and results
Payment information reported to CMS from January 2013 to December 2018 was obtained from the publicly available Open Payments data set using the online query tool. The data were analyzed by an individual provider and by state. An in-depth analysis of payments in the year 2018 payments was performed. From 2014 to 2018, there was an 18% increase in the total number of payments reported from 88 877 payments in 2014 to 105 000 in 2018. Despite the increase in the total number of payments reported, the average payment steadily decreased over time, resulting in an overall reduction in the total amount of payments from 2014 to 2018 ($34.9 million to $28.2 million). Payments to the top 5% of individual recipients have also decreased over this time. In 2018, 2888 unique providers received reportable payments, a total of 105 000 payments, with a median payment amount of $1378 (interquartile range: $165-$5781). The majority of these payments were for food and beverage (82%) and travel/lodging (10%). The top five payers include Boston Scientific, Medtronic Vascular, Abbott Laboratories, Janssen Pharmaceuticals, and Biotronik.
Conclusion
Among cardiac electrophysiologists, there is increased reporting of payments in the Open Payments program over time, with a notable decrease in the payment amount.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 20 Sep 2020; epub ahead of print
Tseng AS, Hu TY, Lee JZ, Amin M, ... Asirvatham SJ, Mulpuru SK
J Cardiovasc Electrophysiol: 20 Sep 2020; epub ahead of print | PMID: 32955151
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Impact:
Abstract

Management of cardiac implantable electronic device follow-up in COVID-19 pandemic: Lessons learned during Italian lockdown.

Piro A, Magnocavallo M, Della Rocca DG, Neccia M, ... Fedele F, Lavalle C
Introduction
Remote monitoring (RM) has significantly transformed the standard of care for patients with cardiac electronic implantable devices. It provides easy access to valuable information, such as arrhythmic events, acute decompensation manifestations and device-related issues, without the need of in-person visits.
Methods
Starting March 1st, 332 patients were introduced to an RM program during the Italian lockdown to limit the risk of in-hospital exposure to severe acute respiratory syndrome-coronavirus-2. Patients were categorized into two groups based on the modality of RM delivery (home [n = 229] vs. office [n = 103] delivered). The study aimed at assessing the efficacy of the new follow-up protocol, assessed as mean RM activation time (AT), and the need for technical support. In addition, patients\' acceptance and anxiety status were quantified via the Home Monitoring Acceptance and Satisfaction Questionnaire and the Generalized Anxiety Disorder 7-item scale.
Results
AT time was less than 48 h in 93% of patients and 7% of them required further technical support. Despite a higher number of trans-telephonic technical support in the home-delivered RM group, mean AT was similar between groups (1.33 ± 0.83 days in home-delivered vs 1.28 ± 0.81 days in office-delivered patients; p = .60). A total of 28 (2.5%) urgent/emergent in-person examinations were required. A high degree of patient satisfaction was reached in both groups whereas anxiety status was higher in the office-delivered group.
Conclusions
The adoption of RM resulted in high patient satisfaction, regardless of the modality of modem delivery; nonetheless, in-office modem delivery was associated with a higher prevalence of anxiety symptoms.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 19 Sep 2020; epub ahead of print
Piro A, Magnocavallo M, Della Rocca DG, Neccia M, ... Fedele F, Lavalle C
J Cardiovasc Electrophysiol: 19 Sep 2020; epub ahead of print | PMID: 32954600
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Impact:
Abstract

Fractionation mapping software to map ganglionated plexus sites during sinus rhythm.

Aksu T, Yalin K, Gopinathannair R

Ablation of ganglionated plexuses (GPs) is a relatively new technique in patients with vasovagal syncope. Due to individual variation of GP settlement, reproducible GP detection methods are needed to during electrophysiologic study. In the present case, fractionation mapping software of Ensite system was tested to detect localization of GPs and first compared with previously validated fractionated electrograms based strategy.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 19 Sep 2020; epub ahead of print
Aksu T, Yalin K, Gopinathannair R
J Cardiovasc Electrophysiol: 19 Sep 2020; epub ahead of print | PMID: 32954554
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Impact:
Abstract

Sex-based differences in procedural complications associated with atrial fibrillation catheter ablation: A systematic review and meta-analysis.

Campbell ML, Larson J, Farid T, Westerman S, ... El-Chami MF, Merchant FM
Background
Women undergoing atrial fibrillation catheter ablation (AFCA) have higher rates of vascular complications and major bleeding. However, most studies have been underpowered to detect differences in rarer complications such as stroke/transient ischemic attack (TIA) and procedural mortality.
Methods
We performed a systematic review of databases (PubMed, World of Science, and Embase) to identify studies published since 2010 reporting AFCA complications by sex. Six complications of interest were (1) vascular/groin complications; (2) pericardial effusion/tamponade; (3) stroke/TIA; (4) permanent phrenic nerve injury; (5) major bleeding; and (6) procedural mortality. For meta-analysis, random effects models were used when heterogeneity between studies was ≥50% (vascular complications and major bleeding) and fixed effects models for other endpoints.
Results
Of 5716 citations, 19 studies met inclusion criteria, comprising 244,353 patients undergoing AFCA, of whom 33% were women. Women were older (65.3 ± 11.2 vs. 60.4 ± 13.2 years), more likely hypertensive (60.6% vs. 55.5%) and diabetic (18.3% vs. 16.5%), and had higher CHA DS -VASc scores (3.0 ± 1.8 vs. 1.4 ± 1.4) (p < .0001 for all comparisons). The rates of all six complications were significantly higher in women. However, despite statistically significant differences, the overall incidences of major complications were very low in both sexes: stroke/TIA (women 0.51% vs. men 0.39%) and procedural mortality (women 0.25% vs. men 0.19%).
Conclusion
Women experience significantly higher rates of AFCA complications. However, the incidence of major procedural complications is very low in both sexes. The higher rate of complications in women may be partially attributable to older age and a higher prevalence of comorbidities at the time of ablation. More detailed studies are needed to better define the mechanisms of increased risk in women and to identify strategies for closing the sex gap.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Campbell ML, Larson J, Farid T, Westerman S, ... El-Chami MF, Merchant FM
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966681
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Impact:
Abstract

Injectable conductive hydrogel restores conduction through ablated myocardium.

van Zyl M, Pedrotty DM, Karabulut E, Kuzmenko V, ... Gatenholm P, Kapa S
Introduction
Therapies for substrate-related arrhythmias include ablation or drugs targeted at altering conductive properties or disruption of slow zones in heterogeneous myocardium. Conductive compounds such as carbon nanotubes may provide a novel personalizable therapy for arrhythmia treatment by allowing tissue homogenization.
Methods
A nanocellulose carbon nanotube-conductive hydrogel was developed to have conduction properties similar to normal myocardium. Ex vivo perfused canine hearts were studied. Electroanatomic activation mapping of the epicardial surface was performed at baseline, after radiofrequency ablation, and after uniform needle injections of the conductive hydrogel through the injured tissue. Gross histology was used to assess distribution of conductive hydrogel in the tissue.
Results
The conductive hydrogel viscosity was optimized to decrease with increasing shear rate to allow expression through a syringe. The direct current conductivity under aqueous conduction was 4.3 × 10  S/cm. In four canine hearts, when compared with the homogeneous baseline conduction, isochronal maps demonstrated sequential myocardial activation with a shift in direction of activation to surround the edges of the ablated region. After injection of the conductive hydrogel, isochrones demonstrated conduction through the ablated tissue with activation restored through the ablated tissue. Gross specimen examination demonstrated retention of the hydrogel within the tissue.
Conclusions
This proof-of-concept study demonstrates that conductive hydrogel can be injected into acutely disrupted myocardium to restore conduction. Future experiments should focus on evaluating long-term retention and biocompatibility of the hydrogel through in vivo experimentation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
van Zyl M, Pedrotty DM, Karabulut E, Kuzmenko V, ... Gatenholm P, Kapa S
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966655
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Abstract

Phrenic nerve stimulation during right ventricular outflow tract pacing: A rare but possible complication.

Sekihara T, Miyazaki S, Ishida T, Nagao M, ... Uzui H, Tada H

Phrenic nerve stimulation (PNS) caused by a right ventricular (RV) lead is an uncommon complication of pacemaker implantations. We demonstrated a case of left PNS caused by an RV lead placed in the RV outflow tract (RVOT). The PNS was dependent on ventricular capture. This case highlighted a risk of PNS even during RVOT pacing.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Sekihara T, Miyazaki S, Ishida T, Nagao M, ... Uzui H, Tada H
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966650
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Abstract

A new clinical risk score for predicting the prevalence of low-voltage areas in patients undergoing atrial fibrillation ablation.

Matsuda Y, Masuda M, Asai M, Iida O, ... Uematsu H, Mano T
Introduction
Although the presence of left atrial low-voltage areas (LVAs) is strongly associated with the recurrence of atrial fibrillation (AF) after ablation, few methods are available to classify the prevalence of LVAs. The purpose of this study was to establish a risk score for predicting the prevalence of LVAs in patients undergoing ablation for AF.
Methods
We enrolled 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; female, 346 (34%); persistent AF, 513 (51%)). LVAs were deemed present when the voltage map after pulmonary vein isolation demonstrated low-voltage areas with a peak-to-peak bipolar voltage of <0.5 mV covering ≥5 cm of the left atrium.
Results
LVAs were present in 206 (21%) patients. The SPEED score was obtained as the total number of independent predictors as identified on multivariate analysis, namely female sex (odds ratio [OR], 3.4 [95% confidence interval {CI} 2.2-5.2], p < .01), persistent AF (OR, 1.8 [95% CI, 1.1-3.0], p = .02), age ≥ 70 years (OR, 2.3 [95% CI, 1.5-3.4], p < .01), elevated brain natriuretic peptide ≥100 pg/ml or N-terminal probrain natriuretic peptide ≥400 pg/ml (OR, 1.7 [95% CI, 1.02-2.8], p = .04), and diabetes mellitus (OR, 1.8 [95% CI, 1.1-2.8], p = .02). LVAs were more frequent in patients with a higher SPEED score, and prevalence increased with each additional SPEED score point (OR, 2.4 [95% CI, 2.0-2.8], p < .01).
Conclusion
The SPEED score accurately predicts the prevalence of LVAs in patients undergoing ablation for AF.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print
Matsuda Y, Masuda M, Asai M, Iida O, ... Uematsu H, Mano T
J Cardiovasc Electrophysiol: 22 Sep 2020; epub ahead of print | PMID: 32966648
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Abstract

Within-patient comparison of His-bundle pacing, right ventricular pacing, and right ventricular pacing avoidance algorithms in patients with PR prolongation: Acute hemodynamic study.

