Journal: J Cardiovasc Electrophysiol

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Abstract

Safety and Complications of Catheter Ablation for Atrial fibrillation: Predictors of complications from an updated analysis the National Inpatient Database.

Wu L, Narasimhan B, Ho KS, Zheng Y, Shah AN, Kantharia BK
Background
Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials.
Objectives
The aim of this study was to analyze safety and complications of AF ablation performed in a \'real world\' setting outside of clinical trials, and obtain insights on predictors of complications.
Methods
We utilized the National Inpatient Sample (NIS) database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease -Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications.
Results
Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1,884 complications were identified among 1,080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension, (adjusted odds ratio [aOR]: 1.99, p = 0.041) and chronic kidney disease, (aOR: 1.67, p = 0.024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates.
Conclusions
Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and chronic kidney disease are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print
Wu L, Narasimhan B, Ho KS, Zheng Y, Shah AN, Kantharia BK
J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print | PMID: 33650749
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Abstract

Safety and Chronic Lesion Characterization of Pulsed Field Ablation in a Porcine Model.

Stewart MT, Haines DE, Miklavčič D, Kos B, ... Howard B, Verma A
Background
Pulsed field ablation (PFA) has been identified as an alternative to thermal-based ablation systems for treatment of atrial fibrillation patients. The objective of this Good Laboratory Practice (GLP) study was to characterize the chronic effects and safety of overlapping lesions created by a PFA system at intracardiac locations in a porcine model.
Methods
A circular catheter with nine gold electrodes was used for overlapping low- or high-dose PFA deliveries in the superior vena cava (SVC), right atrial appendage (RAA), and right superior pulmonary vein (RSPV) in six pigs. Electrical isolation was evaluated acutely and chronic lesions were assessed via necropsy and histopathology after 4-week survival. Acute and chronic safety data were recorded peri- and post-procedurally.
Results
No animal experienced ventricular arrhythmia during PFA delivery, and there was no evidence of periprocedural PFA-related adverse events. Lesions created in all anatomies resulted in electrical isolation post-procedure. Lesions were circumferential, contiguous, and transmural, with all converting into consistent lines of chronic replacement fibrosis, regardless of trabeculated or smooth endocardial surface structure. Ablations were non-thermally generated with only minimal post-delivery temperature rises recorded at the electrodes. There was no evidence of extracardiac damage, stenosis, aneurysms, endocardial disruption, or thrombus.
Conclusions
PFA deliveries to the SVC, RAA, and RSPV resulted in complete circumferential replacement fibrosis at 4-weeks post-ablation with an excellent chronic myocardial and collateral tissue safety profile. This GLP study evaluated the safety and efficacy of a dosage range in preparation for a clinical trial and characterized the non-thermal nature of PFA. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print
Stewart MT, Haines DE, Miklavčič D, Kos B, ... Howard B, Verma A
J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print | PMID: 33650743
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Abstract

Atrial Electrophysiological Characteristics of Aging.

van der Does WFB, Houck CA, Heida A, van Schie MS, ... Bogers AJJC, de Groot NMS
Introduction
Advancing age is a known risk factor for developing atrial fibrillation (AF), yet it is unknown which electrophysiological changes contribute to this increased susceptibility. The goal of this study is to investigate conduction disturbances and unipolar voltages (UV) related to aging.
Methods
We included 216 patients (182 male, age 36-83 years) without a history of AF, undergoing elective coronary artery bypass surgery. Five seconds of sinus rhythm were recorded intra-operatively at the right atrium (RA), Bachmann\'s Bundle (BB), the left atrium and the pulmonary vein area (PVA). Conduction delay (CD), -block (CB), - velocity (CV), length of longest CB lines and UV were assessed in all regions.
Results
With aging, increasing conduction disturbances were found, particularly at RA and BB (RA: longest CB line rs 0.158, p=0.021; BB: CB prevalence rs 0.206, p=0.003; CV rs -0.239, p<0.0005). Prevalence of low UV areas (UV<5th percentile) increased with aging at the BB and PVA (BB: rs 0.237, p<0.0005 and PVA: rs 0.228, p=0.001).
Conclusions
Aging is accompanied by an increase in conduction disturbances during sinus rhythm and a higher prevalence of low UV areas, particularly at BB and in the RA. These electrophysiological alterations could in part explain the increasing susceptibility to AF development associated with aging. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print
van der Does WFB, Houck CA, Heida A, van Schie MS, ... Bogers AJJC, de Groot NMS
J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print | PMID: 33650738
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Abstract

Novel energy source for ablating the pulmonary veins; Is Pulsed Field Ablation the new ablation modality?

Ishidoya Y, Ranjan R
Catheter ablation is well-recognized treatment for symptomatic and drug-refractory atrial fibrillation (AF). This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print
Ishidoya Y, Ranjan R
J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print | PMID: 33650733
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Abstract

Ventricular pre-excitation in primary care patients: evaluation of the risk of mortality.

Paixão GM, Lima EM, Batista LM, Santos LF, ... Gomes PR, Ribeiro AL
Background
Ventricular pre-excitation is characterized by the presence of atrioventricular accessory pathways, predisposing to arrhythmias. Although it is well established that risk stratification in symptomatic patients should be invasive, there is a lack of evidence of the benefit in asymptomatics.
Objective
Evaluate ventricular pre-excitation in the electrocardiogram (ECG) as a risk factor for overall mortality in patients of Telehealth Network of Minas Gerais (TNMG), Brazil.
Methods
This observational study was developed with the database of digital ECGs (2010-2017) from TNMG. The electronic cohort was obtained by linking data from ECG exams and those from national mortality information system. Only the first ECG was considered. Clinical data were self-reported, and ECGs were interpreted manually by cardiologists and automatically by the Glasgow University Interpreter software. Hazard ratio (HR) for mortality was estimated using weighted Cox regression.
Results
1,665,667 patients were included (median age 50 [Q1:34; Q3:63] years; 41.4% were male). In a mean follow-up of 3.7 years, the overall mortality rate was 3.1%. The prevalence of ventricular pre-excitation was 0.07%. In multivariate analysis, adjusting for sex and age, ventricular pre-excitation was not associated with an increased risk of mortality (HR 1.41, 95% CI 0.56-3.57; p=0.47) when compared to the whole sample or to patients with normal ECG (HR 1.41, 95% CI 0.53-4.36; p=0.43). In a sub analysis on accessory pathway location, there was no evidence of a higher risk of death related to any location.
Conclusion
Ventricular pre-excitation was not associated with an increased risk of mortality in a primary care cohort. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print
Paixão GM, Lima EM, Batista LM, Santos LF, ... Gomes PR, Ribeiro AL
J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print | PMID: 33650721
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Abstract

Impact of Age on Catheter Ablation of Premature Ventricular Contractions.

Badertscher P, John L, Payne J, Bainey A, ... Winterfield JR, Gold MR
Introduction
Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages. The aim of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.
Methods
Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and ≥80% reduction of PVC burden determined by Holter-ECG during long-term follow. Patients were sub-grouped based on age (< 65 years vs. ≥ 65 years).
Results
A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%, p=0.04). The median procedure time was significantly shorter in elderly patients (160 min vs. 193 min, p=0.02). The rates of both acute (86% vs. 92%, p=0.32) and sustained success (70% vs. 71%, p=0.90) were similar between groups. Complications rates (3.7%) did not differ between the two groups.
Conclusion
In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print
Badertscher P, John L, Payne J, Bainey A, ... Winterfield JR, Gold MR
J Cardiovasc Electrophysiol: 01 Mar 2021; epub ahead of print | PMID: 33650717
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Abstract

Impact of Age on the Outcome of Cryoballoon Ablation as the primary approach in the interventional treatment of atrial fibrillation - Insights from a large all-comer study.

Hartl S, Dorwarth U, Pongratz J, Aurich F, ... Hoffmann E, Straube F
Introduction
The objective was to analyze the impact of patient age on clinical characteristics, procedural results, safety and outcome of cryoballoon ablation (CBA) as the primary approach in the interventional treatment of symptomatic atrial fibrillation (AF).
Methods and results
The single-center prospective observational study investigated consecutive patients who underwent initial left atrial ablation for symptomatic paroxysmal (PAF) or persistent AF (persAF). Age groups (A-F) of <40, 40-49, 50-59, 60-69, 70-79 and ≥80 years were evaluated. Follow-up (FU) included ECG, Holter monitoring and assessment of AF-symptoms. From 2012 to 2016, a total of 786 patients (64±11 years, range 21-85) underwent CBA. With advancing age, more cardiovascular comorbidities and larger LA diameter were observed, more females were included (each p<0.001). PAF (57%) and persAF (43%, p=0.320) were equally distributed over all age groups. Age was neither related to procedural parameters, nor to the complication rate (3.9%, p=0.233). Median FU was 38 months. Two non-procedure related non-cardiac deaths occurred late during FU. Freedom from arrhythmia was independent of age at 18 months (p=0.210) but decreased for patients ≥ 70 years at 24 months (p=0.02). At 36 months, freedom from arrhythmia was 66-74% (groups A-D), 54% (E) and 49% (F), respectively (p=0.002). LA diameter and persAF were independent predictors, whereas age was a dependent predictor of recurrence.
Conclusion
CBA as the primary approach in the initial ablation procedure is safe and highly effective in the young, middle aged, and elderly population. LA diameter and persAF, but not ageing, were independent predictors for arrhythmia recurrence. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 27 Feb 2021; epub ahead of print
Hartl S, Dorwarth U, Pongratz J, Aurich F, ... Hoffmann E, Straube F
J Cardiovasc Electrophysiol: 27 Feb 2021; epub ahead of print | PMID: 33644913
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Abstract

Ablation Index guided high-power (50W) short-duration for left atrial anterior and roof line ablation: feasibility, procedural data and lesion analysis (AI High-Power Linear Ablation).

Zanchi S, Chen S, Bordignon S, Bianchini L, ... Julian Chun KR, Schmidt B
Objectives
To evaluate the feasibility, procedural data, and lesion characteristics of anterior line (AL) and roof line (RL) ablation by using ablation index (AI) guided high-power(50W) among patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT) after pulmonary vein isolation (PVI).
Methods
Data from 35 consecutive patients with macro-reentrant left atrial tachycardia (LAT) or substrate at LA anterior wall or roof after previous PVI were collected. Ablation power was set to 50W, targeting AI 500 for AL and 400 for RL. First-pass conduction block (FPB) was evaluated. The AL was arbitrarily divided into 3(caudal, middle and cranial) segments to analyze the location of conduction gaps in non-FPB patients.
Results
A total of 32 AL and 17 RL were deployed and FPB was achieved in 24 (75%) and 14 (82%) of them respectively. In non-FPB group, the most frequent gap location along the AL was the middle third. Final block of AL was achieved in 97%, and block of RL was achieved in 100%. The RF ablation time was short (2,9 ± 0,8 min for AL and 46,2 ± 15,6 sec for RL). For AL, female gender was significantly more frequent in FPB than in non-FPB patients(p 0,028); patients with non-FPB were associated with significantly longer RF time as compared to patients with FPB (204 ± 47 sec vs 161 ± 41 sec; p = 0,02). No procedural complications occurred.
Conclusion
AI guided high-power (50W) ablation appears to be a feasible, effective and fast technique for AL and RL ablation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 25 Feb 2021; epub ahead of print
Zanchi S, Chen S, Bordignon S, Bianchini L, ... Julian Chun KR, Schmidt B
J Cardiovasc Electrophysiol: 25 Feb 2021; epub ahead of print | PMID: 33634549
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Abstract

Dormant Conduction in the Right Ventricular Outflow Tract Unmasked by Adenosine in a Patient with Brugada Syndrome.

Kamakura T, Duchateau J, Sacher F, Jais P, Haïssaguerre M, Hocini M
Recent data of electrophysiological mapping in patients with Brugada syndrome (BrS) suggest that the presence of an abnormal arrhythmogenic substrate in the epicardial right ventricular outflow tract (RVOT) is responsible for ST-segment elevation and ventricular fibrillation (VF). Complete elimination of the epicardial abnormal potentials normalizes Brugada-pattern electrocardiogram and suppresses VF recurrence. We herein report the first case of BrS in which an injection of adenosine unmasked dormant conduction in the epicardial RVOT after the disappearance of the epicardial potentials. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 25 Feb 2021; epub ahead of print
Kamakura T, Duchateau J, Sacher F, Jais P, Haïssaguerre M, Hocini M
J Cardiovasc Electrophysiol: 25 Feb 2021; epub ahead of print | PMID: 33634535
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Abstract

Dielectric Imaging for Electrophysiology Procedures: The Technology, Current State and Future Potential.

Abeln BGS, van den Broek JLPM, van Dijk VF, Balt JC, ... Dekker LRC, Boersma LVA
Electroanatomic mapping systems have become an essential tool to guide the identification and ablation of arrhythmic substrate. Recently, a novel guiding system for electrophysiology procedures was introduced that uses dielectric sensing to perform high resolution anatomical imaging. Dielectric imaging systems use electrical fields to differentiate anatomic structures based on their conductivity and permittivity. This technique enables non-fluoroscopic, non-contact mapping of anatomic structures, assessment of pulmonary vein occlusion state during cryoballoon ablation, and has the potential to assess for additional tissue characterization including tissue thickness and tissue type. This article elaborates on the functioning and potential of dielectric imaging systems and provides two cases to illustrate the clinical impact for electrophysiology procedures. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 24 Feb 2021; epub ahead of print
Abeln BGS, van den Broek JLPM, van Dijk VF, Balt JC, ... Dekker LRC, Boersma LVA
J Cardiovasc Electrophysiol: 24 Feb 2021; epub ahead of print | PMID: 33629788
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Abstract

Lead damage after cardiac implantable device replacement procedure: Comparison between electrical plasma tool and electrocautery.

Ananwattanasuk T, Jamé S, Bogun FM, Chugh A, ... Saeed M, Jongnarangsin K
Background
Lead damage is a complication caused by lead manipulation or heating damage from conventional electrocautery (EC) after cardiovascular implantable electronic device (CIED) replacement. Application of electrical plasma (PEAK PlasmaBlade) is a new technology that reportedly reduces this risk.
Objectives
This study was designed to compare the effect of EC versus PEAK PlasmaBlade on lead parameters and complications after generator replacement procedures.
Methods
We retrospectively studied 410 consecutive patients (840 leads) who underwent CIED replacement using EC (EC group) and 410 consecutive patients (824 leads) using PEAK PlasmaBlade (PlamaBlade group). Pacing lead impedance, incidence of lead damage, and complications were compared between both groups.
Results
Lead impedance increased in 393 leads (46.8%) in the EC group versus 282 leads (34.2%) in the PlasmaBlade group (p < .01) with average percent changes of 6.7% and 4.0% (p < .01), respectively. Lead impedance decreased in 438 leads (52.1%) in the EC group versus 507 leads (61.5%) in the PlasmaBlade group (p < .01) with average percent changes of -5.7% and -7.1% (p < .01), respectively. Lead damage requiring lead revision occurred in five leads (0.6%) or after five procedures (1.2%) in the EC group compared to three leads (0.4%, p = .50) or after three procedures (0.7%, p = .48) in the PlasmaBlade group. There were no significant differences in the procedural-related complications between the EC group (nine patients, 2.2%) and the PlasmaBlade group (five patients, 1.2%, p = .28).
Conclusion
Conventional electrocautery can potentially damage lead insulations. However, this study shows that when used carefully electrocautery is as safe as the PEAK PlasmaBlade™.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Ananwattanasuk T, Jamé S, Bogun FM, Chugh A, ... Saeed M, Jongnarangsin K
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625785
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Abstract

A unique mapping strategy for localization and ablation of the atrial input of an antegrade only conducting accessory pathway.