Keene D, Shun-Shin MJ, Arnold AD, March K, ... Francis DP, Whinnett ZI
Aims
A prolonged PR interval may adversely affect ventricular filling and, therefore, cardiac function. AV delay can be corrected using right ventricular pacing (RVP), but this induces ventricular dyssynchrony, itself harmful. Therefore, in intermittent heart block, pacing avoidance algorithms are often implemented. We tested His-bundle pacing (HBP) as an alternative.
Methods
Outpatients with a long PR interval (>200 ms) and intermittent need for ventricular pacing were recruited. We measured within-patient differences in high-precision hemodynamics between AV-optimized RVP and HBP, as well as a pacing avoidance algorithm (Managed Ventricular Pacing [MVP]).
Results
We recruited 18 patients. Mean left ventricular ejection fraction was 44.3 ± 9%. Mean intrinsic PR interval was 266 ± 42 ms and QRS duration was 123 ± 29 ms. RVP lengthened QRS duration (+54 ms, 95% CI 42-67 ms, p < .0001) while HBP delivered a shorter QRS duration than RVP (-56 ms, 95% CI -67 to -46 ms, p < .0001). HBP did not increase QRS duration (-2 ms, 95% CI -8 to 13 ms, p = .6). HBP improved acute systolic blood pressure by mean of 5.0 mmHg (95% CI 2.8-7.1 mmHg, p < .0001) compared to RVP and by 3.5 mmHg (95% CI 1.9-5.0 mmHg, p = .0002) compared to the pacing avoidance algorithm. There was no significant difference in hemodynamics between RVP and ventricular pacing avoidance (p = .055).
Conclusions
HBP provides better acute cardiac function than pacing avoidance algorithms and RVP, in patients with prolonged PR intervals. HBP allows normalization of prolonged AV delays (unlike pacing avoidance) and does not cause ventricular dyssynchrony (unlike RVP). Clinical trials may be justified to assess whether these acute improvements translate into longer term clinical benefits in patients with bradycardia indications for pacing.

© 2020 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 24 Sep 2020; epub ahead of print
Keene D, Shun-Shin MJ, Arnold AD, March K, ... Francis DP, Whinnett ZI
J Cardiovasc Electrophysiol: 24 Sep 2020; epub ahead of print | PMID: 32976636
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Impact:
Abstract

Impedance decrement indexes for avoiding steam-pop during bipolar radiofrequency ablation: An experimental study using a dual-bath preparation.

Saitoh O, Oikawa A, Sugai A, Chinushi M
Introduction
This experimental study was conducted to explore impedance monitoring for safely performing bipolar (BIP) radiofrequency (RF) ablation targeted to arrhythmia focus.
Methods and results
Using a newly designed dual-bath experimental model, contact-force-controlled (20-g) BIP ablation (50 W, 60 s) was attempted for porcine left ventricle (17.0 ± 2.7 mm thickness). BIP ablation was successfully accomplished for 60 s in 75 of the 89 RF applications (84.3%), whereas audible steam-pop occurred in the other 14 RF applications (15.7%). Receiver operating characteristic analysis demonstrated the optimal predictive values regarding the occurrence of steam-pop as follows; thinner myocardial wall (≤14.8 mm), low minimum impedance (≤89 ohm), greater total impedance decrement (TID) (≤ -25 ohm) and %TID (≤ -22.5%). Greater impedance decrement was not observed immediately preceding the occurrence of steam-pop but appeared around 15 s before. Four steam-pops happened before reaching the optimal predictive values of minimum impedance, whereas all 14 steam-pops developed 11.5 ± 9.2 and 8.1 ± 8.1 s after reaching the optimal predictive values of TID and %TID, respectively. Total lesion depth (endocardial plus epicardial) was 10.7 ± 1.2 mm on average, and was well correlated with TID and %TID. Transmural lesion through the myocardial wall was created in 22 RF applications.
Conclusion
Relatively thinner areas of the myocardium are likely to be at greater risk for steam-pop during BIP RF ablation. Lowering the RF application energy to reduce the impedance decrement may help to lessen this risk.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 26 Sep 2020; epub ahead of print
Saitoh O, Oikawa A, Sugai A, Chinushi M
J Cardiovasc Electrophysiol: 26 Sep 2020; epub ahead of print | PMID: 32981132
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Abstract

Differences between cardiac implantable electronic device envelopes evaluated in an animal model.

Ip JE, Xu L, Lerman BB
Introduction
Cardiac implantable electronic device (CIED) pocket related problems such as infection, hematoma, and device erosion cause significant morbidity and the clinical consequences are substantial. Bioabsorbable materials have been developed to assist in the prevention of these complications but there has not been any direct comparison of these adjunctive devices to reduce these complications. We sought to directly compare the TYRX absorbable antibacterial and CanGaroo extracellular matrix (ECM) envelopes in an animal model susceptible to these specific CIED-related complications (i.e., skin erosion and infection).
Methods and results
Sixteen mice undergoing implantation with biopotential transmitters were divided into three groups (no envelope = 4, TYRX = 5, and CanGaroo = 7) and monitored for device-related complications. Following 12 weeks of implantation, gross and histological analysis of the remaining capsules was performed. Three animals in the CanGaroo group (43%) had device erosion compared to none in the TYRX group. The remaining capsules excised at 12 weeks were qualitatively thicker following CanGaroo compared to TYRX and no envelope and histological evaluation demonstrated increased connective tissue with CanGaroo.
Conclusion
CanGaroo ECM envelopes did not reduce the incidence of device erosion and were associated with qualitatively thicker capsules and connective tissue staining at 12 weeks compared to no envelope or TYRX. Further studies regarding the use of these envelopes to prevent device erosion and their subsequent impact on capsule formation are warranted.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Ip JE, Xu L, Lerman BB
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010088
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Abstract

Topographical anatomy of the right atrial appendage vestibule and its isthmuses.

Hołda J, Słodowska K, Tyrak K, Bolechała F, ... Hołda MK, Walocha JA
Introduction
The right atrial appendage (RAA) vestibule is an area located in the right atrium between the RAA orifice and the right atrioventricular valve annulus and may be a target for invasive transcatheter procedures.
Methods and results
We examined 200 autopsied human hearts. Three isthmuses (an inferior, a middle, and a superior isthmus) were detected. The average length of the vestibule was 67.4 ± 10.1 mm. Crevices and diverticula were observed within the vestibule in 15.3% of specimens. The isthmuses had varying heights: superior: 14.0 ± 3.4 mm, middle: 11.2 ± 3.1 mm, and inferior: 10.1 ± 2.7 mm (p < .001). The superior isthmus had the thickest atrial wall (at midlevel: 16.7 ± 5.6 mm), the middle isthmus had the second thickest wall (13.5 ± 4.2 mm), and the inferior isthmus had the thinnest wall (9.3 ± 3.0 mm; p < .001). This same pattern was observed when analyzing the thickness of the adipose layer (superior isthmus had a thickness of 15.4 ± 5.6 mm, middle: 11.7 ± 4.1 mm and inferior: 7.1 ± 3.1 mm; p < .001). The average myocardial thickness did not vary between isthmuses (superior isthmus: 1.3 ± 0.5 mm, middle isthmus: 1.8 ± 0.8 mm, inferior isthmus: 1.6 ± 0.5 mm; p > .05). Within each isthmus, there were variations in the thickness of the entire atrial wall and of the adipose layer. These were thickest near the valve annulus and thinnest near the RAA orifice (p < .001). The thickness of the myocardial layer followed an inverse trend (p < .001).
Conclusions
This study was the first to describe the detailed topographical anatomy of the RAA vestibule and that of its adjoining isthmuses. The substantial variability in the structure and dimensions of the RAA isthmuses may play a role in planning interventions within this anatomic region.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Hołda J, Słodowska K, Tyrak K, Bolechała F, ... Hołda MK, Walocha JA
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010077
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Abstract

Clinical, electrocardiographic and electrophysiological characteristics, and catheter ablation results of left upper septal premature ventricular complexes.

Kose S, Vurgun VK, Gokoglan Y, Balli M, Kabul HK
Background
To investigate the clinical, electrocardiographic and electrophysiological characteristics, and results of catheter ablation of left upper septal (LUS) premature ventricular complexes (PVCs) arising from the proximal left fascicular system.
Methods
Thirty-one patients who had undergone radiofrequency catheter ablation (RFCA) for idiopathic PVCs were enrolled in the study. All PVCs presented with narrow QRS complexes (<110 ms) with precordial QRS morphology of incomplete right bundle branch block type or identical to the sinus rhythm (SR) QRS morphology. RFCA was applied to the LUS area where the earliest fascicular potential (FP) was recorded during mapping.
Results
The mean QRS duration during SR and PVCs were 92.3 ± 7.9 and 103.2 ± 7.3 ms, respectively. The mean fascicular potential-ventricular interval during PVC at the target site was 32.7 ± 2.7 ms. The mean His-ventricular (H-V) interval during SR and PVCs were 45.1 ± 2.7 and 21.3 ± 3.6 ms, respectively. Left anterior hemiblock/left posterior hemiblock and left bundle branch block (LBBB) were observed in 16 (53.3%) and 4 (12.9%) patients after RFCA, respectively. The His to FP interval in SR and H-V interval during PVC were found as significant markers for predicting the postablation LBBB. RFCA was acutely successful in 29 of 31 patients (93.5%) in the first procedure. Two patients had a recurrence of PVCs during follow-up and one of them underwent a second successful ablation. The overall success rate was 90.3% (28/31) in a mean follow-up duration of 24.3 ± 15.4 months.
Conclusions
LUS-PVCs have distinctive electrocardiographic and electrophysiologic characteristics and can be managed successfully by focal RFCA with detailed FP mapping of the left upper septum with a mild risk of left bundle branch injury.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print
Kose S, Vurgun VK, Gokoglan Y, Balli M, Kabul HK
J Cardiovasc Electrophysiol: 02 Oct 2020; epub ahead of print | PMID: 33010075
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Abstract

Outcomes and Mortality Associated with Atrial Arrhythmias Among Patients Hospitalized with COVID-19.

Peltzer B, Manocha KK, Ying X, Kirzner J, ... Goyal P, Cheung JW
Introduction
The impact of atrial arrhythmias on COVID-19-associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with atrial arrhythmias among patients hospitalized with COVID-19.
Methods
An observational cohort study of 1053 patients with SARS-CoV2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30-day mortality was assessed with multivariable analysis.
Results
Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared to patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B-type natriuretic peptide, C-reactive protein, ferritin and D-dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; P<0.001). After adjustment for age and co-morbidities, AF/AFL (adjusted OR 1.93; P = 0.007) and newly detected AF/AFL (adjusted OR 2.87; P <0.001) were independently associated with 30-day mortality.
Conclusions
Atrial arrhythmias are common among patients hospitalized with COVID-19. The presence of AF/AFL tracked with markers of inflammation and cardiac injury. Atrial arrhythmias were independently associated with increased mortality. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print
Peltzer B, Manocha KK, Ying X, Kirzner J, ... Goyal P, Cheung JW
J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print | PMID: 33017083
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Abstract

A novel screening tool to unmask potential interference between S-ICD and left ventricular assist device.

Zormpas C, Eiringhaus J, Hillmann HAK, Hohmann S, ... Veltmann C, Duncker D
Introduction
In patients with a left ventricular assist device (LVAD), the subcutaneous implantable cardioverter-defibrillator (S-ICD) can be an alternative to transvenous ICD systems due to reduced risk of systemic infection, which could lead to extraction of the ICD as well as the LVAD. S-ICD eligibility is lower in patients with LVAD than in patients with end-stage heart failure without LVAD. Several reports have shown inappropriate S-ICD therapy in the coexistence of LVAD and S-ICD. The aim of the present study was to evaluate S-ICD eligibility in patients with LVAD using the established electrocardiogram (ECG)-based screening test as well as a novel device-based screening test to identify potentially inappropriate S-ICD sensing in this specific patient cohort.
Methods and results
The present study included 115 patients implanted with an LVAD. The standard ECG-based screening test and a novel device-based screening test were performed in all patients. Eighty patients (70%) were eligible for S-ICD therapy with the standard ECG-based screening test. Performance of the novel device-based screening test identified device-device interference in 14 of these 80 patients (12%).
Conclusion
Using a novel extended device-based S-ICD screening method, a small number of patients with LVAD deemed eligible for S-ICD with the standard ECG-based screening test exhibit device-device interference. Careful S-ICD screening should be performed in patients with LVAD, who are candidates for S-ICD therapy, to prevent inappropriate sensing or ICD therapy.

© 2020 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print
Zormpas C, Eiringhaus J, Hillmann HAK, Hohmann S, ... Veltmann C, Duncker D
J Cardiovasc Electrophysiol: 04 Oct 2020; epub ahead of print | PMID: 33017069
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Abstract

Multiple procedure outcomes for nonparoxysmal atrial fibrillation: Left atrial posterior wall isolation versus stepwise ablation.

Barbhaiya CR, Knotts RJ, Beccarino N, Vargas-Pelaez AF, ... Aizer A, Chinitz LA
Objective
To compare multiple-procedure catheter ablation outcomes of a stepwise approach versus left atrial posterior wall isolation (LA PWI) in patients undergoing nonparoxysmal atrial fibrillation (NPAF) ablation.
Background
Unfavorable outcomes for stepwise ablation of NPAF in large clinical trials may be attributable to proarrhythmic effects of incomplete ablation lines. It is unknown if a more extensive initial ablation strategy results in improved outcomes following multiple ablation procedures.
Methods
Two hundred twenty two consecutive patients with NPAF underwent first-time ablation using a contact-force sensing ablation catheter utilizing either a stepwise (Group 1, n = 111) or LA PWI (Group 2, n = 111) approach. The duration of follow-up was 36 months. The primary endpoint was freedom from atrial arrhythmia >30 s. Secondary endpoints were freedom from persistent arrhythmia, repeat ablation, and recurrent arrhythmia after repeat ablation.
Results
There was similar freedom from atrial arrhythmias after index ablation for both stepwise and LA PWI groups at 36 months (60% vs. 69%, p = .1). The stepwise group was more likely to present with persistent recurrent arrhythmia (29% vs. 14%, p = .005) and more likely to undergo second catheter ablation (32% vs. 12%, p < .001) compared to LA PWI patients. Recurrent arrhythmia after repeat ablation was more likely in the stepwise group compared to the LA PWI group (15% vs. 4%, p = .003).
Conclusions
Compared to a stepwise approach, LA PWI for patients with NPAF resulted in a similar incidence of any atrial arrhythmia, lower incidence of persistent arrhythmia, and fewer repeat ablations. Results for repeat ablation were not improved with a more extensive initial approach.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Barbhaiya CR, Knotts RJ, Beccarino N, Vargas-Pelaez AF, ... Aizer A, Chinitz LA
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022816
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Abstract

Healthcare utilization and cost in patients with atrial fibrillation and heart failure undergoing catheter ablation.

Field ME, Gold MR, Rahman M, Goldstein L, ... Piccini JP, Friedman DJ
Background
Catheter ablation is an effective treatment for patients with atrial fibrillation (AF) and heart failure (HF). However, little is known about how healthcare utilization and cost change after ablation in this population. We sought to determine healthcare utilization and cost patterns among patients with AF and HF undergoing ablation.
Methods
Using a large United States administrative database, we identified (n = 1568) treated with ablation with a primary and secondary diagnosis of AF and HF, respectively, were evaluated 1-year pre- and postablation for outcomes including inpatient admissions (AF or HF), emergency department (ED) visits, cardioversions, length of stay (LOS), and cost. A secondary analysis was extended to 3-years postablation.
Results
Reductions were observed in AF-related admissions (64%), LOS (65%), cardioversions (52%), ED visits (51%, all values, p < .0001), and HF-related admissions (22%, p = .01). There was a 40% reduction in inpatient admission cost ($4165 preablation to $2510 postablation, p < .0001). In a sensitivity analysis excluding repeat-ablation patients, a greater reduction in overall AF management cost was observed compared to the full cohort (-43% vs. -2%). Comparing 1-year pre- to 3-years postablation, both total mean AF-management cost ($850 per-patient per-month 1-year pre- to $546 3-years postablation, p < .0001) and AF-related healthcare utilization was reduced.
Conclusions
Catheter ablation in patients with AF and HF resulted in significant reductions in healthcare utilization and cost through 3-years of follow-up. This reduction was observed regardless of whether repeat ablation was performed, reflecting the positive impact of ablation on longer term cost reduction.

© 2020 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Field ME, Gold MR, Rahman M, Goldstein L, ... Piccini JP, Friedman DJ
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022815
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Abstract

Supraventricular tachycardia in patients with coronary sinus stenosis/atresia: Prevalence, anatomical features, and ablation outcomes.

Weng S, Tang M, Zhou B, Yu F, ... Fang P, Zhang S
Background
Supraventricular tachycardia (SVT) with coronary sinus (CS) ostial atresia (CSA) or coronary sinus stenosis (CSS) causes difficulty in electrophysiological procedures, but its characteristics are poorly understood.
Objective
Study the anatomical and clinical features of SVT patients with CSA/CSS.
Methods
Of 6128 patients with SVT undergoing electrophysiological procedures, consecutive patients with CSA/CSS were enrolled, and the baseline characteristics, imaging materials, intraoperative data, and follow-up outcomes were analyzed.
Results
Thirteen patients, seven with CSA and six with CSS, underwent the electrophysiological procedure. Decapolar catheters were placed into the proximal CS in three cases, while the rest were placed at the free wall of the right atrium. Fourteen arrhythmias were confirmed: four atrioventricular nodal reentrant tachycardias, five left-sided accessory pathways, three paroxysmal atrial fibrillations, and two atrial flutters (AFLs). In addition to three patients who underwent only an electrophysiological study, the acute ablation success rate was 100% in 10 cases, with no procedure-related complications. After a median follow-up period of 59.6 months, only one case of atypical AFL recurred. For those cases (seven CSA and two CSS) with a total of 10 anomalous types of CS drainage, three types were classified: from the CS to the persistent left superior vena cava (n = 3), from an unroofed CS (n = 3), and from the CS to the small cardiac vein (n = 3) or Thebesian vein (n = 1).
Conclusion
Patients with CSA/CSS may develop different kinds of SVT. Electrophysiological procedures for such patients are feasible and effective. An individualized mapping strategy based on the three types of CS drainage will be helpful.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Weng S, Tang M, Zhou B, Yu F, ... Fang P, Zhang S
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022772
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Abstract

Clinical and cardiac characteristics of COVID-19 mortalities in a diverse New York City Cohort.