Ward C, Kamp A, Kertesz N, Kalbfleisch S
The standard technique for accessory pathway ablation involves mapping along the mitral and tricuspid annulus to localize the regions of earliest ventricular activation during antegrade pathway conduction, earliest atrial activation during retrograde conduction or detection of an accessory pathway potential. In some cases despite what appears to be appropriate mapping, catheter positioning and adequate power delivery the ablation is not successful. In many of these cases, the pathway is felt to be inaccessible because of a location remote from the mitral or tricuspid annulus that cannot be affected by endocardial power delivery along the annulus. In the case of difficult left sided pathways, some may be reached and ablated via the coronary sinus or its branches. Right sided pathways cannot be approached in this fashion since there is no venous structure analogous to the coronary sinus around the tricuspid annulus. Alternative mapping and ablation techniques for these difficult pathways have included epicardial mapping via direct pericardial access or attempts to localize pathway insertion areas remote from the valve annulus which may be amenable to endocardial ablation. We describe the use of post-pacing interval mapping to localize the atrial input of a right sided antegrade only accessory pathway that was resistant to conventional mapping and ablation strategies. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Ward C, Kamp A, Kertesz N, Kalbfleisch S
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625775
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Abstract

Arrhythmia Induced Cardiomyopathy: What are Predictors of Myocardial Recovery?

Nahlawi A, Refaat MM
Cardiomyopathies cause a significant public health burden and improvement in sudden cardiac death risk stratification helped in decreasing mortality by improved pharmacotherapy as well as device implantations including implantable cardiac defibrillators and cardiac resynchronization therapy [1-4]. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Nahlawi A, Refaat MM
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625774
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Abstract

Predictors of Myocardial Recovery in Arrhythmia Induced Cardiomyopathy: A Multicenter Study.

Gopinathannair R, Dhawan R, Lakkireddy DR, Murray A, ... Atkins D, Olshansky B
Background
Arrhythmia-induced cardiomyopathy (AIC) is characterized by improvement in left ventricular ejection fraction (LVEF) following arrhythmia treatment. Predictors of recovery in LVEF are not well understood.
Objective
We evaluated predictors of AIC recovery in a large multicenter cohort.
Methods
243 patients (age 65±11, 73% male) with AIC caused by atrial fibrillation (49%), atrial tachycardia (20%) and premature ventricular contractions (PVCs: 31%) were treated and included. LVEF was assessed before and after treatment. Patients were stratified by arrhythmia duration (Known [KN, n=132] vs unknown [UKN, n=111]), arrhythmia type, LVEF and presence of structural heart disease (SHD).
Results
Arrhythmia treatment was rhythm control in 95%. Median arrhythmia duration in the KN group was 47 months (25-75th percentile 24-80 months). Post-treatment LVEF was higher in KN group (55.9±7 vs46.2±12%, p<0.0001) but the degree of LVEF improvement was similar (21.2±9 vs 19.4±11, p=0.16). Comparing highest quartile (longest arrhythmia duration) vs rest of KN group, extent of LVEF improvement was similar (21.5±8 vs 21±9%, p=0.1). Patients in lowest index LVEF quartile (n=74) had more PVC-induced AIC, greater EF improvement after treatment [24±17 vs 19±7%; p <0.0001] but lower post-treatment EF [45±14 vs 54±8%; p<0.0001] vs other patients. Patients with SHD had lower index EF (28±8 vs 34±8%, p<0.0001) and lower final EF (47±12 vs 56± 7; p<0.0001). In multivariate regression, low index LVEF predicted myocardial recovery (OR 11.4; p<0.005).
Conclusions
In this AIC cohort, LVEF improved regardless of arrhythmia duration or type but those with PVCs had lower index LVEF and had less recovery. Low index LVEF predicted LVEF recovery following arrhythmia treatment. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Gopinathannair R, Dhawan R, Lakkireddy DR, Murray A, ... Atkins D, Olshansky B
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625771
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Abstract

His-Purkinje system longitudinal dissociation: from bench to bedside. A case of Output Dependent Fascicular Capture.

Marinaccio L, Vetta F, Ignatiuk B, Giacopelli D, Patrassi LA, Marchese D
Histological studies reported that the His bundle (HB) is partitioned into narrow cords by collagen running in its long axis, providing the anatomical setting necessary for its longitudinal dissociation. Further confirmations came from the demonstration that direct HB pacing normalizes the QRS axis and duration in subjects with proximal HB lesions causing bundle branch block. However, there is no evidence of the possibility of selective HB partitions pacing destined to the composition of branches and fascicles. We describe a case of intra-Hisian left bundle branch block in which permanent distal HB pacing corrects left ventricular delay and produces different QRS morphology at different voltage outputs, as an expression of different selective HB compartments recruitment. This case would strengthen the limited data in the literature about HB longitudinal dissociation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Marinaccio L, Vetta F, Ignatiuk B, Giacopelli D, Patrassi LA, Marchese D
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625765
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Abstract

Evolution of high-grade atrioventricular conduction disorders after transcatheter aortic valve implantation in patients who underwent implantation of a pacemaker with specific mode - that minimizes ventricular pacing - activated.

Irles D, Salerno F, Cassagneau R, Eschalier R, ... Frey P, other members of the STIMulation cardiaque post-TAVI (STIM-TAVI) study
Introduction
The evolution of atrioventricular conduction disorders after transcatheter aortic valve implantation (TAVI) remains poorly understood. We sought to identify factors associated with late (occurring ≥7 days after the procedure) high-grade atrioventricular block(s) after TAVI, based on specific pacemaker memory data.
Methods and results
STIM-TAVI (NCT03338582) was a prospective, multicentre, observational study that enrolled all patients (from November 2015 to January 2017) implanted with a specific dual chamber pacemaker after TAVI, with the SafeR® algorithm activated, allowing continuous monitoring of atrioventricular conduction. The primary endpoint was the occurrence of centrally adjudicated late high-grade atrioventricular block(s) during the year after TAVI. Among 197 patients, 138 (70.1%) had ≥1 late high-grade atrioventricular block. Whereas oversizing (P=.005), high-grade atrioventricular block during TAVI (P<.001), and early (within 6 days) high-grade atrioventricular block (P<.001) were associated with occurrence of late high-grade atrioventricular block, self-expanding prothesis (P=.88), prior right bundle branch block (P=.45), low implantation (P=.06) and new or wider left bundle branch block and lengthening of PR interval (P=.24) were not. In multivariable analysis, only post-TAVI early high-grade atrioventricular block remained associated with late high-grade atrioventricular block(s) (days 0-1: odds ratio [OR] 3.25; 95% confidence interval [CI] 1.57-6.74; P=.001; days 2-6: OR 4.13; 95% CI 2.06-8.31; P<.001), whereas other conventionally used predictors were not.
Conclusion
One-third of pacemaker-implanted patients do not experience late high-grade atrioventricular block(s). Our findings suggest that post-TAVI early high-grade atrioventricular block is the main factor associated with occurrence of late high-grade atrioventricular block(s). This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Irles D, Salerno F, Cassagneau R, Eschalier R, ... Frey P, other members of the STIMulation cardiaque post-TAVI (STIM-TAVI) study
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625762
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Abstract

Use of the Inverse Solution Guidance Algorithm method for RF ablation catheter guidance.

Lv W, Barrett CD, Arai T, Bapat A, ... Cohen RJ, Lee K
We previously introduced the Inverse Solution Guidance Algorithm (ISGA) methodology using a Single Equivalent Moving Dipole model of cardiac electrical activity to localize both the exit site of a re-entrant circuit and the tip of a radiofrequency (RF) ablation catheter. The purpose of this study was to investigate the use of ISGA for ablation catheter guidance in an animal model. Ventricular tachycardia (VT) was simulated by rapid ventricular pacing at a target site in eleven Yorkshire swine. The ablation target was established using three different techniques: a pacing lead placed into the ventricular wall at the mid-myocardial level (Type-1), an intracardiac mapping catheter (Type-2), and an RF ablation catheter placed at a random position on the endocardial surface (Type-3). In each experiment, one operator placed the catheter/pacing lead at the target location, while another used the ISGA system to manipulate the RF ablation catheter starting from a random ventricular location to locate the target. The average localization error of the RF ablation catheter tip was 0.31 ± 0.08 cm. After analyzing ~35 cardiac cycles of simulated VT, the ISGA system\'s accuracy in locating the target was 0.4 cm after 4 catheter movements in the Type-1 experiment, 0.48 cm after 6 movements in the Type-2 experiment, and 0.67 cm after 7 movements in the Type-3 experiment. We demonstrated the feasibility of using the ISGA method to guide an ablation catheter to the origin of a VT focus by analyzing a few beats of body surface potentials without electro-anatomic mapping. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Lv W, Barrett CD, Arai T, Bapat A, ... Cohen RJ, Lee K
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625757
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Abstract

Making the Cut for Generator Replacements.

Ravi V, Wasserlauf J
Cardiac implantable electronic devices (CIED) have become a common treatment modality for cardiac arrhythmia with over 300,000 new implants every year in the United States. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Ravi V, Wasserlauf J
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625754
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Abstract

QTc Shortening Effect of Ganglionated Plexi Ablation.

Aksu T, Bozyel S, Yalin K, Tanboga IH, Gopinathannair R
In previous studies, patients undergoing ablation of ganglionated plexi (GPA) for vagally mediated bradyarrhythmias were noted to have shortening of their corrected QT interval (QTc). In this study, we aimed to compare the effects of GPA (group 1) to pulmonary vein isolation + GPA (group 2) on QTc. We enrolled 39 patients, n=25 in group 1 and n=14 in group 2. QTc was calculated at baseline, at 24h after ablation, and at 9-12 months in the follow-up. Recurrent syncope, asystole > 2s, and/or second- or third-degree AVB episodes were carefully documented as the primary outcome in group 1. Any atrial arrhythmia ≥30 seconds documented on 24-h Holter monitoring was defined as the primary outcome in group 2. The mean follow-up time was 14.9 ± 4 months. Acute success was achieved in all cases. In whole cohort, a significant shortening on QTcBazett, QTcFramingham, QTcFredericia, and QTcHodges was observed [416 vs 398ms (p=0.002), 411vs 378 ms (p<0.001), 412 vs 379ms (p<0.001), and 420 vs 383ms (p<0.001), respectively]. In the linear mixed model analysis, the longitudinal reduction tendency in the QTc level was more pronounced in group 1. Event-free survival was detected in 90.7% (59/65) of cases. Our results demonstrate a significant shortening of QTc in addition to high medium-term success rates after GPA. Pulmonary vein isolation + GPA was associated with lower QTc shortening effect which implies structural disease may change electrophysiological response to ablation. The most likely mechanism is the effect of GPA on the sympathetic system. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print
Aksu T, Bozyel S, Yalin K, Tanboga IH, Gopinathannair R
J Cardiovasc Electrophysiol: 23 Feb 2021; epub ahead of print | PMID: 33625749
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Abstract

Reflections from the Book of the Dead: Weighing the Impact of Epicardial Fat on Atrial Fibrillation Vulnerability.

Bunch TJ
The ancient Egyptians wrote in the Book of the Dead, that all deeds in life, whether good or bad, remain in our hearts. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print
Bunch TJ
J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print | PMID: 33600058
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Abstract

Efficacy of LGE-MRI-Guided Fibrosis Ablation vs. Conventional Catheter Ablation of Atrial Fibrillation: The DECAAF II Trial: Study Design.

Marrouche NF, Greene T, Dean JM, Kholmovski EG, ... Akoum N, DECAAF II investigators
Background
Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment.
Objective
We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes.
Methods
The DECAAF II trial (ClinicalTrials.gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional PVI ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3 to 12 months post-ablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia post-ablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day post-ablation blanking period. Patients were followed for a period of 12 to 18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc., San Francisco, CA, United States). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint.
Conclusion
The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print
Marrouche NF, Greene T, Dean JM, Kholmovski EG, ... Akoum N, DECAAF II investigators
J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print | PMID: 33600025
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Abstract

An Anatomical Approach to Determine the Location of the Sinoatrial Node During Catheter Ablation.

Shimamoto K, Yamagata K, Nakajima K, Kamakura T, ... Nagase S, Kusano KF
Introduction
The sinoatrial node (SAN) should be identified before superior vena cava (SVC) isolation to avoid SAN injury. However, its location cannot be identified without restoring sinus rhythm. This study evaluated the usefulness of the anatomically defined SAN by comparing it with the electrically confirmed SAN (e-SAN) to predict the top-most position of e-SAN and thus establish a safe and more efficient anatomical reference for SVC isolation than the previously reported reference of the right superior pulmonary vein (RSPV) roof.
Methods and results
The e-SAN was identified as the earliest activation site in the electro-anatomical map obtained during sinus rhythm. The anatomically defined SAN, the cranial edge of the crista terminalis (CT) visualized with intracardiac echocardiography (CT top), and the RSPV roof, which was obtained from the overlaid electroanatomical image of SVC and RSPV, were tagged on one map. The distance from the e-SAN to each reference was measured. Among 77 patients, the height of the e-SAN from the CT top was a median (interquartile range) of -2.0 (-8.0 to 4.0) mm. The e-SAN existed from 10 mm above the CT top or lower in 74 (96%) patients and from the RSPV roof or below in 73 (95%) patients. The reference of 10 mm above the CT top is more proximal to the right atrium than the RSPV roof and can provide longer isolatable SVC sleeves (30.0 [20.0 to 35.0] vs. 24.0 [18.0 to 30.0] mm, p < 0.001). The e-SAN tended to be found above the CT top when the heart rate during mapping was faster (adjusted OR [95% CI] per 10-bpm increase: 1.71 [1.20-2.43], p < 0.01).
Conclusion
The CT top is useful for predicting the upper limit of the e-SAN and can provide a better reference for SVC isolation than the RSPV roof. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print
Shimamoto K, Yamagata K, Nakajima K, Kamakura T, ... Nagase S, Kusano KF
J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print | PMID: 33600020
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Abstract

Effect of Obesity and Epicardial Fat/Fatty Infiltration on Electrical and Structural Remodeling Associated With Atrial Fibrillation in a Novel Canine Model of Obesity and Atrial Fibrillation: A Comparative Study.

Otsuka N, Okumura Y, Arai M, Kurokawa S, ... Taniguchi Y, Li Y
Background
How obesity and epicardial fat influence atrial fibrillation (AF) is unknown.
Methods
To investigate the effect of obesity/epicardial fat on the AF substrate, we divided 20 beagle dogs of normal weight into 4 groups (n=5 each): One of the 4 groups (Obese-rapid atrial pacing [RAP] group) served as a novel canine model of obesity and AF. The other 3 groups comprised dogs fed a standard diet without RAP (Control group), dogs fed a high-fat diet without RAP (Obese group), or dogs fed a standard diet with RAP (RAP group). All underwent electrophysiology study, and hearts were excised for histopathologic and fibrosis-related gene expression analyses.
Results
Left atrial (LA) pressure was significantly higher in the Obese group than in the Control, RAP, and Obese-RAP groups (23.4±6.9 vs. 11.4±2.1, 11.9±6.4, and 13.5±2.9 mmHg, P=0.005). The effective refractory period of the inferior PV was significantly shorter in the RAP and Obese-RAP groups than in the Control group (P=0.043). Short-duration AF was induced at greatest frequency in the Obese-RAP and Obese groups (P<0.05). Fatty infiltration was greatest in the Obese-RAP group, and greater in the Obese and RAP groups than in the Control group. %interstitial fibrosis/fibrosis-related gene expression were significantly greater in the Obese-RAP and RAP groups (P<0.05).
Conclusions
Vulnerability to AF was associated with increased LA pressure and increased epicardial fat/fatty infiltration in our Obese group, and with increased epicardial fat/fibrofatty infiltration in the RAP and Obese-RAP groups. These may explain the role of obesity/epicardial fat in the pathogenesis of AF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print
Otsuka N, Okumura Y, Arai M, Kurokawa S, ... Taniguchi Y, Li Y
J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print | PMID: 33600010
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Abstract

Effect of Metformin on Outcomes of Catheter Ablation for Atrial Fibrillation.