Abrams MP, Wan EY, Waase MP, Morrow JP, ... Garan H, Saluja D
Introduction
Electrocardiographic characteristics in COVID-19-related mortality have not yet been reported, particularly in racial/ethnic minorities.
Methods and results
We reviewed demographics, laboratory and cardiac tests, medications, and cardiac rhythm proximate to death or initiation of comfort care for patients hospitalized with a positive SARS-CoV-2 reverse-transcriptase polymerase chain reaction in three New York City hospitals between March 1 and April 3, 2020 who died. We described clinical characteristics and compared factors contributing toward arrhythmic versus nonarrhythmic death. Of 1258 patients screened, 133 died and were enrolled. Of these, 55.6% (74/133) were male, 69.9% (93/133) were racial/ethnic minorities, and 88.0% (117/133) had cardiovascular disease. The last cardiac rhythm recorded was VT or fibrillation in 5.3% (7/133), pulseless electrical activity in 7.5% (10/133), unspecified bradycardia in 0.8% (1/133), and asystole in 26.3% (35/133). Most 74.4% (99/133) died receiving comfort measures only. The most common abnormalities on admission electrocardiogram included abnormal QRS axis (25.8%), atrial fibrillation/flutter (14.3%), atrial ectopy (12.0%), and right bundle branch block (11.9%). During hospitalization, an additional 17.6% developed atrial ectopy, 14.7% ventricular ectopy, 10.1% atrial fibrillation/flutter, and 7.8% a right ventricular abnormality. Arrhythmic death was confirmed or suspected in 8.3% (11/133) associated with age, coronary artery disease, asthma, vasopressor use, longer admission corrected QT interval, and left bundle branch block (LBBB).
Conclusions
Conduction, rhythm, and electrocardiographic abnormalities were common during COVID-19-related hospitalization. Arrhythmic death was associated with age, coronary artery disease, asthma, longer admission corrected QT interval, LBBB, ventricular ectopy, and usage of vasopressors. Most died receiving comfort measures.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print
Abrams MP, Wan EY, Waase MP, Morrow JP, ... Garan H, Saluja D
J Cardiovasc Electrophysiol: 05 Oct 2020; epub ahead of print | PMID: 33022765
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Impact:
Abstract

Patient-reported outcomes and subsequent management in atrial fibrillation clinical practice: Results from the Utah mEVAL AF program.

Zenger B, Zhang M, Lyons A, Bunch TJ, ... Hess R, Steinberg BA
Background
Atrial fibrillation (AF) significantly reduces health-related quality of life (HRQoL), previously measured in clinical trials using patient-reported outcomes (PROs). We examined AF PROs in clinical practice and their association with subsequent clinical management.
Methods
The Utah My Evaluation (mEVAL) program collects the Toronto AF Symptom Severity Scale (AFSS) in AF outpatients at the University of Utah. Baseline factors associated with worse AF symptom score (range 0-35, higher is worse) were identified in univariate and multivariable analyses. Secondary outcomes included AF burden and AF healthcare utilization. We also compared subsequent clinical management at 6 months between patients with better versus worse AF HRQoL.
Results
Overall, 1338 patients completed the AFSS symptom score, which varied by sex (mean 7.26 for males vs. 10.27 for females; p < .001), age (<65, 9.73; 65-74, 7.66; ≥75, 7.58; p < .001), heart failure (9.39 with HF vs. 7.67 without; p < .001), and prior ablation (7.28 with prior ablation vs. 8.84; p < .001). In multivariable analysis, younger age (mean difference 2.92 for <65 vs. ≥75; p < .001), female sex (mean difference 2.57; p < .001), pulmonary disease (mean difference 1.88; p < .001), and depression (mean difference 2.46; p < .001) were associated with higher scores. At 6-months, worse baseline symptom score was associated with the use of rhythm control (37.1% vs. 24.5%; p < .001). Similar cofactors and results were associated with increased AF burden and health care utilization scores.
Conclusions
AF PROs in clinical practice identify highly-symptomatic patients, corroborating findings in more controlled, clinical trials. Increased AFSS score correlates with more aggressive clinical management, supporting the utility of disease-specific PROs guiding clinical practice.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Oct 2020; epub ahead of print
Zenger B, Zhang M, Lyons A, Bunch TJ, ... Hess R, Steinberg BA
J Cardiovasc Electrophysiol: 29 Oct 2020; epub ahead of print | PMID: 33124710
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Impact:
Abstract

Association of septal late gadolinium enhancement on cardiac magnetic resonance with ventricular tachycardia ablation targets in nonischemic cardiomyopathy.

Kuo L, Liang JJ, Han Y, Frankel DS, ... Desjardins B, Nazarian S
Background
Ablation of septal substrate-associated ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) is challenging. We sought to standardize the characterization of septal substrates on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and to examine the association of that substrate with VT exit and isthmus sites on invasive mapping.
Methods
LGE-CMR was performed before electroanatomic mapping and ablation for VT in 20 NICM patients. LGE extent and distribution were quantified using myocardial signal-intensity Z scores (SI-Z). The SI-Z thresholds correlating to previously validated voltage thresholds, for abnormal tissue and dense scar were defined.
Results
Bipolar and unipolar (electrogram) voltage amplitude measurements from the LV and RV were negatively associated with SI-Z from LGE-CMR imaging (p < .05). SI-Z thresholds for appropriate CMR identification of septal substrates were determined to be greater than -.15 for border zone and greater than .03 for a dense scar. Among all patients, 34 critical VT sites were identified with SI-Z distribution in the range of -.97 to .06. Thirty (88.2%) critical sites were located in the dense LGE, 1 (2.9%) in the border zone, and 3 (8.9%) in healthy tissue but within 7 mm of LGE. Of note, critical VT sites were all located at the basal septum close to valves (distance to aortic valve: 17.5 ± 31.2 mm, mitral valve: 21.2 ± 8.7 mm) in nonsarcoidosis cases.
Conclusions
Critical sites of septal VT in NICM patients are predominantly in the CMR defined dense scar when using standardized signal-intensity thresholds.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print
Kuo L, Liang JJ, Han Y, Frankel DS, ... Desjardins B, Nazarian S
J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print | PMID: 33070414
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Impact:
Abstract

Vascular entrapment of a multipolar basket catheter (Orion ) during catheter ablation.

Ollitrault P, Champ-Rigot L, Ferchaud V, Pellissier A, Coffin O, Milliez P

The IntellaMap Orion (Boston Scientific) is a 64-electrode basket catheter allowing for ultrahigh-density mapping of complex cardiac arrhythmias. We report the case of a basket catheter vascular entrapment, requiring surgical removal.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 14 Oct 2020; epub ahead of print
Ollitrault P, Champ-Rigot L, Ferchaud V, Pellissier A, Coffin O, Milliez P
J Cardiovasc Electrophysiol: 14 Oct 2020; epub ahead of print | PMID: 33058383
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Impact:
Abstract

Recognition and clinical implications of high prevalence of migraine in patients with Brugada syndrome and drug-induced type 1 Brugada pattern.

Hasdemir C, Gokcay F, Orman MN, Kocabas U, ... Nyholt DR, Antzelevitch C
Introduction
We have previously reported high 1-year prevalence of migraine in patients with atrial arrhythmias associated with DI-type 1 BrP. The present study was designed to determine the lifetime prevalence of migraine in patients with Brugada syndrome (BrS) or drug-induced type 1 Brugada pattern (DI-type 1 BrP) and control group, to investigate the demographic and clinical characteristics, and to identify clinical variables to predict underlying BrS/DI-type 1 BrP among migraineurs.
Methods and results
Lifetime prevalence of migraine and migraine characteristics were compared between probands with BrS/DI-type 1 BrP (n = 257) and control group (n = 370). Lifetime prevalence of migraine was 60.7% in patients with BrS/DI-type 1 BrP and 30.3% in control group (p = 3.6 × 10 ). On stepwise regression analysis, familial migraine (odds ratio [OR] of 4.4; 95% confidence interval [CI]: 2.0-9.8; p = 1.3 × 10 ), vestibular migraine (OR of 5.4; 95% CI: 1.4-21.0); p = .013), migraine with visual aura (OR of 1.8; 95% CI: 1.0-3.4); p = .04) and younger age-at-onset of migraine (OR of 0.95; 95% CI: 0.93-0.98); p = .004) were predictors of underlying BrS/DI-type 1 BrP among migraineurs. Use of anti-migraine drugs classified as \"to be avoided\" or \"preferably avoided\" in patients with BrS and several other anti-migraine drugs with potential cardiac I /I channel blocking properties was present in 25.6% and 26.9% of migraineurs with BrS/DI-type 1 BrP, respectively.
Conclusion
Migraine comorbidity is common in patients with BrS/DI-type 1 BrP. We identify several clinical variables that point to an underlying type-1 BrP among migraineurs, necessitating cautious use of certain anti-migraine drugs.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 14 Oct 2020; epub ahead of print
Hasdemir C, Gokcay F, Orman MN, Kocabas U, ... Nyholt DR, Antzelevitch C
J Cardiovasc Electrophysiol: 14 Oct 2020; epub ahead of print | PMID: 33058326
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Impact:
Abstract

Implantation of leadless pacemakers via inferior vena cava filters is feasible and safe: Insights from a multicenter experience.

Houmsse M, Karki R, Gabriels J, Reinig M, ... Epstein LM, Cha YM
Background
The leadless Micra transcatheter-pacing system (Micra-TPS) is implanted via a femoral approach using a 27-French introducer sheath. The Micra Transcutaneous Pacing Study excluded patients with inferior vena cava (IVC) filters.
Objective
To examine the feasibility and safety of Micra-TPS implantation through an IVC filter.
Methods
This multicenter retrospective study included patients with an IVC filter who underwent a Micra-TPS implantation. Data for clinical and IVC filter characteristics, preprocedure imaging, and procedural interventions were collected. The primary outcome was a successful leadless pacemaker (LP) implantation via a femoral approach in the presence of an IVC filter. Periprocedural and delayed clinical complications were also evaluated.
Results
Of the 1528 Micra-TPS implants attempted, 23 patients (1.5%) had IVC filters. The majority (69.6%) of IVC filters were permanent. Six (26.1%) patients underwent preprocedural imaging to assess for filter patency. One patient\'s filter was retrieved before LP implantation. The primary outcome was achieved in 21 of 22 patients (95.5%) with an existing IVC filter. An occluded IVC precluded LP implantation in one patient. Difficulty advancing the stiff guidewire or the 27-Fr sheath was encountered in five patients. These cases required repositioning of the wire (n = 2), gradual sheath upsizing (n = 2), or balloon dilation of the filter (n = 1). Postprocedure fluoroscopy revealed intact filters in all cases. During a median 6-month follow-up, there were no clinical complications related to the filter or the Micra-TPS.
Conclusion
This multicenter experience demonstrates the feasibility and safety of Micra-TPS implantation via an IVC filter without acute procedural or delayed clinical complications.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 14 Oct 2020; epub ahead of print
Houmsse M, Karki R, Gabriels J, Reinig M, ... Epstein LM, Cha YM
J Cardiovasc Electrophysiol: 14 Oct 2020; epub ahead of print | PMID: 33058275
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Impact:
Abstract

Safety and efficacy of catheter ablation for atrial fibrillation in abdominal solid organ (renal and hepatic) transplant recipients: A single-center pilot experience.

Su X, Zhao X, Long DY, Sang CH, ... Dong JZ, Ma CS
Background
Atrial fibrillation (AF) is common in abdominal solid organ transplant recipients and a cause of morbidity and mortality in this population. However, the outcomes of catheter ablation (CA) in transplant recipients with AF remain unclear. This study aimed to elucidate the outcomes of CA in renal and hepatic transplant recipients.
Methods and results
Between 2015 and 2019, 14 transplant recipients (nine with kidney transplantation and five with liver transplantation) were enrolled from among 10,741 AF patients and underwent CA at Anzhen Hospital. Another 56 patients matched by age, sex, and AF type were selected as the control group (four controls for each transplant recipient). During a mean follow-up of 30.0 ± 13.3 months after the initial procedure, 10 (71.4%) of the transplant patients, compared to 41 (73.2%) of the control patients, remained free from AF recurrence (p = 1.000). A repeated procedure was performed in one transplant patient and in six control subjects. Consequently, 11 (78.6%) of the transplant patients, compared to 46 (82.1%) of controls, were in sinus rhythm after the repeated ablation (p = .715). Notably, Kaplan-Meier analysis did not demonstrate any significant differences in the atrial arrhythmia-free rate after the initial and repeated procedure between the two groups. Vascular complications were identified in one transplant patient and two control subjects, while no life-threatening complications were observed in either group. There was no transient allograft dysfunction in transplant recipients after CA.
Conclusion
CA is safe and effective in abdominal solid transplant recipients, and maybe an optimal therapeutic strategy for this group.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 13 Oct 2020; epub ahead of print
Su X, Zhao X, Long DY, Sang CH, ... Dong JZ, Ma CS
J Cardiovasc Electrophysiol: 13 Oct 2020; epub ahead of print | PMID: 33051930
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Impact:
Abstract

Feasibility of superior vena cava isolation in patients with cardiac implantable electronic devices.

Kataoka S, Ejima K, Yazaki K, Kanai M, ... Shoda M, Hagiwara N
Introduction
Some patients with cardiac implantable electronic devices (CIEDs) require atrial fibrillation (AF) ablation, and the superior vena cava (SVC) has been identified as one of the most common non-pulmonary vein foci of AF. This study aimed to investigate the interaction between SVC isolation (SVCI) and CIED leads implanted through the SVC.
Methods and results
We studied 34 patients with CIEDs who had undergone SVCI as part of AF ablation (CIED group), involving a total of 71 CIED leads. A similar number of age-, sex-, and AF type-matched patients without CIEDs formed a control group (non-CIED group). Patients\' background and procedural characteristics were compared between the groups. In the CIED group, lead parameters before and after AF ablation were compared, and lead failure after AF ablation was also examined in detail. Procedural characteristics other than fluoroscopic time were similar in both groups. The success rate of SVCI after the final ablation procedure was 91.2% in the CIED group and 100% in the non-CIED group; however, these differences were not statistically significant. Lead parameters before and after the AF ablation did not significantly differ between the two groups. Lead failure was observed in three patients, with a sensing noise in one patient and an impedance increase in two patients after SVCI.
Conclusion
SVCI was achievable without lead failure and significant change in lead parameters in most patients with CIEDs; however, it should be noted that lead failure was observed in 8.8% of the study patients after SVCI.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 19 Oct 2020; epub ahead of print
Kataoka S, Ejima K, Yazaki K, Kanai M, ... Shoda M, Hagiwara N
J Cardiovasc Electrophysiol: 19 Oct 2020; epub ahead of print | PMID: 33079461
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Impact:
Abstract

Atrial fibrillation ablation success defined by duration of recurrence on cardiac implantable electronic devices.

Lohrmann G, Kaplan R, Ziegler PD, Monteiro J, Passman R
Introduction
Ablation for atrial fibrillation (AF) has emerged as an effective method of rhythm control. This exploratory analysis aimed to determine how various measures of recurrence would influence the definition of treatment success.
Methods
Using an electronic health record data set from January 2007 to June 2019 linked with Medtronic cardiac implantable electronic device (CIED) data, patients who underwent a first AF ablation procedure following CIED implantation were identified. Data were analyzed for recurrence of AF stratified by varying definitions of successful ablation. The performance of various simulated external AF monitoring strategies was assessed.
Results
A total of 665 patients were analyzed including 248 with paroxysmal AF (mean age: 66.2 ± 9.3 years, 73.0% male) and 417 patients with persistent AF (mean age: 67.3 ± 9.0 years, 73.6% male). Among patients with paroxysmal AF, survival free from recurrence at 1 year ranged from 28.2% to 72.1% (>6 min and >23 h thresholds, respectively) with an overall median percentage of time in AF reduction of 99.6%. Among patients with persistent AF, survival free from recurrence at 1 year ranged from 24.9% to 60.0% (>6 min and 7 consecutive days > 23 h thresholds, respectively) with an overall median percentage of time in AF reduction of 99.3%. A single 7-day monitoring strategy had a sensitivity of less than 50% for detecting AF greater than 6 min in patients with paroxysmal and persistent AF.
Conclusion
In this real-world data set of AF patients with CIEDs undergoing catheter ablation, treatment success varied substantially with different definitions of minimally required AF duration and is significantly impacted by the method of recurrence detection.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 19 Oct 2020; epub ahead of print
Lohrmann G, Kaplan R, Ziegler PD, Monteiro J, Passman R
J Cardiovasc Electrophysiol: 19 Oct 2020; epub ahead of print | PMID: 33079437
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Impact:
Abstract

Very long-term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: How does cryoenergy differ from radiofrequency?

Chaumont C, Mirolo A, Savouré A, Godin B, ... Eltchaninoff H, Anselme F
Introduction
Either cryoenergy or radiofrequency can be used during atrioventricular nodal reentrant tachycardia (AVNRT) ablation. There are still limited data comparing their respective long-term efficacy (>1 year). This study sought to compare the very long-term outcomes of AVNRT ablation using radiofrequency or cryotherapy.
Methods
We retrospectively included all patients who had undergone a first AVNRT ablation in our institution between January 2010 and December 2017. The primary endpoint was recurrence of documented AVNRT.
Results
The study population consisted of 409 patients (274 females; mean age, 49.9 years). Ablation was performed using cryoenergy in 260 patients and radiofrequency in 149. High acute procedural success rate (>98%) was obtained and no permanent AV block was observed using both techniques. During a mean follow-up of 3.3 ± 2.3 years, documented AVNRT recurrence occurred in 24 (9.2%) and 4 patients (2.7%) in the cryoablation (CA) and radiofrequency (RF) group, respectively. The risk of AVNRT recurrence was significantly higher in the CA group as compared with the RF group (hazard ratio [HR] = 3.7; 95% confidence interval [CI], 1.3-5.9). Most of the recurrences after CA occurred between 1- and 6-year follow-up (14/24; 58.3%), with one-third of late recurrences after 3-year follow-up. In multivariable analysis, only Koch\'s triangle anatomical variant was associated with AVNRT recurrence after CA (HR = 6.7; 95% CI, 2.7-16.3).
Conclusion
While AVNRT recurrence rates were similar at 1 year of follow-up regardless of the energy used, long-term efficacy appeared higher after radiofrequency ablation. Strikingly, recurrences occured much later after cryotherapy compared with radiofrequency ablation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 19 Oct 2020; epub ahead of print
Chaumont C, Mirolo A, Savouré A, Godin B, ... Eltchaninoff H, Anselme F
J Cardiovasc Electrophysiol: 19 Oct 2020; epub ahead of print | PMID: 33079433
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Impact:
Abstract

Difference in the prevalence of intracardiac thrombus on the first presentation of atrial fibrillation versus flutter in the pediatric and congenital heart disease population.

Meziab O, Marcondes L, Friedman KG, O\'Leary ET, ... Triedman JK, Mah DY
Introduction
Guidelines recommend trans-esophageal echocardiography (TEE) for patients with atrial fibrillation (AF) or atrial flutter (AFL) for >48 h, due to risk of intracardiac thrombus formation. With growing evidence that AFL in adults with structurally normal hearts has less thrombogenic potential compared to AF, and the need for TEE questioned, we compared prevalence of intracardiac thrombus detected by TEE in pediatric and congenital heart disease (CHD) patients presenting in AF and AFL.
Methods/results
Single-center, cross-sectional analysis for unique first-time presentations of patients for either AF, AFL, or intra-atrial reentrant tachycardia (IART) between 2000 and 2019. Patients were categorized by presenting arrhythmia (AF vs. AFL/IART), with the exclusion of other forms of atrial tachycardia, hemodynamic instability, chronic anti-coagulation before TEE, and presentation for a reason other than TEE examination for thrombus. A total of 201 patients had TEE with co-diagnosis of AF or AFL. Of these, 105 patients (29 AF, 76 AFL) met inclusion criteria, with no difference in age between AF (median 24.9 years; IQR 18.6-38.3 years) and AFL/IART (23.3 years; 15.4-38.4 years). The prevalence of thrombus in the entire cohort was 9.5%, with no difference between AF (13.8%) and AFL groups (7.9%), p = .46. Patients with thrombus demonstrated no difference in age, systemic ventricular function, cardiac complexity, or CHADS2/CHA2DS2VASc score at presentation.
Conclusions
The risk for intracardiac thrombus is high in the pediatric and CHD population, with no apparent distinguishing factors to warrant a change in the recommendations for TEE, with all levels of cardiac complexity being at risk for clot.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 27 Oct 2020; epub ahead of print
Meziab O, Marcondes L, Friedman KG, O'Leary ET, ... Triedman JK, Mah DY
J Cardiovasc Electrophysiol: 27 Oct 2020; epub ahead of print | PMID: 33112018
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Impact:
Abstract

Relationship between dominant frequency, organization index, and left atrial size in patients with atrial fibrillation.