Deshmukh A, Ghannam M, Liang J, Saeed M, ... Oral E, Oral H
Background
Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF). The effect of antidiabetic medications on AF or the outcomes of catheter ablation (CA) have not been well-described. We sought to determine whether metformin treatment is associated with a lower risk of atrial arrhythmias after CA in patients with DM and AF.
Methods and results
A 1st CA was performed in 271 consecutive patients with DM and AF (age: 65±9 years, women: 34 %; and paroxysmal AF: 51%). At a median of 13 months after CA (IQR: 6-30), 100/182 patients (55%) treated with metformin remained in sinus rhythm without antiarrhythmic drug therapy, compared to 36/89 patients (40%) not receiving metformin (P=0.03). There was a significant association between metformin therapy and freedom from recurrent atrial arrhythmias after CA in multivariable Cox hazards models (HR: 0.66, ±95% CI: 0.44-0.98, P=0.04) that adjusted for age, sex, BMI, AF type (paroxysmal vs. non-paroxysmal), antiarrhythmic medication, obstructive sleep apnea, chronic kidney disease, coronary artery disease, left ventricular ejection fraction, and left atrial diameter. A Cox model that also incorporated other antidiabetic agents and fasting blood glucose demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with metformin treatment (HR: 0.63; ±95% CI: 0.42-0.96, P=0.03).
Conclusions
In patients with DM, treatment with metformin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after CA for AF. Whether this effect is due to glycemic control or pleiotropic effects on electroanatomical mechanisms of AF remains to be determined. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print
Deshmukh A, Ghannam M, Liang J, Saeed M, ... Oral E, Oral H
J Cardiovasc Electrophysiol: 17 Feb 2021; epub ahead of print | PMID: 33600005
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Abstract

Periodontitis and the outcome of atrial fibrillation ablation: Porphyromonas gingivalis is related to atrial fibrillation recurrence.

Miyauchi S, Tokuyama T, Shintani T, Nishi H, ... Komatsuzawa H, Nakano Y
Introduction
Inflammation is one of the main causes of atrial fibrillation (AF) recurrence after ablation. Porphyromonas gingivalis is a key periodontal pathogen in the oral-systemic disease connection and serum immunoglobulin G (IgG) antibody titers against P. gingivalis reflect the clinical status of periodontitis. This study aimed to investigate the relationship between late recurrence of AF after radiofrequency catheter ablation (RFCA) and serum IgG antibody titers against P. gingivalis.
Methods
A total of 596 AF patients (mean age, 64.9 ± 10.0 years; 69% male; 61% paroxysmal AF) who underwent a first session of RFCA were enrolled. Patients were carefully examined for late recurrence during a mean follow-up period of 17.1 ± 14.5 months. Serum IgG antibody titers against P. gingivalis (types I-IV) were measured using enzyme-linked immunosorbent assay. The results of serum antibody titers were divided into a high-value and a low-value group.
Results
Among the five P. gingivalis subtypes, serum antibody titer against P. gingivalis type IV was associated with late recurrence (odds ratio, 1.937; 95% confidence interval [CI], 1.301-2.884; p = .002). Multivariate Cox proportional-hazards regression analysis revealed that high-value serum antibody titer against P. gingivalis type IV independently predicted late recurrence (paroxysmal AF: adjusted hazard ratio [HR], 1.569; 95% CI, 1.010-2.427; p = .04; non-paroxysmal AF: adjusted HR, 1.909; 95% CI, 1.213-3.005; p = .004).
Conclusion
Periodontitis was related to the late recurrence of AF after RFCA. P. gingivalis type IV may be pathogenic for AF recurrence after RFCA.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 14 Feb 2021; epub ahead of print
Miyauchi S, Tokuyama T, Shintani T, Nishi H, ... Komatsuzawa H, Nakano Y
J Cardiovasc Electrophysiol: 14 Feb 2021; epub ahead of print | PMID: 33590642
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Abstract

A Second Cryoballoon System- new and improved?

Su WW
Generations of cryoballoon transformed the atrial fibrillation ablation landscape. New advancements continue to make cryoballoon more successful and safer treatment. A new cryoballoon PolaRx from Boston Scientific has unique features compared to that of the Medtronic Arctic Front Advance system. Comparison of the two available cryoballoons will require ongoing larger trial and clinical experience. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Feb 2021; epub ahead of print
Su WW
J Cardiovasc Electrophysiol: 14 Feb 2021; epub ahead of print | PMID: 33590586
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Abstract

First experience of POLARx™ versus Arctic Front Advance™: An early technology comparison.

Creta A, Kanthasamy V, Schilling RJ, Rosengarten J, ... Hunter RJ, Finlay M
Introduction
Cryoballoon ablation is an established technique to achieve pulmonary vein isolation in patients with atrial fibrillation (AF). Recently, a new manufacturer of cryoballoon achieved regulatory CE marking (POLARx™, Boston Scientific). We describe our early experience of using this new market entrant of the technology and describe procedural aspects in comparison to the incumbent Medtronic Arctic Front Advance™.
Methods
We assessed the first 40 AF ablations performed with the POLARx catheter at the Barts Heart Centre. These patients were compared with a contemporaneous series of patients undergoing ablation by the same operators using the Arctic Front Advance. Procedural metrics were prospectively recorded.
Results
A total of 4 operators undertook 40 cases using the POLARx catheter, compared with 40 cases using the Arctic Front Advance. Procedure times (60.0 vs 60.0 minutes) were similar between the two technologies, however left atrial dwell time (35.0 vs 39.0 minutes) and fluoroscopy times (3.3 vs 5.2 minutes) were higher with the POLARx. Measured nadir and isolation balloon temperatures were significantly lower with POLARx. Almost all veins were isolated with a median freezing time of 16.0 (POLARx) vs 15.0 (Arctic Front Advance) minutes. The rate of procedural complications was low in both groups.
Conclusion
The POLARx cryoballoon is effective for pulmonary vein isolation. Measured isolation and nadir temperatures are lower compared to the predicate Arctic Front Advance catheter. The technology appears similar in acute efficacy and has a short learning curve, but formal dosing studies may be required to prove equivalence of efficacy. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Feb 2021; epub ahead of print
Creta A, Kanthasamy V, Schilling RJ, Rosengarten J, ... Hunter RJ, Finlay M
J Cardiovasc Electrophysiol: 14 Feb 2021; epub ahead of print | PMID: 33590568
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Abstract

Unusual cause for loss of left ventricular capture in patient with cardiac resynchronization due to tuberculous pericarditis.

Tse YH, Tse HF
We report a case of 37-year-old man implanted with cardiac resynchronization therapy-defibrillator presented with persistent low-grade fever and sudden loss of left ventricular (LV) capture from coronary sinus lead after generator replacement. 18 F-fluorodeoxyglucose positron emission tomography with computed tomography scan showed increased uptake at posterolateral region of the pericardium adjacent to the LV lead, suggestive of possible lead-related infection. Combined percutaneous and surgical lead extraction revealed purulent pericarditis and polymerase chain reaction testing confirmed tuberculous (TB) pericarditis. TB pericarditis is an unusual cause of loss of LV capture, but should be considered in countries where TB is still endemic.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 13 Feb 2021; epub ahead of print
Tse YH, Tse HF
J Cardiovasc Electrophysiol: 13 Feb 2021; epub ahead of print | PMID: 33586262
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Abstract

Brugada phenocopy in a patient with unstable angina and three-vessel coronary artery disease.

Casu G, Berne P, Viola G, Bandino S, Baranchuk A
A 52-year-old male was admitted with unstable angina and three-vessel coronary artery disease. Electrocardiography (ECG) changes consistent with type-1 Brugada ECG pattern were noted during admission. The patient was asymptomatic for syncope and had no family history of sudden cardiac death, ICD implantation, and Brugada syndrome. After coronary by-pass graft the Brugada ECG pattern resolved, and ajmaline test did not elicit type-1 ECG pattern, confirming the suspicion of Brugada phenocopy.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 13 Feb 2021; epub ahead of print
Casu G, Berne P, Viola G, Bandino S, Baranchuk A
J Cardiovasc Electrophysiol: 13 Feb 2021; epub ahead of print | PMID: 33586167
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Abstract

Novel mapping techniques for rotor core detection using simulated intracardiac electrograms.

Ravikumar V, Annoni E, Parthiban P, Zlochiver S, ... Mulpuru SK, Tolkacheva EG
Background
Catheter ablation is associated with limited success rates in patients with persistent atrial fibrillation (AF). Currently, existing mapping systems fail to identify critical target sites for ablation. Recently, we proposed and validated several techniques (multiscale frequency [MSF], Shannon entropy [SE], kurtosis [Kt], and multiscale entropy [MSE]) to identify pivot point of rotors using ex-vivo optical mapping animal experiments. However, the performance of these techniques is unclear for the clinically recorded intracardiac electrograms (EGMs), due to the different nature of the signals.
Objective
This study aims to evaluate the performance of MSF, MSE, SE, and Kt techniques to identify the pivot point of the rotor using unipolar and bipolar EGMs obtained from numerical simulations.
Methods
Stationary and meandering rotors were simulated in a 2D human atria. The performances of new approaches were quantified by comparing the \"true\" core of the rotor with the core identified by the techniques. Also, the performances of all techniques were evaluated in the presence of noise, scar, and for the case of the multielectrode multispline and grid catheters.
Results
Our results demonstrate that all the approaches are able to accurately identify the pivot point of both stationary and meandering rotors from both unipolar and bipolar EGMs. The presence of noise and scar tissue did not significantly affect the performance of the techniques. Finally, the core of the rotors was correctly identified for the case of multielectrode multispline and grid catheter simulations.
Conclusion
The core of rotors can be successfully identified from EGMs using novel techniques; thus, providing motivation for future clinical implementations.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print
Ravikumar V, Annoni E, Parthiban P, Zlochiver S, ... Mulpuru SK, Tolkacheva EG
J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print | PMID: 33570241
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Abstract

Long-term clinical outcomes of cardiac sympathetic denervation in patients with refractory ventricular arrhythmias.

Barwad P, Sinkar K, Bachani N, Shah R, ... Desai N, Lokhandwala Y
Background
Cardiac sympathetic denervation (CSD) is a useful therapeutic option in patients with structural heart disease (SHD) and ventricular tachycardia (VT) who are otherwise refractory to standard antiarrhythmic drug (AAD) therapy or catheter ablation (CA). In this study, we sought to retrospectively analyze the long-term outcomes of CSD in patients with refractory VT and/or VT storm with a majority of the patients being taken up for CSD ahead of CA.
Methods
We included consecutive patients with SHD who underwent CBD from 2010 to 2019 owing to refractory VT. A complete response to CSD was defined as a greater than 75% reduction in the frequency of ICD shocks for VT.
Results
A total of 65 patients (50 male, 15 female) were included. The underlying VT substrate was ischemic heart disease (IHD) in 30 (46.2%) patients while the remaining 35 (53.8%) patients had other nonischemic causes. The mean duration of follow-up was 27 ± 24 months. A complete response to CSD was achieved in 47 (72.3%) patients. There was a significant decline in the number of implantable cardioverter-defibrillator (ICD) or external defibrillator shocks post-CSD (24 ± 37 vs. 2 ± 4, p < .01). Freedom from a combined endpoint of ICD shock or death at 2 years was 51.5%. An advanced New York Heart Association class (III and IV) was the only parameter found to be associated with this combined endpoint.
Conclusion
The current retrospective analysis re-emphasizes the role of surgical CSD and explores its role ahead of CA in the treatment of patients with refractory VT or VT storm.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print
Barwad P, Sinkar K, Bachani N, Shah R, ... Desai N, Lokhandwala Y
J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print | PMID: 33570234
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Abstract

Elective replacement of a 4-year-old leadless pacemaker: New approach for end-of-life management.

De Filippo P, Malanchini G, Leidi C, Racheli M, ... Senni M, Ferrari P
We report the first case of new technique of replacement of a Micra TPS, due to battery depletion. A 38-year-old patient was admitted due to battery depletion of a TPS, after 44 months of regular pacemaker functioning. After routine implantation of a new TPS, we use a snare loop inserted in the delivery system to capture the old TPS. We believe this approach a good option not to abandon the depleted device, to avoid possible electrical interference or space occupation in right ventricle. This new approach allows to change the strategy during procedure and does not increase significantly the procedure costs.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print
De Filippo P, Malanchini G, Leidi C, Racheli M, ... Senni M, Ferrari P
J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print | PMID: 33570232
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Abstract

Identification of deliberate catheter motion at the left atrial posterior wall during pulmonary vein isolation: Validity of respiratory motion adjustment.

Tomlinson DR, Biscombe K, True J, Hosking J, Streeter AJ
Background
During automated radiofrequency (RF) annotation-guided pulmonary vein isolation (PVI), respiratory motion adjustment (RMA) is recommended, yet lacks in vivo validation.
Methods
Following contact force (CF) PVI (continuous RF, 30 W) using general anesthesia and automated RF annotation-guidance (VISITAG™: force-over-time 100% minimum 1 g; 2 mm position stability; ACCURESP™ RMA \"off\") in 25 patients, we retrospectively examined RMA settings \"on\" versus \"off\" at the left atrial posterior wall (LAPW).
Results
Respiratory motion detection occurred in eight, permitting offline retrospective comparison of RMA settings. Significant differences in LAPW RF auto-annotation occurred according to RMA setting, with curves displaying catheter position, CF and impedance data indicating \"best-fit\" for catheter motion detection using RMA \"off.\" Comparing RMA \"on\" versus \"off,\" respectively: total annotated sites, 82 versus 98; median RF duration per-site, 13.3 versus 10.6 s (p < 0.0001); median force time integral 177 versus 130 gs (p = 0.0002); mean inter-tag distance (ITD), 6.0 versus 4.8 mm (p = 0.002). Considering LAPW annotated site 1-to-2 transitions resulting from deliberate catheter movement, 3 concurrent with inadvertent 0 g CF demonstrated < 0.6 s difference in RF duration. However, 13 deliberate catheter movements during constant tissue contact (ITD range: 2.1-7.0 mm) demonstrated (mean) site-1 RF duration difference 3.7 s (range: -1.3 to 11.3 s): considering multiple measures of catheter position instability, the appropriate indication of deliberate catheter motion occurred with RMA \"off\" in all.
Conclusions
ACCURESP™ respiratory motion adjustment importantly delayed the identification of deliberate and clinically relevant catheter motion during LAPW RF delivery, rendering auto-annotated RF display invalid. Operators seeking greater accuracy during auto-annotated RF delivery should avoid RMA use.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print
Tomlinson DR, Biscombe K, True J, Hosking J, Streeter AJ
J Cardiovasc Electrophysiol: 10 Feb 2021; epub ahead of print | PMID: 33570226
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Abstract

Efficacy of medical and ablation therapy for inappropriate sinus tachycardia: A single-center experience.

Shabtaie SA, Witt CM, Asirvatham SJ
Background
Effective therapy for inappropriate sinus tachycardia (IST) remains challenging with high rates of treatment failure and symptom recurrence. It is uncertain how effective pharmacotherapy and procedural therapy are long-term, with poor response to medical therapy in general.
Methods
We retrospectively reviewed all patients with the diagnosis of IST at a tertiary academic medical center from 1998 to 2018. We extracted data related to prescribing patterns and symptom response to medical therapy and sinus node modification (SNM), assessing efficacy and periprocedural complication rates.
Results
A total of 305 patients with a formal diagnosis of IST were identified, with 259 (84.9%) receiving at least one prescription medication related to the condition. Beta-blockers were the most commonly used medication (n = 245), with a majority of patients reporting no change or worsening of symptoms, and poor response was seen to other medication classes. Improvement was seen significantly more often with ivabradine than beta blockers, though the sample size was limited (p = .003). Fifty-five patients (18.0% of all IST patients), mean age 32.0 ± 9.1 years, underwent a SNM procedure, with an average of 1.8 ± 0.9 procedures per patient. Acute symptomatic improvement (<6 months) was seen in 58.2% of patients. Long-term complete resolution of symptoms was seen in 5.5% of patients, modest improvement in 29.1%, and no long-term benefit was seen in 65.5% of patients.
Conclusions
Among all medical therapies, there were high rates of treatment failure or symptom worsening in over three-quarters of patients in our study. Ivabradine was most beneficial, though the sample size was small. While most patients receiving SNM ablation for IST perceive an acute symptomatic improvement, almost two-thirds of patients have no long-term improvement, and resolution of symptoms is quite rare. AV node ablation with pacemaker implantation following lack of response to SNM offered increased success, though the sample size was limited.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 09 Feb 2021; epub ahead of print
Shabtaie SA, Witt CM, Asirvatham SJ
J Cardiovasc Electrophysiol: 09 Feb 2021; epub ahead of print | PMID: 33566447
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Abstract

Tricuspid valve annuloplasty and mitral valve replacement are associated with bradyarrhythmia after mitral valve surgery.

Herrmann FEM, Schleith AS, Graf H, Sadoni S, ... Bagaev E, Juchem G
Introduction
Mitral valve surgery has developed into a strong subspecialty of cardiac surgery with operative techniques and outcomes constantly improving. The development of bradyarrhythmias after mitral valve surgery is not completely understood.
Methods
We investigated a cohort of 797 patients requiring mitral valve surgery with and without concomitant procedures. Incidences and predictors of pacemaker requirement as well as survival were analyzed.
Results
In the complete follow-up period (median follow-up time: 6.09 years [95% confidence interval [CI]: 5.94-6.22 years, maximum 8.77 years) 80 patients (10% of the complete cohort) required pacemaker implantation for bradyarrhythmia. The cumulative rate of pacemaker implantation was 6.4% at 50 days (48 patients) with most (54.2%) requiring pacing for atrioventricular block. Mitral valve replacement (odds ratio [OR]: 1.905; 95% CI: 1.206-3.536; p = .041) and tricuspid ring annuloplasty (OR: 2.348; 95% CI: 1.165-4.730, p = .017) were identified as operative risk factors of pacemaker requirement after mitral valve surgery. Insulin-dependent diabetes mellitus was also identified as a predictor of pacemaker requirement (OR: 4.665; 95% CI: 1.975-11.02; p = .001). There was no difference in survival in the paced and unpaced groups.
Conclusions
After mitral valve surgery, a relevant subgroup of patients requires pacemaker implantation-most for atrioventricular block. We identified mitral valve replacement and tricuspid ring annuloplasty as significant operative risk factors and insulin-dependent diabetes mellitus as a demographic risk factor. While anatomic relationships help explain the operative risk factors the role of diabetes mellitus is not completely understood.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 09 Feb 2021; epub ahead of print
Herrmann FEM, Schleith AS, Graf H, Sadoni S, ... Bagaev E, Juchem G
J Cardiovasc Electrophysiol: 09 Feb 2021; epub ahead of print | PMID: 33566390
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Impact:
Abstract

Increased incidence of electrical abnormalities in a pacemaker lead family.

Adelstein E, Zhang L, Nazeer H, Loka A, Steckman D
Introduction
Several recent studies have raised concern about noise detections on Tendril pacemaker leads, which may represent insulation failure or algorithm-driven overreporting of physiologic signals.
Methods
We identified all pacemaker leads actively followed at Albany Medical Center, of which 1111 leads (262 Abbott Tendril, 576 Medtronic CapSure, 30 Fineline, 195 Ingevity, 48 Dextrus) in 703 patients were included in this observational study. Electrical abnormalities, comprising low-impedance measurements <200 Ω and repeated noise detections, were catalogued, as was initial management and subsequent need for surgical intervention.
Results
During 54 months median follow-up (interquartile range 24-105), 63 leads (5.7%) demonstrated electrical abnormalities, including low impedances in 21 and noise in 59. Tendril leads manifested abnormalities most frequently (n = 50; 19.1%) compared with CapSure (n = 9; 1.6%), Fineline (n = 0), Ingevity (n = 0), and Dextrus (n = 4; 8.3%) leads. The risk of abnormalities was significantly higher in Tendril leads (HR 9.6, 95% CI 5.2-17.6; p < .001). Low impedances were measured on 19 Tendril leads, a significantly higher risk than on other leads (HR 23.8, 95% CI 5.5-102.1; p < .001). Although observation and reprogramming sensitivity were the initial management strategy for 45 and 7 leads, respectively, 18 ultimately required surgical intervention, including 15 Tendrils. No electrical abnormalities were observed in 12 non-Tendril leads attached to Abbott devices compared with 48 of 252 Tendrils attached to Abbott devices (log-rank p = .035).
Conclusion
Tendril leads demonstrate significantly higher risk of repeated low impedances and noise compared to other manufacturers\' models, raising concern that these findings reflect early insulation failure. Increased scrutiny is warranted.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 09 Feb 2021; epub ahead of print
Adelstein E, Zhang L, Nazeer H, Loka A, Steckman D
J Cardiovasc Electrophysiol: 09 Feb 2021; epub ahead of print | PMID: 33566384
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Impact:
Abstract

A method to screen left ventricular dysfunction through ECG based on convolutional neural network.

Sun JY, Qiu Y, Guo HC, Hua Y, ... Zhang CY, Wang RX
Objective
This study aims to develop an artificial intelligence-based method to screen patients with left ventricular ejection fraction (LVEF) of 50% or lesser using electrocardiogram (ECG) data alone.
Methods
Convolutional neural network (CNN) is a class of deep neural networks, which has been widely used in medical image recognition. We collected standard 12-lead ECG and transthoracic echocardiogram (TTE) data including the LVEF value. Then, we paired the ECG and TTE data from the same individual. For multiple ECG-TTE pairs from a single individual, only the earliest data pair was included. All the ECG-TTE pairs were randomly divided into the training, validation, or testing data set in a ratio of 9:1:1 to create or evaluate the CNN model. Finally, we assessed the screening performance by overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value.
Results
We retrospectively enrolled a total of 26 786 ECG-TTE pairs and randomly divided them into training (n = 21 732), validation (n = 2 530), and testing data set (n = 2 530). In the testing set, the CNN algorithm showed an overall accuracy of 73.9%, sensitivity of 69.2%, specificity of 70.5%, positive predictive value of 70.1%, and negative predictive value of 69.9%.
Conclusion
Our results demonstrate that a well-trained CNN algorithm may be used as a low-cost and noninvasive method to identify patients with left ventricular dysfunction.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 Feb 2021; epub ahead of print
Sun JY, Qiu Y, Guo HC, Hua Y, ... Zhang CY, Wang RX
J Cardiovasc Electrophysiol: 08 Feb 2021; epub ahead of print | PMID: 33565217
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Impact:
Abstract

Multi-lead cephalic venous access and long-term performance of high-voltage leads.

Akhtar Z, Harding I, Elbatran AI, Gonna H, ... Beeton I, Gallagher MM
Background
Cardiac resynchronization therapy-defibrillator (CRT-D) implantation via the cephalic vein is feasible and safe. Recent evidence has suggested a higher implantable cardioverter-defibrillator (ICD) lead failure in multi-lead defibrillator therapy via the cephalic route. We evaluated the relationship between CRT-D implantation via the cephalic and ICD lead failure.
Methods
Data was collected from three CRT-D implanting centers between October 2008 and September 2017. In total 633 patients were included. Patient and lead characteristics with ICD lead failure were recorded. Comparison of \"cephalic\" (ICD lead via cephalic) versus \"non-cephalic\" (ICD lead via non-cephalic route) cohorts was performed. Kaplan-Meier survival and a Cox-regression analysis were applied to assess variables associated with lead failure.
Results
The cephalic and non-cephalic cohorts were equally male (81.9% vs. 78%; p = .26), similar in age (69.7 ± 11.5 vs. 68.7 ± 11.9; p = .33) and body mass index (BMI) (27.7 ± 5.1 vs. 27.1 ± 5.7; p = .33). Most ICD leads were implanted via the cephalic vein (73.5%) and patients had a mean of 2.9 ± 0.28 leads implanted via this route. The rate of ICD lead failure was low and statistically similar between both groups (0.36%/year vs. 0.13%/year; p = .12). Female gender was more common in the lead failure cohort than non-failure (55.6% vs. 17.9%, respectively; p = .004) as was hypertension (88.9% vs. 54.2%, respectively, p = .038). On multivariate Cox-regression, female sex (p = .008; HR, 7.12 [1.7-30.2]), and BMI (p = .047; HR, 1.12 [1.001-1.24]) were significantly associated with ICD lead failure.
Conclusion
CRT-D implantation via the cephalic route is not significantly associated with premature ICD lead failure. Female gender and BMI are predictors of lead failure.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 Feb 2021; epub ahead of print
Akhtar Z, Harding I, Elbatran AI, Gonna H, ... Beeton I, Gallagher MM
J Cardiovasc Electrophysiol: 08 Feb 2021; epub ahead of print | PMID: 33565195
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Impact:
Abstract

Premature battery depletion of EMBLEM subcutaneous implantable cardioverter-defibrillators.

Ip JE
The EMBLEM subcutaneous implantable cardioverter defibrillator (S-ICD) has an expected longevity of 7 years. In August 2019, Boston Scientific released an advisory regarding a limited subset of ~400 S-ICDs that exhibited an increased likelihood of an electrical component malfunction causing accelerated battery depletion. We observed several cases of nonadvisory S-ICD early battery depletion and sought to systematically evaluate the cohort of EMBLEM devices implanted and followed in our medical center. Out of 118 nonadvisory EMBLEM S-ICDs with a median time to most recent follow-up after implant of 735 days (interquartile range 375-1219 days), there were four premature battery failures identified. Serial device interrogations showed a sudden reduction in battery life at 1 195, 1 205, 1 300, and 678 days after implant. The number of shocks delivered during the lifetime of the devices did not explain the premature depletion. There was a sudden departure from the gradual linear decrease in battery longevity observed over time. We are the first to report a signal of premature battery depletion among S-ICD EMBLEM devices that were not among the initial advisory devices. The prevalence of premature battery failure in our cohort was 3.4%, occurring at an average of 1 095 days. Following these reports, Boston Scientific issued an advisory on EMBLEM devices in December 2020 extending beyond the initial advisory subset. The current projected occurrence rate for hydrogen-induced accelerated battery depletion is 3.7% at 5 years. Increased surveillance of this potential device issue and mitigation to identify patients at risk for this is warranted.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 Feb 2021; epub ahead of print
Ip JE
J Cardiovasc Electrophysiol: 08 Feb 2021; epub ahead of print | PMID: 33565169
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Impact:
Abstract

Late-gadolinium enhancement properties associated with atrial fibrillation rotors in patients with persistent atrial fibrillation.

Nakamura T, Kiuchi K, Fukuzawa K, Takami M, ... Ashihara T, Hirata KI
Background
A computational model demonstrated that atrial fibrillation (AF) rotors could be distributed in patchy late-gadolinium enhancement (LGE) areas and play an important role in AF drivers. However, this was not validated in humans.
Objective
The purpose of this study was to evaluate the LGE properties of AF rotors in patients with persistent AF.
Methods
A total of 287 segments in 15 patients with persistent AF (long-standing persistent AF in 9 patients) that underwent AF ablation were assessed. Non-passively activated areas (NPAs), where rotational activation (AF rotor) was frequently observed, were detected by the novel real-time phase mapping (ExTRa Mapping). The properties of the LGE areas were assessed using the LGE heterogeneity and the density which was evaluated by the entropy (LGE-entropy) and the volume ratio of the enhancement voxel (LGE-volume ratio), respectively.
Results
NPAs were found in 61 (21%) of 287 segments and were mostly found around the pulmonary vein antrum. A receiver operating characteristic curve analysis yielded an optimal cutoff value of 5.7% and 10% for the LGE-entropy and LGE-volume ratio, respectively. The incidence of NPAs was significantly higher at segments with an LGE-entropy of >5.7 and LGE-volume ratio of >10% than at the other segments (38 [30%] of 126 vs. 23 [14%] of 161 segments; p = .001). No NPAs were found at segments with an LGE-volume ratio of >50% regardless of the LGE-entropy. Of five patients with AF recurrence, NPAs outside the PV antrum were not ablated in three patients and the remaining NPAs were ablated, but their LGE-entropy and LGE-volume ratio were low.
Conclusion
AF rotors are mostly distributed in relatively weak and much more heterogenous LGE areas.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print
Nakamura T, Kiuchi K, Fukuzawa K, Takami M, ... Ashihara T, Hirata KI
J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print | PMID: 33556994
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Impact:
Abstract

Protection of the esophagus during catheter ablation of atrial fibrillation.

Houmsse M, Daoud EG
Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print
Houmsse M, Daoud EG
J Cardiovasc Electrophysiol: 07 Feb 2021; epub ahead of print | PMID: 33556991
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Impact:
Abstract

Cryoballoon atrial fibrillation ablation: Single-center safety and efficacy data using a novel cryoballoon technology compared to a historical balloon platform.

Kochi AN, Moltrasio M, Tundo F, Riva S, ... Tondo C, Fassini G
Introduction
Catheter ablation is superior to drugs regarding atrial fibrillation (AF) recurrence, symptoms improvement, and mortality reduction in heart failure. POLARx™ is a novel cryoballoon, with technical improvements seeking to improve outcomes. So far, its clinical evidence is restricted to a case report.
Methods
To compare the POLARx™ cryoballoon procedural safety and efficacy to the already established Arctic Front Advance PRO™ (AFAP) in a single-center cohort study, consecutive patients undergoing AF cryoablation with the POLARx™ were enrolled. Data were prospectively gathered. POLARx™ patients were compared with a historical cohort of patients submitted to AF cryoablation with the AFAP.
Results
Seventy patients were analyzed, 20 in POLARx™, and 50 in the AFAP group. They all underwent first-time pulmonary vein isolation, 77% were male, 94% had paroxysmal AF, median age was 62.5 years, median CHA2 DS2 -VASc 1, left-atrium size 34 ml/m², and 65% were receiving anticoagulation. The primary end-point, all pulmonary veins isolation, was 100% in both groups. The complication rate was similar (0% POLARx™ vs. 5.7% AFAP, p = .39). The median total procedural time was longer in the POLARx™ group (90 min vs. 60 min, p < .001), but the overall time-to-isolation (TTI; 44.8 s vs. 39 s, p = .253) and ablation time (15 min vs. 13.7 min, p = .122) was similar between POLARx™ and AFAP groups, respectively. Despite equal TTI, the POLARx™ had a lower minimal temperature reached (-57°C vs -47°C, p < .001).
Conclusion
The novel POLARx™ cryoballoon had similar efficacy and safety compared with the AFAP. It was also associated with longer procedural times, similar TTI, and lower minimum temperature reached.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 02 Feb 2021; epub ahead of print
Kochi AN, Moltrasio M, Tundo F, Riva S, ... Tondo C, Fassini G
J Cardiovasc Electrophysiol: 02 Feb 2021; epub ahead of print | PMID: 33537996
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Impact:
Abstract

Circulating intermediate monocytes and atrial structural remodeling associated with atrial fibrillation recurrence after catheter ablation.

Suehiro H, Kiuchi K, Fukuzawa K, Yoshida N, ... Yamashita T, Hirata KI
Background
Inflammation, such as that associated with intermediate CD14++ CD16+ monocytes and atrial structural remodeling (SRM), may be important in the recurrence of atrial fibrillation (AF) after catheter ablation. However, the relationship between the intermediate CD14++ CD16+ monocytes, SRM, and AF recurrence is unclear.
Methods
Twenty-four patients with AF were enrolled. The proportion of intermediate monocytes (PIM) was assessed before ablation by flow cytometry. As a surrogate marker of SRM, the volume ratio (VR) of signal intensity greater than 1 standard deviation on late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) was calculated. We investigated whether PIM correlated with SRM on LGE-MRI and determined the optimal cutoff value for predicting AF recurrence.
Results
Univariate analysis revealed positive correlations between PIM and BNP with SRM (PIM: r = .593, p = .002; BNP: r = .567, p = .004). Multivariable analysis revealed that PIM was independently associated with VR on LGE-MRI (β = .522; p = .033). The finding of an area under the receiver operating characteristic curve of 0.750 revealed that a VR ≥ 13.3% on LGE-MRI as the optimal cutoff value to predict AF recurrence with 80% sensitivity and 71% specificity, which was associated with PIM ≥ 10.0%.
Conclusion
Intermediate monocytes were significantly positively correlated with SRM. PIM ≥ 10% was associated with a VR ≥ 13.3% on LGE-MRI, which predicted AF recurrence after catheter ablation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 01 Feb 2021; epub ahead of print
Suehiro H, Kiuchi K, Fukuzawa K, Yoshida N, ... Yamashita T, Hirata KI
J Cardiovasc Electrophysiol: 01 Feb 2021; epub ahead of print | PMID: 33533109
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Impact:
Abstract

Intracardiac echocardiography-guided implantation of the Watchman FLX left atrial appendage closure device.