Choi YJ, Sohn JJ, Kwon S, Lee SR, ... Kim HC, Oh S
Introduction
Frequency domain analysis is a methodology for quantifying the organization of atrial fibrillation (AF) pattern to understand the pathophysiology of the electrical mechanism. We aimed to investigate whether the dominant frequency (DF) and organization index (OI) can indicate left atrial (LA) dilatation in patients with AF.
Methods and results
This observational, retrospective, single-center cohort study assessed 100 patients with persistent AF. The study population was divided into two groups based on an anterior-posterior LA dimension (LAD of 50 mm) measured by transthoracic echocardiography. The groups were one-to-one propensity score-matched. Frequency domain analysis was performed using signals at leads II and V1 on surface electrocardiogram to calculate the DF and OI. In all patients, the DF was shown to have an inverse relationship with LAD (R = -.369, p < .001 in lead II; R = -.330, p = .001 in lead V1), while the OI was directly associated with LAD (R = .234, p = .190 in lead II; R = .283, p = .004 in lead V1). However, no significant relationship between the signal amplitude and LAD was observed. Compared to patients with LAD ≤ 50 mm, those with LAD > 50 mm had a lower DF (5.057 ± 0.740 vs. 4.542 ± 0.898, p = .002) and higher OI (0.261 ± 0.104 vs. 0.322 ± 0.116, p = .007) in lead V1. These findings were consistent with those found in lead II.
Conclusion
Patients with persistent AF and a larger LA size had a significantly higher OI and lower DF than those with a smaller LA size. Atrial electrical properties of structural remodeling are associated with increased organization of atrial signals.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 21 Oct 2020; epub ahead of print
Choi YJ, Sohn JJ, Kwon S, Lee SR, ... Kim HC, Oh S
J Cardiovasc Electrophysiol: 21 Oct 2020; epub ahead of print | PMID: 33091184
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Impact:
Abstract

Brugada syndrome and syncope: A systematic review.

Mascia G, Della Bona R, Ameri P, Canepa M, Porto I, Brignole M
Introduction
Distinguishing syncope due to malignant arrhythmias from an incidental benign form in Brugada syndrome (BrS) is often difficult. Through systematic literature review, we evaluated the role of syncope in predicting subsequent malignant arrhythmias in BrS.
Methods
A comprehensive literature search was performed on PubMed (MeSH search terms \"Brugada syndrome\" and \"syncope\"). Overall, 9 studies for a total of 1347 patients were included. Patients were stratified as affected by suspected arrhythmic syncope (SAS), undefined syncope (US) or neurally-mediated syncope (NMS).
Results
Overall, 15.7% of the 279 patients with SAS had malignant arrhythmic events during a mean follow-up of 67 months, corresponding to 2.8 events per 100/person year. At the same time, 7% of the 527 patients affected by US had malignant arrhythmias during a mean follow-up of 39 months, corresponding 2.2 events per 100/person year. Conversely, 0.7% of 541 patients with NMS had malignant arrhythmic events at follow-up, corresponding to 0.13 events per 100/person year (p = .0001 NMS versus SAS and US pooled).
Conclusion
In BrS population, the risk of arrhythmic events in the follow-up may be stratified according to the clinical evaluation. The \"relatively\" low predictive value of the clinical diagnosis of SAS warrants for a more accurate multi-parametric assessment, to restrict the number of candidates for implantable cardioverter-defibrillator therapy.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 21 Oct 2020; epub ahead of print
Mascia G, Della Bona R, Ameri P, Canepa M, Porto I, Brignole M
J Cardiovasc Electrophysiol: 21 Oct 2020; epub ahead of print | PMID: 33090608
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Impact:
Abstract

EvaLuation Using Cardiac Insertable Devices And TelephonE in Hypertrophic Cardiomyopathy (ELUCIDATE HCM): A prospective observational study on incidence of arrhythmias.

Magnusson P, Mörner S
Background
Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease associated with arrhythmias. Non-sustained ventricular tachycardia (NSVT) is a risk factor for sudden cardiac death and part of the current risk stratification. Furthermore, atrial fibrillation (AF), which increases the risk of stroke, is believed to be common in HCM patients. Routine ambulatory monitoring captures the rhythm only periodically over 24-48 h; thus, the true burden of arrhythmia is unknown. The insertable cardiac monitor (ICM) should help determine a more realistic arrhythmia assessment in HCM patients.
Objective
The purpose of this study was to ascertain the incidence of NSVT, AF, and bradycardia in unselected HCM patients by the use of an ICM.
Methods
Thirty adults, mean age 49.9 ± 12.3 years, 25 (83.3%) males were implanted with a Confirm Rx ICM. The monitoring application was installed on the patient\'s smartphone, which allowed for patient activation in case of symptoms. The ICM was programmed as follows: ventricular tachycardia (VT) ≥ 160 beats per minute (bpm) for ≥8 intervals, AF ≥ 2 min of duration, and bradycardia ≤ 40 bpm or pause ≥ 3.0 s.
Results
The mean calculated 5-year risk was 2.3%, and 29/30 of the patients had a risk <4%. During follow-up, AF was found in nine patients (30.0%). At least one episode of NSVT was detected in seven patients (23.3%). In 13 patients (43.3%), sinoatrial block/sinus arrest/sinus bradycardia were seen. No arrhythmia was detected in nine patients (30.0%).
Conclusion
In this first prospective study using an ICM, the arrhythmia burden in HCM patients yielded 30.0% AF and 23.3% NSVT.

© 2020 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 26 Oct 2020; epub ahead of print
Magnusson P, Mörner S
J Cardiovasc Electrophysiol: 26 Oct 2020; epub ahead of print | PMID: 33108031
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Impact:
Abstract

Same-day discharge following catheter ablation of atrial fibrillation: A safe and cost-effective approach.

Creta A, Ventrella N, Providência R, Earley MJ, ... Finlay M, Hunter RJ
Introduction
The frequency of catheter ablation for atrial fibrillation (AF) has increased dramatically, stretching resources. Discharge on the same day as treatment may increase the efficiency and throughput. There are limited data regarding the safety of this strategy.
Methods
We performed a retrospective analysis of consecutive patients undergoing AF ablation in a tertiary center and in a district general hospital, and identified those discharged on the same day of treatment. The safety endpoint was any complication and/or presentation to hospital in the 48-h and at 30 days postdischarge. We performed an economic analysis to calculate potential cost saving.
Results
Among a total population of 2628 patients, we identified 727 subjects (61.1 ± 12.5 years, 69.6% male) undergoing day-case AF ablation. Cryoballoon technique was used in 79.2% of the day-cases, and 91.6% of the procedures were performed under conscious sedation. 1.8% (13) of the participants met the safety composite endpoint at 48-h, however only 0.7% (5) required at least 1 day of hospitalization. Bleeding or hematoma at the femoral access site (0.5%) and pericarditic chest pain (0.5%) were the main reasons for readmission. None experienced cardiac tamponade or other life-threatening complications in the 48-h postdischarge. Overall rate of complication and/or presentation to hospital at 30 days was 3.7%. Our day-case policy resulted in an annual cost-saving of approximately of £83 927 for our hospital.
Conclusion
In this large multicentre cohort, same-day discharge in selected patients following AF ablation appears to be safe and cost-effective, with a very low rate of early readmission or post-discharge complication.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 26 Oct 2020; epub ahead of print
Creta A, Ventrella N, Providência R, Earley MJ, ... Finlay M, Hunter RJ
J Cardiovasc Electrophysiol: 26 Oct 2020; epub ahead of print | PMID: 33107171
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Impact:
Abstract

Electrophysiologic approach to diagnosis and ablation of patients with permanent junctional reciprocating tachycardia associated with complex anatomy and/or physiology.

Oesterle A, Lee AC, Voskoboinik A, Moss JD, ... Gerstenfeld EP, Scheinman MM
Introduction
Permanent junctional reciprocating tachycardia (PJRT) is a rare supraventricular tachycardia (SVT), typically involving a single decremental posteroseptal accessory pathway (AP).
Methods
Four patients with long RP SVT underwent electrophysiology (EP) study and ablation. The cases were reviewed.
Results
Case 1 recurred despite 3 prior ablations at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia (ORT). Mapping during a repeat EP study demonstrated a prepotential in the coronary sinus (CS). Ablation over the earliest atrial activation in the CS resulted in dissociation of the potential from the atrium during sinus rhythm. The potential was traced back to the CS os and ablated. Case 2 underwent successful ablation at 6 o\'clock on the mitral annulus (MA). ORT recurred and successful ablation was performed at 1 o\'clock on the MA. Case 3 had tachycardia with variation in both V-A and A-H intervals which precluded the use of usual maneuvers so we used simultaneous atrial and ventricular pacing and introduced a premature atrial contraction with a closely coupled premature ventricular contraction. Case 4 had had two prior atrial fibrillation ablations with continued SVT over a decremental atrioventricular bypass tract that was successfully ablated at 5 o\'clock on the tricuspid annulus. A second SVT consistent with a concealed nodoventricular pathway was successfully ablated at the right inferior extension of the AV nodal slow pathway.
Conclusion
We describe challenging cases of PJRT by virtue of complex anatomy, diagnostic features, and multiple arrhythmia mechanisms.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 26 Oct 2020; epub ahead of print
Oesterle A, Lee AC, Voskoboinik A, Moss JD, ... Gerstenfeld EP, Scheinman MM
J Cardiovasc Electrophysiol: 26 Oct 2020; epub ahead of print | PMID: 33107135
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Impact:
Abstract

Noncentrifugal activation patterns in focal RVOT PVC/VT: New insights from high density multielectrode mapping.