Turagam MK, Neuzil P, Petru J, Hala P, ... Dukkipati SR, Reddy VY
Background
The next-generation Watchman FLX left atrial appendage closure (LAAC) device has: (1) an atraumatic closed distal end, (2) reduced height, (3) a recessed screw hub to decrease device-related thrombus (DRT), (4) two rows of J-shape anchors so redeployment is possible after full recapture, and (5) ability to treat a greater size range of LAA ostia.
Objective
To report, for the first time, the feasibility and safety of intracardiac echocardiography (ICE)-guided Watchman FLX implantation.
Methods
A single-center prospective registry of atrial fibrillation patients planned for LAAC with the FLX device underwent ICE-guided implantation with conscious sedation. Transesophageal echocardiography (TEE) imaging was done preprocedure (to assess LAA size and exclude thrombus) and at clinical follow-up at 6-12 weeks. Clinical outcomes were LAA closure success, complications, leak, or DRT on follow-up TEE and major safety events.
Results
The study included 30 patients: age 75 ± 8 years, 53% men, CHA2 DS2 -VASc 4.6 ± 1.6, and HAS-BLED 3.4 ± 1.1. The primary indication was prior bleeding in 60% (72% GI bleeding). The LAA orifice width and length were 22.7 ± 3.1 and 25.7 ± 5.7 mm, respectively. Technical success was 100% (the first-choice device was used in 28 of 30). Procedure time was less than 30 min in 27 of 30 cases, with 36 ± 15 ml contrast used. The final device size was 29.2 ± 4.7 mm with 21.6 ± 4.5% compression. There were no procedure-related complications. Follow-up TEE at a median 47 days follow-up showed 100% device success with no DRT or peridevice leak ≥5 mm. Major safety events occurred in 6.6% (2/30).
Conclusion
The Watchman FLX device can be safely implanted with intraprocedural ICE imaging instead of TEE.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 01 Feb 2021; epub ahead of print
Turagam MK, Neuzil P, Petru J, Hala P, ... Dukkipati SR, Reddy VY
J Cardiovasc Electrophysiol: 01 Feb 2021; epub ahead of print | PMID: 33533089
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Impact:
Abstract

Feasibility of catheter ablation in patients with persistent atrial fibrillation guided by fragmented late-gadolinium enhancement areas.

Kiuchi K, Fukuzawa K, Takami M, Watanabe Y, ... Kono A, Hirata KI
Background
A computer simulation model has demonstrated that atrial fibrillation (AF) driver can be attached to heterogeneous fibrosis assessed by late gadolinium enhancement magnetic resonance imaging (LGE-MRI). However, it has not been well elucidated in patients with persistent AF. The aim of this study was to investigate whether radiofrequency (RF) applications in the fragmented LGE area (FLA) could terminate AF or convert it to atrial tachycardia (AT) and improve the rhythm outcome.
Methods
A total of 31 consecutive persistent AF patients with FLAs were enrolled (FLA ablation group, mean age: 69 ± 8 years, mean left atrial diameter: 42 ± 6 mm). A favorable response was defined as direct AF termination or AT conversion during RF applications at the FLA. The rhythm outcome was compared between the FLA ablation group and FLA burden-matched pulmonary vein isolation (PVI) group.
Results
Favorable responses were found in 15 (48%) of 31 patients in the FLA group (AF termination in seven, AT conversion in eight patients), but not in the PVI group. AF recurrence at 12 months follow-up was significantly less in the FLA ablation group than in the PVI group (4 [13%] vs. 12 [39%] of 31 patients, log-rank p = .023). In patients with a favorable response, AT recurred in 1 (7%) of 15 patients, but AF did not.
Conclusions
FLA ablation could terminate AF or convert it to AT in half of the patients. No AF recurrence was documented in patients with a favorable response.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 31 Jan 2021; epub ahead of print
Kiuchi K, Fukuzawa K, Takami M, Watanabe Y, ... Kono A, Hirata KI
J Cardiovasc Electrophysiol: 31 Jan 2021; epub ahead of print | PMID: 33527586
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Impact:
Abstract

Long-term outcomes of index cryoballoon ablation or point-by-point radiofrequency ablation in patients with atrial fibrillation and systolic heart failure.

Prabhu S, Ahluwalia N, Tyebally SM, Dennis ASC, ... Schilling RJ, Hunter RJ
Catheter ablation is an established effective approach for the treatment of atrial fibrillation (AF) in patients with heart failure, however, the role of cryoablation in this setting is unclear. Procedural success and left ventricular systolic dysfunction (LVEF) improvement in patients with LVEF ≤ 45% undergoing index catheter ablation with cryoablation were evaluated. Freedom from AF recurrence was seen in 43% rising to 59% following repeat procedure. There were significant improvements in LVEF and functional status at long-term follow-up. Results were comparable to a contemporaneous cohort of heart failure patients undergoing index ablation with radiofrequency ablation. Cryoablation is an effective first-line AF ablation approach in the setting of heart failure.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 31 Jan 2021; epub ahead of print
Prabhu S, Ahluwalia N, Tyebally SM, Dennis ASC, ... Schilling RJ, Hunter RJ
J Cardiovasc Electrophysiol: 31 Jan 2021; epub ahead of print | PMID: 33527562
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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: 30 Jan 2021; 32:523-532
Zou F, Brar V, Worley SJ
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:523-532 | PMID: 32945053
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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 OrionTM (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: 30 Jan 2021; 32:545-546
Ollitrault P, Champ-Rigot L, Ferchaud V, Pellissier A, Coffin O, Milliez P
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:545-546 | PMID: 33058383
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Impact:
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 The Authors. Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:533-539
El-Chami MF, Bhatia NK, Merchant FM
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:533-539 | PMID: 33179814
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Impact:
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: 30 Jan 2021; 32:212-223
Nayyar S, Ha ACT, Timmerman N, Suszko A, Ragot D, Chauhan VS
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:212-223 | PMID: 33179399
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Impact:
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: 30 Jan 2021; 32:547-550
Nakatani Y, Vlachos K, Ramirez FD, Nakashima T, ... Sacher F, Romain T
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:547-550 | PMID: 33179375
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Impact:
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 right atrial pressure (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
One hundred 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 (odds ratio [OR]: 0.24 [0.1-0.5], p = .04), while MV disease (OR: 8.7 [3.3-23], p = .03) and loop diuretics (OR: 4.8 [2.6-9.1], p = .01) were hazardous. AF-free HF occurred in 9% of patients and correlated with higher LAP and RAP, and chronic kidney disease.
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.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:325-332
Gilge JL, Ahmed A, Clark BA, Slaten A, ... Ravichandran AK, Patel PJ
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:325-332 | PMID: 33270311
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Impact:
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: 30 Jan 2021; 32:477-483
Sanchez R, Nadkarni A, Buck B, Daoud G, ... Daoud EG, Afzal MR
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:477-483 | PMID: 33205561
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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: 30 Jan 2021; 32:370-375
Pook C, Kuhn E, Singh A, Kovach J
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:370-375 | PMID: 33205493
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Impact:
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 the 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 left ventricular ejection fraction 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 an upgrade to cardiac resynchronization therapy (CRT) device (n = 3), bridging after extraction of an infected transvenous system (n = 3), elevated thresholds (n = 3), and non-Micra-related bacteremia (n = 2). The median time from implantation to extraction was 78 days (interquartile range: 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 the 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 the requirement for CRT pacing. These patients were managed successfully with extraction or abandonment.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:484-490
Bhatia NK, Kiani S, Merchant FM, Delurgio DB, ... Shah AD, El-Chami MF
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:484-490 | PMID: 33251698
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Impact:
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 (PDLs), following LAmbre-assisted left atrial appendage closure (LAAC).
Methods
We performed transesophageal echocardiography (TEE) on patients participating in the LAmbre multicenter study, at Day 1 postimplantation, then at 3 and 12 months to assess PDL, device-related thrombus, left atrial appendage (LAA) thrombus, and left atrial thrombus. Clinical events were recorded during follow-up.
Result
A total of 152 patients with atrial fibrillation 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. Patients with PDL 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 an increased risk for thromboembolic events.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:354-359
Wang G, Kong B, Qin T, Liu Y, Huang C, Huang H
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:354-359 | PMID: 33251673
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Impact:
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
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 implantable cardioverter-defibrillator (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 = < .001; goodness-of-tip p = .347; odds ratio: 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 < .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.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:515-522
Darma A, Arya A, Dagres N, Kühl M, ... Leclercq C, Galand V
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:515-522 | 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 out of 164 (97.6%) patients did not receive a UC. Additionally, 39 out of 41 (95.1%) patients received heparin without protamine reversal and no access site bleeding-related ambulation delays, and 18 out of 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.
Conclusion
The VVCS was effective for achieving hemostasis following catheter-based procedures; access site closure-related complications and adverse events were well managed.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:191-199
Al-Ahmad A, Mittal S, DeLurgio D, Joseph Gallinghouse G, ... David Burkhardt J, Natale A
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:191-199 | PMID: 33270306
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Abstract

Clinical impact of eliminating nonpulmonary vein triggers of atrial fibrillation and nonpulmonary vein premature atrial contractions at initial ablation for persistent atrial fibrillation.

Tohoku S, Fukunaga M, Nagashima M, Korai K, ... Ando K, Hiroshima K
Background
The role of nonpulmonary 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. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence.
Results
A total of 300 patients (230 males, age 64 ± 10) were enrolled. The 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 two groups (Group 1; 74.7%, 67.2% vs. Group 2; 75.8%, 68.3% vs. Group 3: 52.1%, 38.6%, p = .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 (hazard ratio = 1.80, 95% confidence interval = 1.07-2.95, p = .026).
Conclusion
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 remain in patients with PEAF.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:224-234
Tohoku S, Fukunaga M, Nagashima M, Korai K, ... Ando K, Hiroshima K
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:224-234 | PMID: 33270298
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Impact:
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, Chinese Atrial Fibrillation Registry Study Group
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 subtypes 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 trial Fibrillation Registry study, we included 8290 PAF patients. Half of them underwent initial AF ablation at enrollment. The 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%) nonablated 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% confidence interval [CI] = 3.64-4.12) per 100 patient-years, being higher in nonablated compared to ablated patients. Older age, longer AF history, heart failure, hypertension, coronary artery disease, respiratory diseases, and larger atrial diameter were associated with a higher incidence of AF progression, while antiarrhythmic drug use and AF ablation were inversely related to it. For nonablated patients, AF progression was independently associated with an increased risk of IS/SE (hazard ratio [HR] = 1.52, 95% CI = 1.15-2.01) and cardiovascular hospitalizations (HR = 1.40, 95% CI = 1.23-1.58).
Conclusion
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.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:333-341
Yang WY, Du X, Fawzy AM, He L, ... Ma CS, Chinese Atrial Fibrillation Registry Study Group
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:333-341 | PMID: 33269504
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Impact:
Abstract

Clinical impact of defibrillation testing in a real-world S-ICD population: Data from the ELISIR registry.

Ricciardi D, Ziacchi M, Gasperetti A, Schiavone M, ... Biffi M, Forleo GB
Background
Current guidelines recommend defibrillation testing (DT) performance in patients with a subcutaneous implantable cardioverter defibrillator (S-ICD), theoretically to reduce the amount of ineffective shocks. DT, however, has been proven unnecessary in transvenous ICD and real-world data show a growing trend in avoidance of DT after S-ICD implantation.
Methods
All patients undergoing S-ICD implant at nine associated Italian centers joining in the ELISIR registry (ClinicalTrials.gov Identifier: NCT04373876) were enrolled and classified upon DT performance. Long-term follow-up events were recorded and compared to report the long-term efficacy and safety of S-ICD implantations without DT in a real-world setting.
Results
A total of 420 patients (54.0 ± 15.5 years, 80.0% male) were enrolled in the study. A DT was performed in 254 (60.5%) patients (DT+ group), while in 166 (39.5%) was avoided (DT- group). Over a median follow-up of 19 (11-31) months, a very low rate (0.7%) of ineffective shocks was observed, and no significant differences in the primary combined arrhythmic outcome were observed between the two groups (p = .656). At regression analysis, the only clinical predictor associated with the primary combined outcome was S-ICD placement for primary prevention (odds ratio: 0.42; p = .013); DT performance instead was not associated with a reduction in primary outcome (p = .375).
Conclusion
Implanting an S-ICD without DT does not appear to impact the safety of defibrillation therapy and overall patients\' survival.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:468-476
Ricciardi D, Ziacchi M, Gasperetti A, Schiavone M, ... Biffi M, Forleo GB
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:468-476 | PMID: 33296533
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Abstract

A simple pacing maneuver to unmask an epicardial connection involving the right-sided pulmonary veins.

Hasebe H, Yoshida K, Nogami A, Furuyashiki Y, ... Baba M, Ieda M
Introduction
An epicardial connection (EC) between the right-sided pulmonary venous (PV) carina and right atrium (RA) is one of the mechanisms for which carinal ablation is required for right-sided PV isolation. The purpose of the study was to devise a simple pacing maneuver to differentiate an EC from a residual conduction gap on the antral ablation line during radiofrequency catheter ablation.
Methods and results
This study included 133 consecutive patients. After one round of ablation, electrograms at the posterior antrum outside the ablation line were recorded during sinus rhythm (SR) and coronary sinus (CS) pacing, and intervals between the antral and PV potentials were measured in each rhythm. The ΔintervalSR-CS was calculated as the difference between the interval during SR and that during CS pacing. Presence of an EC was confirmed by observation of a RA posterior wall breakthrough during right-sided PV pacing, which was then targeted for ablation. Patients with nonachievement of first-pass isolation (N = 35) and with PV reconnection during the procedure (N = 9) were classified into the EC-group (N = 20) and gap-group (N=24), respectively. The prevalence of carina breakthrough during SR was higher in the EC-group than the gap-group (18 [95%] vs. 1 [4%] patients, p < .0001). The ΔintervalSR-CS was larger in the EC-group versus gap-group (71 [interquartile range, 57-97] vs. 6 [2-9] ms, p < .0001). In all patients with an EC, RA ablation resulted in delay (32 [20-40] ms) (N = 15) or elimination of PV potentials (N = 5).
Conclusion
An EC can be efficiently discriminated from a conduction gap by a simple pacing maneuver.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:287-296
Hasebe H, Yoshida K, Nogami A, Furuyashiki Y, ... Baba M, Ieda M
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:287-296 | PMID: 33305884
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Impact:
Abstract

Catheter ablation of premature ventricular contractions originating from periprosthetic aortic valve regions.

Han J, Lee JZ, Padmanabhan D, Naksuk N, ... Zheng LR, Cha YM
Background
Little is known about the ablation outcomes of premature ventricular contractions (PVCs) that originate from the periprosthetic aortic valve (PPAV) regions of patients with aortic valve replacement (AVR).
Methods and results
Our study had 11 patients who underwent catheter ablation for PVCs arising from the PPAV regions (bioprosthetic aortic valve, n = 5; mechanical aortic valve, n = 6). The PVC characteristics, procedure characteristics, and efficacy of ablation were compared with the control group (n = 33). At baseline, the PPAV group had a lower left ventricular ejection fraction (mean [SD], 41% [12%] vs. 51% [8%]; p = .002). The rate of acute ablation success was 90.9% in the PPAV group. Ablation sites were identified above the left coronary cusp (LCC) and right coronary cusp commissure (LRCC) in one PVC, below the prosthetic valve in eight PVCs (four below LCC and four below LRCC), and within the distal coronary sinus in two PVCs. The mean procedure time, fluoroscopy time, and radiation in the PPAV group were all significantly greater than those in the control group (all p < .05). However, the number of radiofrequency ablation energy deliveries was not different. The PPAV group had a long-term success rate compared with the control group (72.7% vs. 87.9%, p = .48) and an increase of left ventricular ejection fraction from 43% to 49% after successful PVC ablation at follow-up (p < .001). Echocardiography showed no significant change in valve regurgitation after ablation. No new atrioventricular block occurred.
Conclusion
PVCs arising from PPAV regions can be successfully ablated in patients with prior AVR, without damaging the prosthetic aortic valve and atrioventricular conduction.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:400-408
Han J, Lee JZ, Padmanabhan D, Naksuk N, ... Zheng LR, Cha YM
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:400-408 | PMID: 33305865
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Impact:
Abstract

Evaluation of left atrial remodeling by 2D-speckle-tracking echocardiography versus by high-density voltage mapping in patients with atrial fibrillation.

Laish-Farkash A, Perelshtein Brezinov O, Valdman A, Tam D, ... Kogan Y, Marincheva G
Background
Strain imaging during left atrial (LA) reservoir phase (LASr) is used as a surrogate for LA structural remodeling and fibrosis. Atrial fibrillation (AF) patients with >5% low-voltage zones (LVZs) obtained by 3D-electro-anatomical-mapping have higher recurrence rate post-ablation. We investigated the relationship between LA remodeling using two-dimensional-speckle-tracking echocardiography (2D-STE) and high-density voltage mapping in AF patients.
Methods
A prospective study of 42 consecutive patients undergoing AF ablation. 2D-echo, 2D-STE, and high-density contact LA bipolar voltage maps were constructed before ablation. LVZs were determined with different bipolar amplitudes and their ratio per patient\'s LA area were investigated for correlation with LASr. We compared 2D-LASr results in patients with LVZs ≥ 5% (LVZs group) versus those with LVZ < 5% (non-LVZs group).
Results
Compared with non-LVZs group (n = 15), LVZs group (n = 27) included significantly older patients, more women, more persistent AF, higher CHA2 DS2 -VASc score, higher E/A ratio and higher LA volume index (p < .05). LVZs group had lower %LASr values (12.4 ± 5.9% vs. 21.1 ± 6.3, respectively; p<.001). LVZs% in different amplitudes (<0.1 mV, <0.2 mV, and <0.5 mV) were negatively correlated with %LASr (r = -.63, r = -.68, and r = -.72, respectively; p< .001). Atrial strain thresholds for LVZs ≥ 5% in amplitudes <0.1 mV, <0.2 mV, and <0.5 mV were associated with %LASr 12.98, 16.16 and 19.55, respectively; p< .05). In a multivariate analysis, %LASr was the only independent indicator of LVZs (OR, 0.8; 95% CI, 0.6-0.9; p= .04).
Conclusions
LVZs ≥ 5% has a negative association with atrial %LASr. Thus, a simple 2D-STE measurement of %LASr can be used as a noninvasive method to evaluate significant LA remodeling and fibrosis in AF patients.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:305-315
Laish-Farkash A, Perelshtein Brezinov O, Valdman A, Tam D, ... Kogan Y, Marincheva G
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:305-315 | PMID: 33331056
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Impact:
Abstract

Ultrasound guided axillary vein access: An alternative approach to venous access for cardiac device implantation.

Chandler JK, Apte N, Ranka S, Mohammed M, ... Reddy M, Sheldon SH
Introduction
Ultrasound guided axillary vein access (UGAVA) is an emerging approach for cardiac implantable electronic device (CIED) implantation not widely utilized.
Methods and results
This is a retrospective, age and sex-matched cohort study of CIED implantation from January 2017 to July 2019 comparing UGAVA before incision to venous access obtained after incision without ultrasound (conventional). The study population included 561 patients (187 with attempted UGAVA, 68 ± 13 years old, 43% women, body mass index (BMI) 30 ± 8 kg/m2 , 15% right-sided, 43% implantable cardioverter-defibrillator, 15% upgrades). UGAVA was successful in 178/187 patients (95%). In nine patients where UGAVA was abandoned, the vein was too deep for access before incision. BMI was higher in abandoned patients than successful UGAVA (38 ± 6 vs. 28 ± 6 kg/m2 , p < .0001). Median time from local anesthetic to completion of UGAVA was 7 min (interquartile range [IQR]: 4-10) and median procedure time 61 min (IQR: 50-92). UGAVA changed implant laterality in two patients (avoiding an extra incision in both) and could have prevented unnecessary incision in four conventional patients. Excluding device upgrades, there was reduced fluoroscopy time in UGAVA versus conventional (4 vs. 6 min; IQR: 2-5 vs. 4-9; p < .001). Thirty-day complications were similar in UGAVA versus conventional (n = 7 vs. 26, 4 vs. 7%; p = .13, p = .41 adjusting for upgrades), partly driven by a trend towards reduced pneumothorax (n = 0 vs. 3, 0 vs. 1%; p = .22).
Conclusions
UGAVA is a safe approach for CIED implantation and helps prevent an extra incision if a barrier is identified changing laterality preincision.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:458-465
Chandler JK, Apte N, Ranka S, Mohammed M, ... Reddy M, Sheldon SH
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:458-465 | PMID: 33337570
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Impact:
Abstract

Can permanent His bundle pacing be safely started by operators new to this technique? Data from a multicenter registry.

Chaumont C, Auquier N, Milhem A, Mirolo A, ... Eltchaninoff H, Anselme F
Background
Right ventricular pacing (RVP) induces ventricular asynchrony in patients with normal QRS and increases the risk of heart failure and atrial fibrillation in long term. His bundle pacing (HBP) is a physiological alternative to RVP, and could overcome its drawbacks. Recent studies assessed the feasibility and safety of HBP in expert centers with a vast experience of this technique. These results may not apply to less experienced centers. We aim to evaluate the feasibility and safety of permanent HBP performed by physicians who are new to this technique.
Methods
We included all patients who underwent pacemaker implantation with attempt of HBP in three hospitals between September 2017 and January 2020. Indication for HBP was left to operators\' discretion. All the operators were new for HBP. His bundle (HB) electrical parameters were recorded at implant, 3- and 12-month follow-up.
Results
HBP was successful in 141 of 170 patients (82.9%); selective HBP was obtained in 96 patients and nonselective HBP in 45. The mean procedure and fluoroscopy durations were 67.0 ± 28.8 min, and 7.3 ± 8.1 min (3.1 ± 4.1 Gy·cm2 ), respectively. The mean HB paced QRS duration was 106 ± 18 ms. The mean HB capture threshold was 1.29 ± 0.77 V and did not increase at 3- and 12-month follow-up. The ventricular lead revision was required in five patients. Our results showed a rapid technical learning allowing a high procedure success rate (89.8%) after 15 procedures.
Conclusion
HBP performed by operators new to this technique appeared feasible and safe. This should encourage HBP to be performed in patients expected to experience high RVP burden.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:417-427
Chaumont C, Auquier N, Milhem A, Mirolo A, ... Eltchaninoff H, Anselme F
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:417-427 | PMID: 33373093
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Impact:
Abstract

Transvenous extraction of permanent pacemaker and defibrillator leads: Reduced procedural complexity and higher procedural success rates in patients with infective versus noninfective indications.

Archontakis S, Pirounaki M, Aznaouridis K, Karageorgopoulos D, ... Tousoulis D, Sideris S
Introduction
Transvenous lead extraction (TLE) is critical in the long-term management of patients with cardiac implanted electronic devices (CIEDs). The aim of the study is to evaluate the outcomes of TLE and to investigate the impact of infection.
Methods and results
Data of patients undergoing extraction of permanent pacemaker and defibrillator leads during October 2014-September 2019 were prospectively analyzed. Overall, 242 consecutive patients (aged 71.0 ± 14.0 years, 31.4% female), underwent an equal number of TLE operations for the removal of 516 leads. Infection was the commonest indication (n = 201, 83.1%). Mean implant-to-extraction duration was 7.6 ± 5.4 years. Complete procedural success was recorded in 96.1%, and clinical procedural success was achieved in 97.1% of attempted lead extractions. Major complications occurred in two (0.8%) and minor complications in seven (2.9%) patients. Leads were removed exclusively by using locking stylets in 65.7% of the cases. In the subgroup of noninfective patients, advanced extraction tools were more frequently required compared to patients with CIED infections, to extract leads (success only with locking stylet: 55.8% vs. 67.8%, p = .032). In addition, patients without infection demonstrated lower complete procedural success rates (90.7% vs. 97.2%, p = .004), higher major complication rates (2.4% vs. 0.5%, p = .31) and longer procedural times (136 ± 13 vs. 111 ± 15 min, p = .001).
Conclusions
Our data demonstrate high procedural efficacy and safety and indicate that in patients with noninfective indications, the procedure is more demanding, thus supporting the hypothesis that leads infection dissolves and/or prohibits the formation of fibrotic adherences.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:491-499
Archontakis S, Pirounaki M, Aznaouridis K, Karageorgopoulos D, ... Tousoulis D, Sideris S
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:491-499 | PMID: 33345428
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Impact:
Abstract

Same-day discharge after cryoballoon ablation of atrial fibrillation: A multicenter experience.

Kowalski M, Parikh V, Salcido JR, Chalfoun N, ... Epstein LM, Aryana A
Background
It is common practice to observe patients during an overnight stay (ONS) following a catheter ablation procedure for the treatment of atrial fibrillation (AF).
Objectives
To investigate the safety and economic impact of a same-day discharge (SDD) protocol after cryoballoon ablation for treatment of AF in high-volume, geographically diverse US hospitals.
Methods
We retrospectively reviewed 2374 consecutive patients (1119 SDD and 1180 ONS) who underwent cryoballoon ablation for AF at three US centers. Baseline characteristics, acute procedure-related complications, and longer-term evaluations of safety were recorded during routine clinical follow-up. The mean cost of an ONS was used in a one-way sensitivity analysis to evaluate yearly cost savings as a function of the percentage of SDD cases per year.
Results
The SDD and ONS cohorts were predominately male (69% vs. 67%; p = .3), but SDD patients were younger (64 ± 11 vs. 66 ± 10; p < .0001) with lower body mass index (30 ± 6 vs. 31 ± 61; p < .0001) and CHA2 DS2 -VASc scores (1.4 ± 1.0 vs. 2.2 ± 1.4; p < .0002). There was no difference between SDD and ONS in the 30-day total complication rate (n = 15 [1.26%] versus n = 24 [2.03%]; p = .136, respectively). The most common complication was hematoma in both the SDD (n = 8; 0.67%) and ONS (n = 11; 0.93%) cohorts. Sensitivity analysis demonstrated that when 50% of every 100 patients treated were discharged the same day, hospital cost savings ranged from $45 825 to $83 813 per year across US hospitals.
Conclusions
SDD following cryoballoon ablation for AF appears to be safe and is associated with cost savings across different US hospitals.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:183-190
Kowalski M, Parikh V, Salcido JR, Chalfoun N, ... Epstein LM, Aryana A
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:183-190 | PMID: 33345408
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Impact:
Abstract

Electrocardiographic predictors of successful resynchronization of left bundle branch block by His bundle pacing.

Arnold AD, Shun-Shin MJ, Keene D, Howard JP, ... Francis DP, Whinnett ZI
Background
His bundle pacing (HBP) is an alternative to biventricular pacing (BVP) for delivering cardiac resynchronization therapy (CRT) in patients with heart failure and left bundle branch block (LBBB). It is not known whether ventricular activation times and patterns achieved by HBP are equivalent to intact conduction systems and not all patients with LBBB are resynchronized by HBP.
Objective
To compare activation times and patterns of His-CRT with BVP-CRT, LBBB and intact conduction systems.
Methods
In patients with LBBB, noninvasive epicardial mapping (ECG imaging) was performed during BVP and temporary HBP. Intrinsic activation was mapped in all subjects. Left ventricular activation times (LVAT) were measured and epicardial propagation mapping (EPM) was performed, to visualize epicardial wavefronts. Normal activation pattern and a normal LVAT range were determined from normal subjects.
Results
Forty-five patients were included, 24 with LBBB and LV impairment, and 21 with normal 12-lead ECG and LV function. In 87.5% of patients with LBBB, His-CRT successfully shortened LVAT by ≥10 ms. In 33.3%, His-CRT resulted in complete ventricular resynchronization, with activation times and patterns indistinguishable from normal subjects. EPM identified propagation discontinuity artifacts in 83% of patients with LBBB. This was the best predictor of whether successful resynchronization was achieved by HBP (logarithmic odds ratio, 2.19; 95% confidence interval, 0.07-4.31; p = .04).
Conclusion
Noninvasive electrocardiographic mapping appears to identify patients whose LBBB can be resynchronized by HBP. In contrast to BVP, His-CRT may deliver the maximum potential ventricular resynchronization, returning activation times, and patterns to those seen in normal hearts.

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

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:428-438
Arnold AD, Shun-Shin MJ, Keene D, Howard JP, ... Francis DP, Whinnett ZI
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:428-438 | PMID: 33345379
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Impact:
Abstract

Unique technique to relieve left ventricular assist device electromagnetic interference with an implantable cardioverter defibrillator.

Jin C, Hsu J, Frenkel D, Jacobson JT, Iwai S, Ferrick A
We introduced a simple technique to eliminate electromagnetic interference between a left ventricular assist device (LVAD) and an implantable cardioverter defibrillator (ICD). A 43-year-old male with heart failure and a reduced ejection fraction who had an ICD presented with decompensated heart failure and received an LVAD as a bridge to transplant. Remote monitoring showed persistent atrial fibrillation causing an inappropriate ICD shock leading to a decision to disable shock therapies. However, an in-office interrogation was unsuccessful due to electromagnetic interference. Patient was instructed to extend his arm above his head on the ipsilateral side of the ICD, thus increasing the distance between LVAD and ICD, eliminating the interaction to allow reprogramming of the device.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:551-553
Jin C, Hsu J, Frenkel D, Jacobson JT, Iwai S, Ferrick A
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:551-553 | PMID: 33345375
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Impact:
Abstract

Short- and long-term associations of atrial fibrillation catheter ablation with left atrial structure and function: A cardiac magnetic resonance study.

Habibi M, Lima JAC, Gucuk Ipek E, Spragg D, ... Calkins H, Nazarian S
Background
The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood.
Objectives
To examine short- and long-term associations of AF catheter ablation with LA function using cardiac magnetic resonance (CMR).
Methods
Fifty-one AF patients (mean age 56 ± 8 years) underwent CMR at baseline, 1 day (n = 17) and 11 ± 2 months after ablation (n = 38). LA phasic volumes, emptying fractions (LAEF), and longitudinal strain were measured using feature-tracking CMR. LA fibrosis was quantified using late gadolinium enhancement (LGE).
Results
There were no acute changes in volume; however, active, total LAEF, and peak LA strain decreased significantly compared to the baseline. During long-term follow-up, there was a decrease in maximum but not minimum LA volume (from 99 ± 5.2 ml to 89 ± 4.7 ml; p = .009) and a decrease in total LAEF (from 43 ± 1.8% to 39 ± 2.0%; p = .001). In patients with AF recurrence, LA volumes were unchanged. However, total LAEF decreased from 38 ± 3% to 33 ± 3%; p = .015. Patients without AF recurrence had no changes in LA functional parameters during follow-up. The amount of LA LGE at long-term follow-up was higher compared to the baseline, however, was significantly less compared to immediately post-procedure (37 ± 1.9% vs. 47 ± 2.8%; p = .015). A higher increase in LA LGE extent compared to the baseline was associated with a greater decrease in total LAEF (r = -.59; p < .001).
Conclusions
LA function is impaired acutely following AF catheter ablation. However, long-term changes of LA function are associated positively with the successful restoration of sinus rhythm and inversely with increased LA LGE.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:316-324
Habibi M, Lima JAC, Gucuk Ipek E, Spragg D, ... Calkins H, Nazarian S
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:316-324 | PMID: 33350536
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Impact:
Abstract

Risk stratification in asymptomatic patients with Brugada syndrome: Utility of multiple risk factor combination rather than programmed electrical stimulation.

Shinohara T, Takagi M, Kamakura T, Sekiguchi Y, ... Aonuma K, Japan Idiopathic Ventricular Fibrillation Study (J-IVFS) Investigators
Background
The prognostic value of programmed electrical stimulation (PES) in Brugada syndrome (BrS) remains controversial. Asymptomatic BrS patients generally have a better prognosis than those with symptoms. The purpose of this study was to evaluate the value of nonaggressive PES with up to two extra stimuli and predict clinical factors for risk stratification in asymptomatic BrS patients.
Methods
The study enrolled 193 consecutive asymptomatic BrS patients with type 1 ECG (mean age: 50 ± 13 years, 180 males) who underwent PES using a nonaggressive uniform protocol. Cardiac events (CEs: sudden cardiac death or ventricular tachyarrhythmia) during the follow-up period were examined.
Results
During a mean follow-up of 101 ± 48 months, seven asymptomatic patients (3.6%) had a CE. The incidence of CEs was not different between patients with and without inducible ventricular tachyarrhythmia by PES (p = .51). The clinical significance of risk factor combinations, including spontaneous type 1 ECG, family history of sudden cardiac death, QRS duration in lead V2 , and presence of J wave, was evaluated. Using the Kaplan-Meier method according to the number of risk factors, the prevalence of CE in patients with three or four risk factors was determined to be significantly higher than in those with one risk factor (p = .02 and p = .004, respectively).
Conclusions
The present study suggests that inducibility of ventricular tachyarrhythmia does not predict future CEs in asymptomatic BrS patients. Combination analysis of the other four clinical risk parameters may be effective for risk assessment.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:507-514
Shinohara T, Takagi M, Kamakura T, Sekiguchi Y, ... Aonuma K, Japan Idiopathic Ventricular Fibrillation Study (J-IVFS) Investigators
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:507-514 | PMID: 33368830
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Impact:
Abstract

Anatomical insights into posterior wall isolation in patients with atrial fibrillation: A hypothesis to protect the esophagus.