Ng J, Chhachhi B, Stobie P, Keren A, Popal S, Reichlin T
Background
Activation from an automatic focus is thought to show centrifugal spread. In patients with premature ventricular complex/ventricular tachycardia (PVC/VT) from the right ventricular outflow tract (RVOT), the presence of preferential conduction and epicardial connections could however also lead to noncentrifugal wavefront propagation.
Objective
To study endocardial activation in RVOT PVC/VT using high-resolution 3D activation mapping.
Methods
Consecutive patients with frequent idiopathic PVC/VT were studied. High-resolution 3D activation maps were acquired using a multielectrode mapping catheter (Orion, Rhythmia, Boston Scientific). Noncentrifugal activation was defined as a pattern of wavefront propagation which does not show uniform propagation in all directions from one focus. Patients without sustained ablation success and patients with a left-sided PVC origin or with insufficient map density were excluded from the analysis.
Results
Sixteen patients (44% female) with a median age of 54 years (interquartile range [IQR], 47-64) and a median PVC burden of 19% (IQR, 15-27) were studied. High-resolution activation maps consisting of a median number of 1863 mapping points (IQR, 1195-2463 points) demonstrated a centrifugal activation in 6/16 (38%) and a noncentrifugal activation in 10/16 (62%). When comparing patients with centrifugal and noncentrifugal activation, patients with centrifugal activation were older (p = .01), but no differences were found in age, gender, QRS duration of the PVC\'s and sites of origin in the RVOT. No procedural complications occurred.
Conclusions
High-resolution multielectrode mapping demonstrates the presence of noncentrifugal activation patterns in some of the patients with idiopathic RVOT PVC/VT. This may indicate the presence of preferential conduction and or epicardial/intramural connections in the outflow tract.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Oct 2020; epub ahead of print
Ng J, Chhachhi B, Stobie P, Keren A, Popal S, Reichlin T
J Cardiovasc Electrophysiol: 28 Oct 2020; epub ahead of print | PMID: 33118678
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Impact:
Abstract

Catheter ablation of atrial arrhythmias following lung transplant: Electrophysiological findings and outcomes.

Mariani MV, Pothineni NVK, Arkles J, Deo R, ... Marchlinski FE, Santangeli P
Introduction
Data on the mechanisms of atrial arrhythmias (AAs) and outcomes of catheter ablation (CA) in lung transplantation (LT) patients are insufficient. We evaluated the electrophysiologic features and outcomes of CA of AAs in LT patients. METHODS AND Results: We conducted a retrospective study of all the LT patients who underwent CA for AAs at our institution between 2004 and 2019. A total of 15 patients (43% males, age: 61 ± 10 years) with a history of LT (60% bilateral and 40% unilateral) were identified. All patients had documented organized AA on surface electrocardiogram and seven patients also had atrial fibrillation (AF; 47% with >1 clinical arrhythmia). At electrophysiological study, 19 organized AAs were documented (48% focal and 52% macro-re-entrant). Focal atrial tachycardias/flutters were targeted along the pulmonary vein (PV) anastomotic site at the left inferior PV (n = 2), ridge and carina of the left superior PV (n = 2), left atrium (LA) posterior wall (n = 3), LA roof (n = 1), and tricuspid annulus (n = 1). Macro-re-entrant AAs included cavotricuspid isthmus-dependent flutter (n = 2), incisional LA flutter (n = 4), LA roof-dependent flutter (n = 1), and mitral annular flutter (n = 3). In patients with LA mapping (n = 13), PV reconnection on the side of the LT was found in six patients (40%, all with clinically documented AF), with a mean of 2.1 ± 0.9 PVs reconnected per patient. Patients with AF underwent successful PV isolation. After a median follow-up of 19 months (range: 6-86 months), 75% of patients remained free from recurrent AAs. No procedural major complications occurred.
Conclusion
In patients with prior LT, recurrent AAs are typically associated with substrate surrounding the surgical anastomotic lines and/or chronically reconnected PVs. CA of AAs in this population is safe and effective to achieve long-term arrhythmia control.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print
Mariani MV, Pothineni NVK, Arkles J, Deo R, ... Marchlinski FE, Santangeli P
J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print | PMID: 33205513
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Abstract

Contact force ablation of accessory pathways in pediatric patients.

Pook C, Kuhn E, Singh A, Kovach J
Introduction
Contact force (CF) catheters provide feedback confirming adequate tissue contact for optimal lesion size and minimal complications. CF ablation catheters have resulted in decreased procedure times and improved outcomes for ablation of atrial fibrillation in adults. There is limited data evaluating CF use for accessory pathway (AP) ablation or in pediatric patients. The aim of our study was to compare a cohort who underwent AP ablation with a CF catheter to historical controls, evaluating for differences in procedure times, number of lesions, and outcomes.
Methods
A retrospective chart review of CF ablation cases at Children\'s Wisconsin performed between June 2015 to April 2018 was compared to a historical control cohort of traditional radiofrequency (RF) ablations between June 2012 and June 2015. 43 patients with APs underwent 49 CF ablation procedures (18 males, 13.6 ± 3 years old) and a control cohort consisted of 77 procedures in 69 patients (38 males, 12.4 ± 4 years).
Results
The groups did not differ significantly on procedure time (CF 2.01 ± 0.48 h, control 1.53 ± 0.48 h, p = .37), or total lesions administered (CF and control 7 ± 6 lesions, p = .89). CF cases showed a trend toward improvement in acute success (98% CF, 90% controls, p = .15) though with increased recurrence compared to controls (13% CF, 4.3% controls, p = .16), neither being statistically significant.
Conclusion
Our study suggests that ablation outcomes using CF are comparable to traditional RF ablation in pediatric patients with APs.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print
Pook C, Kuhn E, Singh A, Kovach J
J Cardiovasc Electrophysiol: 16 Nov 2020; epub ahead of print | PMID: 33205493
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Abstract

Dealing with RV-oversensing; separate sensitivity settings for brady and tachy sensing.

Bhagirath P, Beunder K, van Halm V

An 81-year old male with a history of systolic heart failure due to an underlying ischemic cardiomyopathy with a left ventricular ejection fraction of 13% and QRS duration of 130ms had undergone an uncomplicated CRT-D implantation (Quadra Assura MP, St. Jude Medical, LV lead (SJM Quartet 1458Q-86), RA lead (Biotronik Safio S53) and RV shocklead (Biotronik Linox Smart S65 ProMRI) in 2015. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 24 Nov 2020; epub ahead of print
Bhagirath P, Beunder K, van Halm V
J Cardiovasc Electrophysiol: 24 Nov 2020; epub ahead of print | PMID: 33238071
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Abstract

Life Cycle Management of Micra Transcatheter Pacing System: Data From a High-Volume Center.

Bhatia NK, Kiani S, Merchant FM, Delurgio DB, ... Shah AD, El-Chami MF
Background
Data on management of Micra Transcatheter Pacing System (TPS) at the time of an upgrade or during battery depletion is limited.
Objective
We sought to evaluate the management patterns of patients implanted with a Micra TPS during long-term follow-up Methods: We retrospectively identified patients who underwent Micra implantation from April 2014 to November 2019.We identified patients who underwent extraction (n=11) or had an abandoned Micra (n=12).
Results
We identified 302 patients who received a Micra during the period of the study. Mean age was 72.7±15.4 years, 54.6% were men, and LVEF was 51.9±5.2%. Mean follow up was 1105.5±529.3 days. Procedural complications included pericardial tamponade (n=1) treated with pericardiocentesis, significant rise in thresholds (n=6) treated with reimplantation (n=4), and major groin complications (n=2) Indications for extraction included upgrade to CRT device (n=3), bridging after extraction of an infected trans-venous system (n=3), elevated thresholds (n=3), and non-Micra related bacteremia (n=2). The median time from implantation to extraction was 78 days (IQR 14, 113 days), with the longest extraction occurring at 1442 days. All extractions were successful, with no procedural or long-term complications. Indications for abandonment included need for CRT (n=6), battery depletion (n=2), increasing thresholds/failure to capture (n=3), and pacemaker syndrome (n=1). All procedures were successful, with no procedural or long-term complications Conclusion: In this large single center study, 6% of patients implanted with a Micra required a system modification during long-term follow-up, most commonly due to requirement for CRT pacing. These patients were managed successfully with extraction or abandonment. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Nov 2020; epub ahead of print
Bhatia NK, Kiani S, Merchant FM, Delurgio DB, ... Shah AD, El-Chami MF
J Cardiovasc Electrophysiol: 28 Nov 2020; epub ahead of print | PMID: 33251698
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Abstract

Incidence, risk factors and clinical impact of peridevice Leak following left atrial appendage closure with the LAmbre device- Data from a prospective, multicenter clinical study.

Wang G, Kong B, Qin T, Liu Y, Huang C, Huang H
Background
In the present study, we sought to explore the incidence, risk factors and clinical impact of peridevice leaks (PDL), following LAmbre-assisted left atrial appendage closure (LAAC).
Methods
We performed Transesophageal echocardiography (TTE) on patients participating in the LAmbre multicenter study, at day 1 post-implantation, then at 3 and 12 months to assess PDL, device-related thrombus, LAA thrombus, and left atrial thrombus. Clinical events were recorded during follow-up.
Result
A total of 152 patients with atrial fibrillation (AF) successfully completed LAAC. At 3 months follow-up, 123 patients underwent TEE, with 21 (17%) of them presenting PDL. Among the 121 patients who underwent TEE at 12 months follow-up, 19 (15.7%) presented PDL. PDL patients exhibited larger LAA orifice diameters and larger device sizes compared to those in the no leak group. In addition, we found no significant differences in thromboembolic events between patients in the PDL and no leak groups.
Conclusion
LAmbre-assisted LAA closure, resulted in a relatively low PDL occurrence, and its rate decreased over time. In addition, PDL was more prominent in patients with larger LAA orifice diameter and larger device size. However, the condition was not associated with increased risk for thromboembolic events. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Nov 2020; epub ahead of print
Wang G, Kong B, Qin T, Liu Y, Huang C, Huang H
J Cardiovasc Electrophysiol: 28 Nov 2020; epub ahead of print | PMID: 33251673
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Abstract

Left atrial hypertension and the risk of early incident heart failure after atrial fibrillation ablation.