Lu X, Peng S, Wu X, Zhou G, ... Chen S, Liu S
Introduction
Left atrial posterior wall (LAPW) isolation may be performed as an additional atrial fibrillation (AF) ablation strategy based on pulmonary vein isolation. A modified posterior-inferior line (MPL) was proposed for reducing esophageal injury. The aim of this study was to evaluate the anatomical characteristics of the MPL, compared with the conventional posterior line (CPL).
Methods and results
Multidetector computed tomography was performed in 102 consecutive AF patients (male/female = 60/42) preoperative, and the parameters were evaluated as follows: the distance from MPL and CPL to the esophagus, fat pad presence and thickness in the course of MPL and CPL, and the esophageal route below CPL. The average distance from the MPL to the esophagus was longer than from CPL to the esophagus (3.7 ± 1.5 vs. 1.7 ± 0.4 mm, p < .001). Proportion of fat pad was higher in the course of MPL than CPL. The myocardium tissue and fat pad under MPL was thicker than under CPL (2.9 ± 1.1 vs. 1.6 ± 0.3 mm, p < .001; 1.4 ± 0.6 vs. 0.9 ± 0.2 mm, p < .001), respectively. In patients whose esophagus was unconfined in a triangular space at the left inferior pulmonary vein level, the average distance from MPL to esophagus was longer than the confined patients (4.0 ± 1.7 vs. 3.2 ± 1.0 mm, p = .001).
Conclusion
The MPL was far away from the esophagus with thicker myocardium tissue and more fat pad than the CPL; thus, MPL could serve as a favorable alternative in linear ablation for LAPW isolation.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:270-278
Lu X, Peng S, Wu X, Zhou G, ... Chen S, Liu S
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:270-278 | PMID: 33368802
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Impact:
Abstract

Specific electrogram characteristics impact substrate ablation target area in patients with scar-related ventricular tachycardia-insights from automated ultrahigh-density mapping.

Schwarzl JM, Schleberger R, Kahle AK, Höller A, ... Willems S, Meyer C
Introduction
Substrate-based catheter ablation approaches to ventricular tachycardia (VT) focus on low-voltage areas and abnormal electrograms. However, specific electrogram characteristics in sinus rhythm are not clearly defined and can be subject to variable interpretation. We analyzed the potential ablation target size using automatic abnormal electrogram detection and studied findings during substrate mapping in the VT isthmus area.
Methods and results
Electrogram characteristics in 61 patients undergoing scar-related VT ablation using ultrahigh-density 3D-mapping with a 64-electrode mini-basket catheter were analyzed retrospectively. Forty-four complete substrate maps with a mean number of 10319 ± 889 points were acquired. Fractionated potentials detected by automated annotation and manual review were present in 43 ± 21% of the entire low-voltage area (<1.0 mV), highly fractionated potentials in 7 ± 8%, late potentials in 13 ± 15%, fractionated late potentials in 7 ± 9% and isolated late potentials in 2 ± 4%, respectively. Highly fractionated potentials (>10 ± 1 fractionations) were found in all isthmus areas of identified VT during substrate mapping, while isolated late potentials were distant from the critical isthmus area in 29%.
Conclusion
The ablation target area varies enormously in size, depending on the definition of abnormal electrograms. Clear linking of abnormal electrograms with critical VT isthmus areas during substrate mapping remains difficult due to a lack of specificity rather than sensitivity. However, highly fractionated, low-voltage electrograms were found to be present in all critical VT isthmus sites.

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

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:376-388
Schwarzl JM, Schleberger R, Kahle AK, Höller A, ... Willems S, Meyer C
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:376-388 | PMID: 33368769
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Impact:
Abstract

Ablation guided by STAR-mapping in addition to pulmonary vein isolation is superior to pulmonary vein isolation alone or in combination with CFAE/linear ablation for persistent AF.

Honarbakhsh S, Schilling RJ, Providencia R, Dhillon G, ... Finlay M, Hunter RJ
Introduction
The optimal ablation approach for persistent atrial fibrillation (AF) remains unclear.
Methods and results
Objective was to compare the long-term rates of freedom from AF/AT in patients that underwent STAR mapping guided ablation against outcomes of patients undergoing conventional ablation procedures. Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals (STAR) mapping study were included. Outcomes following \'pulmonary vein isolation (PVI) plus STAR mapping guided ablation (STAR mapping cohort) were compared to patients undergoing PVI alone ablation during the same time period and also a propensity-matched cohort undergoing PVI plus the addition of complex fractionated electrogram (CFAE) and/or linear ablation (\"conventional ablation\"). Rates of procedural AF termination and freedom from AF/AT during follow-up were compared. Sixty-five patients were included in both the STAR cohort and propensity matched conventional ablation cohort. AF termination rates were significantly higher in the STAR cohort (51/65, 78.5%) than conventional ablation cohort (10/65, 15.4%) and PVI alone ablation cohort (13/50, 26.0%; STAR cohort vs. other 2 cohorts both p < .001). There was no significant difference in procedure time between the three cohorts. During ≥20 months follow-up a lower proportion of patients had AF/AT recurrence in the STAR cohort (20.0%) compared with the conventional ablation cohort (50.8%) or the PVI alone ablation cohort (50.0%; both p < .05 compared to STAR cohort).
Conclusions
Outcomes of PVI plus STAR mapping guided ablation was superior to PVI alone or in combination with linear/CFAE ablation. A multicenter randomized controlled trial is planned to confirm these findings.

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

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:200-209
Honarbakhsh S, Schilling RJ, Providencia R, Dhillon G, ... Finlay M, Hunter RJ
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:200-209 | PMID: 33368766
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Impact:
Abstract

Procedure characteristics and outcomes of atrial fibrillation ablation procedures using cryoballoon versus radiofrequency ablation: A report from the GWTG-AFIB registry.

Friedman DJ, Holmes D, Curtis AB, Ellenbogen KA, ... Lewis WR, Piccini JP
Introduction
Cryoballoon ablation (CBA) is an alternative to radiofrequency ablation (RFA) for ablation of atrial fibrillation (AF) and real-world comparisons of this strategy are lacking. As such, we sought to compare patient and periprocedural characteristics and outcomes of CBA versus RFA in the Get With the Guidelines AFIB Registry.
Methods
Categorical variables were compared via the χ2 test and continuous variables were compared via the Wilcoxon rank-sum test. Adjusted analyses were performed using overlap weighting of propensity scores.
Results
A total of 5247 (1465 CBA, 3782 RFA) ablation procedures were reported from 33 sites. Those undergoing CBA more often had paroxysmal AF (60.0% vs. 48.8%) and no prior AF ablation (87.5% vs. 73.8%). CHA2 DS2 -VASc scores were similar. Among de novo ablations, most ablations involved intracardiac echocardiography and electroanatomic mapping, but both were less common with CBA (87.3% vs. 93.9%, p < .0001, and 87.7% vs. 94.6%, p < .0001, respectively). CBA was associated with shorter procedures (129 vs. 179 min, p < .0001), increased fluoroscopy use (19 vs. 11 min, p < .0001), and similar ablation times (27 vs. 35 min, p = .15). Nonpulmonary vein ablation was common with CBA: roof line 38.6%, floor line 20.4%, cavotricuspid isthmus 27.7%. RFA was associated with more total complications compared to CBA (5.4% vs. 2.3%, p < .0001), due to more volume overload and \"other\" events, although phrenic nerve injury was more common with CBA (0.9% vs 0.1%, p = .0001). In the adjusted model, any complication was less common among CBA cases (odds ratio, 0.45; confidence interval, 0.25-0.79, p = .0056).
Conclusion
CBA was associated with fewer complications, and shorter procedure times, and greater fluoroscopy times, compared to RFA. Nonpulmonary vein ablation and electroanatomic mapping system use was common with CBA.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:248-259
Friedman DJ, Holmes D, Curtis AB, Ellenbogen KA, ... Lewis WR, Piccini JP
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:248-259 | PMID: 33368764
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Impact:
Abstract

Surface unipolar electrogram characteristics to predict site of origin of outflow tract arrhythmias using noninvasive mapping.

Coleman KM, Saleh M, Makker P, Vaishnav AS, ... Skipitaris NT, Mountantonakis SE
Background
Noninvasive electroanatomic mapping (NIEAM) demonstrate patterns of depolarization that are useful in identifying the chamber of origin (COO) in outflow tract ventricular arrhythmias (OTVA). However, its use in predicting exact site of origin (SOO) has not yet been validated.
Methods
NIEAMs (CardioInsight, Medtronic) from 40 patients (age 62.5 ± 2.6) undergoing ablation for OTVA were reviewed for diagnostic accuracy in predicting the SOO. Earliest arrhythmia breakout and directionality of earliest instantaneous unipolar electrograms (uEGMs) on NIEAMs were evaluated subjectively by two observers for quality and amplitude. Sites with most negative earliest uEGMs on right and left ventricular outflow tracts, as well as epicardial surface were manually identified. Using NIEAM-based activation timing of the lateral mitral annulus and basal septum COO was identified for each OTVA. Predictions of SOO using NIEAMs was compared with true SOO from invasive study. NIEAMs SOO predictions were compared with subjective 12 lead electrocardiogram (ECG) review by two observers.
Results
Review of arrhythmia breakout and signal directionality had poor diagnostic value in predicting SOO in OTVA (50.6% and 49.4%, 56.6% and 43.4%, respectively) and underperformed compared with ECG interpretation (59.1% and 80.5%). After excluding uEGMs with poor characteristics, the uEGM with most negative amplitude at the COO was predictive of the true SOO with 96.4% sensitivity and specificity.
Conclusion
We propose a stepwise approach when interpreting NIEAMs for OTVA where patterns of activation are evaluated first to determine the COO, followed by identification of the site with most negative amplitude instantaneous uEGM to determine SOO.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:391-399
Coleman KM, Saleh M, Makker P, Vaishnav AS, ... Skipitaris NT, Mountantonakis SE
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:391-399 | PMID: 33368754
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Impact:
Abstract

Left bundle branch area pacing using stylet-driven pacing leads with a new delivery sheath: A comparison with lumen-less leads.

De Pooter J, Calle S, Timmermans F, Van Heuverswyn F
Introduction
Left bundle branch area pacing (LBBAP) aims to achieve physiological pacing by capturing the conduction system in the area of the left bundle branch. LBBAP has exclusively been performed using lumen-less pacing leads (LLLs) with fixed helix design. This study explores the feasibility, safety, and pacing characteristics of LBBAP using stylet-driven leads (SDLs) with an extendable helix design.
Methods
Patients, in which LBBAP was attempted for bradycardia or heart failure pacing indications, were prospectively enrolled at the Ghent University Hospital. LBBAP was attempted with two different systems: 1/LLL with fixed helix (SelectSecure 3830, Medtronic Inc.) delivered through a preshaped sheath (C315His Medtronic Inc.) and 2/SDL with extendable helix (Solia S60, Biotronik, SE & CO) delivered through a new delivery sheath (Selectra 3D, Biotronik).
Results
The study enrolled 50 patients (mean age: 70 ± 14 years, 44% females). LBBAP with SDL was successful in 20/23 (87%) patients compared with 24/27 (89%) of patients in the LLL group (p = 0.834). Screw attempts, screw implant depth, procedural, and fluoroscopy times were comparable among both groups. Acute LBBAP thresholds were low and comparable between SDL and LLL (0.5 ± 0.15 V vs. 0.4 ± 0.17 V, p = 0.251). Pacing thresholds remained low at 3 ± 2.1 months of follow up in both groups and no lead revisions were necessary. Postprocedural echocardiography revealed a septal coronary artery fistula in one patient with SDLLBBAP.
Conclusion
LBBAP using stylet-driven pacing leads is feasible and yields comparable implant success to LBBAP with LLLs. LBBAP thresholds are low and comparable with both types of leads.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:439-448
De Pooter J, Calle S, Timmermans F, Van Heuverswyn F
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:439-448 | PMID: 33355969
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Impact:
Abstract

Catheter ablation of ventricular tachycardia in patients with prior cardiac surgery: An analysis from the International VT Ablation Center Collaborative Group.

Aguilar M, Tedrow UB, Tzou WS, Tung R, ... Marchlinski FE, Sauer WH
Introduction
Patients with prior cardiac surgery may represent a subgroup of patients with ventricular tachycardia (VT) that may be more difficult to control with catheter ablation.
Methods
We evaluated 1901 patients with ischemic and nonischemic cardiomyopathy who underwent VT ablation at 12 centers. Clinical characteristics and VT radiofrequency ablation procedural outcomes were assessed and compared between those with and without prior cardiac surgery. Kaplan-Meier analysis was used to estimate freedom from recurrent VT and survival.
Results
There were 578 subjects (30.4%) with prior cardiac surgery identified in the cohort. Those with prior cardiac surgery were older (66.4 ± 11.0 years vs. 60.5 ± 13.9 years, p < .01), with lower left ventricular ejection fraction (30.2 ± 11.5% vs. 34.8 ± 13.6%, p < .01) and more ischemic heart disease (82.5% vs. 39.3%, p < .01) but less likely to undergo epicardial mapping or ablation (9.0% vs. 38.1%, p<.01) compared to those without prior surgery. When epicardial mapping was performed, a significantly greater proportion required surgical intervention for access (19/52 [36.5%] vs. 14/504 [2.8%]; p < .01). Procedural complications, including epicardial access-related complications, were lower (5.7% vs. 7.0%, p < .01) in patients with versus without prior cardiac surgery. VT-free survival (75.1% vs. 74.1%, p = .805) and survival (86.5% vs. 87.9%, p = .397) were not different between those with and without prior heart surgery, regardless of etiology of cardiomyopathy. VT recurrence was associated with increased mortality in patients with and without prior cardiac surgery.
Conclusion
Despite different clinical characteristics and fewer epicardial procedures, the safety and efficacy of VT ablation in patients with prior cardiac surgery is similar to others in this cohort. The incremental yield of epicardial mapping in predominant ischemic cardiomyopathy population prior heart surgery may be low but appears safe in experienced centers.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:409-416
Aguilar M, Tedrow UB, Tzou WS, Tung R, ... Marchlinski FE, Sauer WH
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:409-416 | PMID: 33355965
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Impact:
Abstract

Ultrahigh resolution electroanatomical mapping of the transverse conduction of the right atrial posterior wall in cases with and without typical atrial flutter.

Sekihara T, Miyazaki S, Nagao M, Kakehashi S, ... Uzui H, Tada H
Introduction
The right atrial posterior wall (RAPW) is known to form a conduction barrier during typical atrial flutter (AFL). We evaluated the transverse conduction properties of RAPW in patients with and without typical AFL using an ultrahigh resolution electroanatomical mapping system.
Methods and results
This study included 41 patients who underwent catheter ablation of AF, typical or atypical AFL, in whom we performed RAPW mapping with an ultrahigh resolution mapping system during typical AFL and coronary sinus ostial pacing with three different pacing cycle lengths (PCLs) (1) PCL1: PCL within 40 ms of the AFL cycle length in patients with typical AFL or 250-300 ms for those without, (2) PCL2: 400 ms, (3) PCL3: PCL just faster than the sinus rate. Local RAPW conduction block was evaluated by propagation mapping and local double potentials separated by an isoelectric line. The functional block was defined as areas blocked during shorter PCLs but conductive during longer PCLs. The degree of blockade was calculated by dividing the blocked length by RAPW length (%blockade). Only two patients demonstrated a fixed complete RAPW block (100%, %blockade). Thirty-one patients demonstrated a partial block of RAPW, and the %blockade during PCL1-3 was 49.4 ± 19.8%, 39.5 ± 19.2%, and 35.0 ± 22.9% in this group, respectively. Functional block areas were frequently observed above the fixed block area adjacent to the RA-inferior vena cava junction. Transverse conduction block was more frequently observed in patients with typical AFL at any longitudinal level of RAPW.
Conclusion
RAPW transverse conduction block is lower-side dominant and greater in patients with typical AFL than those without.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:297-304
Sekihara T, Miyazaki S, Nagao M, Kakehashi S, ... Uzui H, Tada H
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:297-304 | PMID: 33355964
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Impact:
Abstract

Comparison of electrophysiological characteristics of right- and left-sided Mahaim-type accessory pathways.