Gilge JL, Ahmed A, Clark BA, Slaten A, ... Ravichandran AK, Patel PJ
Introduction
Elevated left atrial pressure (LAP) during catheter ablation of atrial fibrillation (AF) is associated with an increased risk of AF recurrence, but it is unknown if this correlates with heart failure (HF). The objective of the study was to determine if elevated LAP after AF ablation correlates with HF events.
Methods
Prospective, single center, cohort study measuring LAP and RAP during AF ablation in 100 patients. The primary endpoint was clinical HF within 30 days of ablation. The secondary outcome was AF-free HF.
Results
100 patients (63% male, mean age 64.5) were enrolled and 20% had clinical HF within 30 days. Bivariate correlates included mitral valve (MV) disease, persistent AF, class III antiarrhythmics, LAP, and recurrent AF. Multivariate analysis revealed class III antiarrhythmics were protective (OR 0.24 [0.1-0.5], p=0.04), while MV disease (OR 8.7 [3.3-23], p=0.03) and loop diuretics (OR 4.8 [2.6-9.1], p=0.01) were hazardous. AF-free HF occurred in 9% of patients and correlated with higher LAP and RAP, and CKD.
Conclusion
Patients with HF after AF ablation had higher LAP. MV disease, diuretic use, and class III antiarrhythmics also correlated to HF. These present opportunities to target future interventions to reduce a common complication of AF ablation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print
Gilge JL, Ahmed A, Clark BA, Slaten A, ... Ravichandran AK, Patel PJ
J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print | PMID: 33270311
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Abstract

Validation of the VT-LVAD Score for Prediction of Late VAs in LVAD Recipients.

Darma A, Arya A, Dagres N, Kühl M, ... Leclercq C, Galand V
Introduction
Objectives This study sought to validate the performance of the VT-LVAD risk model in predicting late ventricular arrhythmias (VAs) in patients after left-ventricular assist device (LVAD) implantation. Background The need for ICD-implantation in LVAD-recipients is not well studied. A better selection of the patients with high risk for late VAs could lead to a more targeted ICD-implantation or replacement. Methods The study evaluated the performance of the VT-LVAD prognostic score [VAs prior LVAD, no ACE-inhibitor in medication, heart failure duration >12 months, early VAs post LVAD implantation, atrial fibrillation prior LVAD, idiopathic dilated cardiomyopathy] for the endpoint of the occurrence of late VAs in 357 LVAD-patients in Heart Centre of Leipzig. Results From the initial 460 patients, 357 (age 58 ± 10 years; left ventricular ejection fraction: 20 ± 6%; HeartWare: 50%; HeartMate III: 42%) were assigned to four risk groups according to their VT-LVAD-score varying from low risk to very high risk. After 25 months, late VAs occurred in 130 patients. The VT-LVAD score was an independent predictor of late VAs (multivariate analysis; p= <0.001; goodness-of-tip p=.347, OR 4.8). While there was no statistically significant difference between the low and intermediate risk group, risk stratification for patients with high risk and very high risk performed more accurately (pairwise comparison p=.005 and p<0.001, respectively). Conclusions The VT-LVAD-score predicted accurately the occurrence of late VAs in high risk LVAD recipients in a large external cohort of LVAD recipients supporting its utility for more targeted ICD implantations. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print
Darma A, Arya A, Dagres N, Kühl M, ... Leclercq C, Galand V
J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print | PMID: 33270307
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Abstract

Results from the Prospective, Multicenter AMBULATE-CAP Trial: Reduced Use of Urinary Catheters and Protamine with Hemostasis via the Mid-Bore Venous Vascular Closure System (Vascade MVP) Following Multi-access Cardiac Ablation Procedures.

Al-Ahmad A, Mittal S, DeLurgio D, Joseph Gallinghouse G, ... David Burkhardt J, Natale A
Introduction
Manual compression (MC), historically the most common method to achieve hemostasis after percutaneous vascular procedures, is time consuming, requires prolonged bedrest, and is uncomfortable for patients and clinicians. Recent studies demonstrate the efficacy and safety of vascular closure devices and suggest shorter times to hemostasis and patient ambulation compared with MC. The current study evaluated the feasibility of the VASCADE® venous vascular closure system (VVCS) while allowing for urinary catheter (UC) elimination, and elimination of protamine and/or same calendar day discharge (SCDD).
Methods and results
In this prospective, multicenter trial, patients were enrolled and assigned to the following groups: no UC, no protamine, and/or SCDD (no co-enrollment in no protamine and SCDD). After completing the catheter-based cardiac procedure, access sites were closed using the VVCS. Outcomes included final hemostasis (all sites) without major access site-related complications at 30 days, rates of access site closure-related complications, device success, and study group success. All 168 patients had hemostasis without major access site-related complications through 30 days. In the no UC group, 160/164 (97.6%) patients did not receive a UC. Additionally, 39/41 (95.1%) patients received heparin without protamine reversal and no access site bleeding-related ambulation delays, and 18/18 (100%) patients were discharged on the same day. There were no major access site closure-related complications, few minor complications, and adverse events were generally mild and well managed.
Conclusions
The VVCS was effective for achieving hemostasis following catheter-based procedures; access site closure-related complications and adverse events were well managed. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print
Al-Ahmad A, Mittal S, DeLurgio D, Joseph Gallinghouse G, ... David Burkhardt J, Natale A
J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print | PMID: 33270306
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Abstract

Clinical Impact of Eliminating Non-Pulmonary Vein Triggers of Atrial fibrillation and Non-Pulmonary Vein Premature Atrial Contractions at Initial Ablation for Persistent Atrial Fibrillation.

Tohoku S, Fukunaga M, Nagashima M, Korai K, ... Ando K, Hiroshima K
Backgrounds
The role of non-pulmonary vein (PV) triggers ablation in persistent atrial fibrillation (PEAF) was suggested but it is still under debate.
Objectives
We aimed to assess the effectiveness of non-PV trigger-targeted ablation for patients with PEAF.
Methods
Consecutive patients with PEAF undergoing catheter ablation (CA) between January 2015 and April 2017 were enrolled. Isoproterenol plus adenosine challenge was performed to provoke non-PV triggers. Non-PV triggers were defined as the trigger beats inducing AF (non-PV AF triggers) and/or frequent premature contractions (non-PV PACs) from other than PVs. Three groups were defined: group 1 (n=186) without non-PV triggers; group 2 (n=65) with non-PV triggers that could be completely eliminated with CA; group 3 (n=49) with non-PV triggers still inducible after CA. Primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence.
Results
A total of 300 patients (230 males, age 64±10) were enrolled. Mean follow-up period was 27±10 months. Freedom from ATa recurrence at 1- and 2 years were significantly lower in group 3 compared to the other 2 groups (group 1; 74.7%, 67.2% vs. group 2; 75.8%, 68.3% vs. group 3: 52.1%, 38.6%, P=0.0005), irrespective of the type of non-PV triggers (non-PV AF triggers vs. non-PV PACs). On multivariate analysis, unsuccessful elimination of non-PV triggers was an independent predictor for ATa recurrence (HR: 1.80, 95%CI: 1.07-2.95, P=0.026).
Conclusions
Successful non-PV triggers elimination can improve the ATa recurrence rate in PEAF ablation. ATa recurrence rate is higher, if non-PV AF triggers or even non-PV PACs remains in patients with PEAF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print
Tohoku S, Fukunaga M, Nagashima M, Korai K, ... Ando K, Hiroshima K
J Cardiovasc Electrophysiol: 02 Dec 2020; epub ahead of print | PMID: 33270298
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Abstract

Associations of Atrial Fibrillation Progression with Clinical Risk Factors and Clinical Prognosis: A report from the Chinese Atrial Fibrillation Registry Study.

Yang WY, Du X, Fawzy AM, He L, ... Ma CS,
Background
An understanding of the risk factors for atrial fibrillation (AF) progression and the associated impacts on clinical prognosis are important for the future management of this common arrhythmia. We aimed to investigate the rate of progression from paroxysmal (PAF) to more sustained sub-types of AF (SAF), the associated risk factors for this progression, and its impact on adverse clinical outcomes.
Methods and results
Using data from the Chinese Atrial Fibrillation Registry study, we included 8290 PAF patients. Half of them underwent initial AF ablation at enrollment. Main outcomes were ischemic stroke/systemic embolism (IS/SE), cardiovascular hospitalization, cardiovascular death, and all-cause mortality. The median follow-up duration was 1091 (704, 1634) days, and progression from PAF to SAF occurred in 881 (22.5%) non-ablated patients, while 130 (3.0%) ablated patients had AF recurrence and developed SAF. The incidence rate of AF progression for the cohort was 3.87 (95%CI: 3.64-4.12) per 100 patient-years, being higher in non-ablated compared to ablated patients. Older age, longer AF history, heart failure, hypertension, coronary artery disease, respiratory diseases, and larger atrial diameter were associated with higher incidence of AF progression, while antiarrhythmic drug use and AF ablation were inversely related to it. For non-ablated patients, AF progression was independently associated with an increased risk of IS/SE (HR 1.52, 95%CI: 1.15-2.01) and cardiovascular hospitalizations (HR 1.40, 95%CI:1.23-1.58).
Conclusions
AF progression was common in its natural course. It was related to comorbidities and whether rhythm control strategies were used, and was associated with an increased risk of IS/SE and cardiovascular hospitalization.
Clinical trial registration
Chinese Clinical Trial Registry ChiCTR-OCH-13003729. URL: http://www.chictr.org.cn/showproj.aspx?proj=5831 This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Dec 2020; epub ahead of print
Yang WY, Du X, Fawzy AM, He L, ... Ma CS,
J Cardiovasc Electrophysiol: 01 Dec 2020; epub ahead of print | PMID: 33269504
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Impact:

This program is still in alpha version.