Ozcan EE, Turan OE, Akdemir B, Inevi UD, ... Alak C, Bayrak F
Aims
Mahaim-type accessory pathways (MAPs) are generally right-sided due to the embryological differentiation, but left-sided localization is also possible. This study aims to compare the clinical and electrophysiological characteristics of right- and left-sided MAPs.
Methods
Of 251 patients diagnosed with AP by electrophysiological study between November 2015 and February 2020, 12 patients with MAP were included (right sided n = 8, left sided n = 4). MAP was diagnosed if; (1) no retrograde conduction; (2) anterograde decremental conduction; (3) adenosine sensitivity; and (4) Mahaim potential at successful ablation site were present.
Results
Ten of twelve MAPs were clustered on the lateral walls of the mitral (n = 3, 75%) and tricuspid annuli (n = 7, 87.5%). Right-sided MAPs were mostly long pathways extending toward the conduction system whereas left-sided MAPs were short extending toward the neighboring myocardium. For right- and left-sided APs, the median QRS times were 129 and 156 ms (p = .042), the median VAbl -RVApex intervals were -12 and 64 ms (p = .007), the median QRS-V(His) intervals were 16 and 86 ms (p = .120), and the median VAbl -QRS interval was -8 and 12 ms (p = .017), respectively. Coexistence of dual atrioventricular node physiology was observed only in right-sided APs (n = 3, 37.5%).
Conclusion
MAPs are more typically located on the right but may rarely be seen on the left. Catheter ablation was associated with high success without complications.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:360-369
Ozcan EE, Turan OE, Akdemir B, Inevi UD, ... Alak C, Bayrak F
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:360-369 | PMID: 33355963
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Impact:
Abstract

Potential overdiagnosis of long QT syndrome using exercise stress and QT stand testing in children and adolescents with a low probability of disease.

Roston TM, De Souza AM, Romans HV, Franciosi S, Armstrong KR, Sanatani S
Background
Long QT syndrome (LQTS) is a dangerous arrhythmia disorder that often presents in childhood and adolescence. The exercise stress test (EST) and QT-stand test may unmask QT interval prolongation at key heart rate transition points in LQTS, but their utility in children is debated.
Objective
To determine if the QT-stand test or EST can differentiate children with a low probability of LQTS from those with confirmed LQTS.
Methods
This retrospective study compares the corrected QT intervals (QTc) of children (<19 years) during the QT-stand test and EST. Patients were divided into three groups for comparison: confirmed LQTS (n = 14), low probability of LQTS (n = 14), and a control population (n = 9).
Results
Using the Bazett formula, confirmed LQTS patients had longer QTc intervals than controls when supine, standing, and at 3-4 min of recovery (p ≤ .01). Patients with a low probability of LQTS had longer QTc duration upon standing (p = .018) and at 1 min of recovery (p = .016) versus controls. There were no significant QTc differences at any transition point between low probability and confirmed LQTS. Using the Fridericia formula, differences in QTc between low probability and confirmed LQTS were also absent at the transition points examined, except at 1 min into exercise, where low probability patients had shorter QTc intervals (437 vs. 460 ms, p = .029).
Conclusion
The diagnostic utility of the QT stand test and EST remains unclear in pediatric LQTS. The formula used for heart rate correction may influence accuracy, and dynamic T-U wave morphology changes may confound interpretation in low probability situations.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:500-506
Roston TM, De Souza AM, Romans HV, Franciosi S, Armstrong KR, Sanatani S
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:500-506 | PMID: 33382510
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Abstract

A porcine study of the area of heated tissue during hot-balloon ablation: Implications for the clinical efficacy and safety.

Nakahara S, Wakamatsu Y, Sato H, Otsuka N, ... Taguchi I, Okumura Y
Introduction
Hot-balloon ablation depends solely on thermal conduction, and myocardial tissue is ablated by only conductive heating from the balloon surface. Despite growing clinical evidence of the efficacy and safety of hot-balloon ablation for atrial fibrillation (AF), the actual tissue temperature and the mechanism of heating during such ablation has not been clarified. To determine, by means of a porcine study, the temperatures of tissues targeted during hot-balloon ablation of AF performed with hot-balloon set temperatures of 73°C or 70°C, in accordance with the temperatures now used clinically.
Methods
After a right thoracotomy, thermocouples with markers were implanted epicardially on the superior vena cava (SVC) and pulmonary veins (PVs) in six pigs. The tissue temperatures during hot-balloon ablation (balloon set temperatures of 73°C and 70°C, 180 s/PV) were recorded, and the maximum tissue temperatures and fluoroscopically measured distance from the balloon surface to the target tissues were assessed.
Results
Sixteen SVC- and 18 PV-targeted energy deliveries were performed. Full-thickness circumferential PV lesions were created with all hot-balloon applications. A significant inverse relation was found between the recorded tissue temperatures and distance (r = -.67; p < .001) from the balloon surface. No tissue temperature exceeded either of the balloon set temperatures. The best distance cutoff value for achieving lethal tissue temperatures more than 50°C was 3.6 mm.
Conclusion
The hot-balloon set temperature, energy delivery time, and tissue temperature data obtained in this porcine study supported the clinical efficacy and safety of the hot-balloon ablation as currently practiced in patients with AF.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:260-269
Nakahara S, Wakamatsu Y, Sato H, Otsuka N, ... Taguchi I, Okumura Y
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:260-269 | PMID: 33382509
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Abstract

Efficacy of catheter ablation for patients with atrial fibrillation and atrial septal defect.

Ogiso M, Ejima K, Shoda M, Sugiyama H, ... Miura M, Hagiwara N
Introduction
Given that few studies investigated the efficacy of catheter ablation (CA) in patients with paroxysmal atrial fibrillation (AF) and atrial septal defect (ASD), this study evaluated its effectiveness in patients with paroxysmal AF and ASD.
Methods and results
Of the 216 patients who underwent ASD device closure at two hospitals, 36 patients had paroxysmal AF. After April 2012, CA for AF was performed before ASD device closure (ASD-CA group; n = 20). The ASD-CA group had a significantly higher AF-free survival rate after ASD device closure compared to patients without CA for AF before ASD device closure (ASD-non-CA group; n = 16) (ASD-CA group: 2 patients vs. ASD-non-CA group: 9 patients; follow-up period: 4.2 ± 2.5 years; log-rank p = .01). In addition, the AF-free survival rates were similar between the ASD-CA group and 80 paroxysmal AF patients who underwent CA without any detectable structural heart disease (non-SHD-CA group). The two groups were matched by propensity scores for age, sex, and left atrium dimension (ASD-CA group: 2 patients vs. non-SHD-CA group: 5 patients; follow-up period: 3.3 ± 1.8 years; log-rank p = .28).
Conclusion
CA for AF before ASD device closure might be an effective treatment option for patients with paroxysmal AF and ASD.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:279-286
Ogiso M, Ejima K, Shoda M, Sugiyama H, ... Miura M, Hagiwara N
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:279-286 | PMID: 33382508
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Abstract

Continuous rhythm monitoring-guided anticoagulation after atrial fibrillation ablation.

Pothineni NVK, Amankwah N, Santangeli P, Schaller RD, ... Marchlinski FE, Frankel DS
Introduction
Oral anticoagulation (OAC) based on estimated stroke risk is recommended following catheter ablation (CA) of atrial fibrillation (AF), regardless of the extent of arrhythmia control. However, discontinuing OAC in selected patients may be safe. We sought to evaluate a strategy of OAC discontinuation following AF ablation guided by continuous rhythm monitoring.
Methods and results
We prospectively studied AF ablations performed at our institution from June 2015 to December 2019. Patients that had pre-existing cardiac implantable electronic devices (CIEDs) or underwent insertable cardiac monitor (ICM) implantation immediately following AF ablation were included. OAC was continued for 6 weeks following CA in all patients, following which OAC management was guided by CHA2 DS2 -VASc score and continuous rhythm monitoring results, according to a prespecified protocol. AF recurrence was defined as ≥30 s (CIEDs) or ≥2 min (ICM). We studied 196 patients (mean age 64.7 ± 11.3 years, 66.8% male, 85.7% ICM, 14.3% CIEDs). Mean CHA2 DS2- VASc score was 2.2  ± 1.5. One-year AF-free survival following CA was 83% for paroxysmal AF and 63% for persistent AF patients. Over 3 year follow-up, OAC was discontinued in 57 (33.7%) patients, mean 7.4 ± 7.1 months following ablation. Following discontinuation, OAC was restarted for AF recurrence in 9 (15.8%) patients, mean 11.7 ± 6.8 months after stopping. This discontinuation protocol led to a 21.9% reduction in overall time exposed to OAC. There were no thromboembolic or major bleeding events.
Conclusion
OAC can be discontinued in a significant percentage of patients following CA of AF. When guided by continuous rhythm monitoring, this practice does not unacceptably increase the risk of thromboembolic events.

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:345-353
Pothineni NVK, Amankwah N, Santangeli P, Schaller RD, ... Marchlinski FE, Frankel DS
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:345-353 | PMID: 33382500
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Abstract

Permanent His bundle pacing using a new tridimensional delivery sheath and a standard active fixation pacing lead: The telescopic technique.

Zingarini G, Notaristefano F, Spighi L, Bagliani G, Cavallini C
Introduction
Permanent His bundle pacing (PHBP) preserves physiological ventricular activation but technical difficulties have limited its widespread use. We report the first experience of PHBP performed with a new specific delivery sheath (Selectra 3D, Biotronik, Berlin, Germany) and an extendable-retractable active screw, stylet-driven pacing lead (Solia S 60, Biotronik).
Methods and results
Clinical, procedural, ECG, and electrical data from consecutive patients undergoing PHBP with this system were collected at implantation, and follow-up was performed after 1 month. Our cohort included 17 patients (71% males; mean age 76 ± 8 years) undergoing permanent pacing for sick sinus syndrome (59%) or atrioventricular block (41%). PHBP was successful in 15 (88%) procedures with mean procedure and fluoroscopy times of 63 ± 14 and 13 ± 5 min, respectively. The pacing threshold was 2.1 ± 1.1 V @1 ms and the sensed R-wave amplitude was 5.6 ± 3.5 mV; bipolar and unipolar pacing impedances were 526 ± 115 and 369 ± 109 Ω, respectively. At discharge, neither procedure-related complications nor lead dislodgement or pacing capture failures was reported. After 1 month, 14 (93%) patients still demonstrated His bundle stimulation and one (7%) lost His bundle capture but the lead revision was not necessary because the myocardial pacing threshold was stable. Follow-up threshold (2 ± 1.1 vs. 2.3 ± 1.2 [email protected] ms, p = .239) and sensed R-wave amplitude (5.6 ± 3.4 vs. 6.4 ± 2.5, p = .403) was unchanged compared to the acute phase.
Conclusion
PHBP performed with a standard active fixation pacing lead and a new delivery sheath for His pacing is feasible, safe and demonstrates clinically acceptable electric performance both at implantation and after 1 month.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:449-457
Zingarini G, Notaristefano F, Spighi L, Bagliani G, Cavallini C
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:449-457 | PMID: 33410557
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Abstract

Targeting the ectopy-triggering ganglionated plexuses without pulmonary vein isolation prevents atrial fibrillation.

Sandler B, Kim MY, Sikkel MB, Malcolme-Lawes L, ... other members of the Imperial College London, Cardiovascular Study Group/Consortium
Background
Ganglionated plexuses (GPs) are implicated in atrial fibrillation (AF). Endocardial high-frequency stimulation (HFS) delivered within the local atrial refractory period can trigger ectopy and AF from specific GP sites (ET-GP). The aim of this study was to understand the role of ET-GP ablation in the treatment of AF.
Methods
Patients with paroxysmal AF indicated for ablation were recruited. HFS mapping was performed globally around the left atrium to identify ET-GP. ET-GP was defined as atrial ectopy or atrial arrhythmia triggered by HFS. All ET-GP were ablated, and PVs were left electrically connected. Outcomes were compared with a control group receiving pulmonary vein isolation (PVI). Patients were followed-up for 12 months with multiple 48-h Holter ECGs. Primary endpoint was ≥30 s AF/atrial tachycardia in ECGs.
Results
In total, 67 patients were recruited and randomized to ET-GP ablation (n = 39) or PVI (n = 28). In the ET-GP ablation group, 103 ± 28 HFS sites were tested per patient, identifying 21 ± 10 (20%) GPs. ET-GP ablation used 23.3 ± 4.1 kWs total radiofrequency (RF) energy per patient, compared with 55.7 ± 22.7 kWs in PVI (p = <.0001). Duration of procedure was 3.7 ± 1.0 and 3.3 ± 0.7 h in ET-GP ablation group and PVI, respectively (p = .07). Follow-up at 12 months showed that 61% and 49% were free from ≥30 s of AF/AT with PVI and ET-GP ablation respectively (log-rank p = .27).
Conclusions
It is feasible to perform detailed global functional mapping with HFS and ablate ET-GP to prevent AF. This provides direct evidence that ET-GPs are part of the AF mechanism. The lower RF requirement implies that ET-GP targets the AF pathway more specifically.

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

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:235-244
Sandler B, Kim MY, Sikkel MB, Malcolme-Lawes L, ... other members of the Imperial College London, Cardiovascular Study Group/Consortium
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:235-244 | PMID: 33421265
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Abstract

A case of anomalous aortic origin of coronary artery associated with a coved-type electrocardiogram.

Kamakura T, Cetran L, Sacher F, Hocini M, Duchateau J
Brugada syndrome (BrS) is a sudden cardiac death syndrome characterized by a coved-type electrocardiogram (ECG). Different disorders, such as ischemia, can emulate a Brugada-pattern ECG (Brugada phenocopy). We report herein, the first case of surgical epicardial electrophysiological mapping in a successfully resuscitated patient with an anomalous aortic origin of the coronary artery (AAOCA) associated with a coved-type ECG. It was debatable whether the coved-type ECG and the abnormal arrhythmogenic substrate in the epicardial right ventricular outflow tract were derived from BrS or from repetitive ischemia due to AAOCA; however, the epicardial electrophysiological mapping helped in deciding the treatment strategy.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Jan 2021; 32:554-557
Kamakura T, Cetran L, Sacher F, Hocini M, Duchateau J
J Cardiovasc Electrophysiol: 30 Jan 2021; 32:554-557 | PMID: 33421212
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Abstract

Effect of family history of atrial fibrillation on recurrence after atrial fibrillation ablation: A report from the Chinese Atrial Fibrillation Registry Study.

Wu Z, Jiang C, Li J, Du J, ... Ma C, Dong J
Background
To evaluate the impact of family history of atrial fibrillation (FAF) on postablation atrial tachyarrhythmia (AT) recurrence.
Methods
All the 8198 patients undergoing initial AF ablation registered in the Chinese Atrial Fibrillation Registry study were analyzed. FAF was defined as having first-degree relatives diagnosed as AF at age 65 years or younger, and before the time the case in this study was diagnosed. Cox proportional hazards models were used to evaluate the impact of FAF on postablation AT recurrence. Age, sex, body mass index, AF type, history of congestive heart failure, hypertension, diabetes mellitus, prior stroke/transient ischemic attack/systemic embolism, vascular diseases, use of contact force-sensing catheter, and completion of high school were adjusted. The definition of AT recurrence was any documented AF, atrial flutter, or AT lasting more than or equal to 30 s after 3 months blanking period.
Results
After a mean follow-up of 26.2 ± 19.6 months, 318 out of the 645 patients (49.3%) with FAF and 3339 out of the 7553 patients (44.2%) without FAF experienced AT recurrence, corresponding to annual recurrence rates of 22.8% and 20.2%, respectively. Patients with FAF had a significant higher risk of AT recurrence (adjusted hazard ratio 1.129, 95% confidence interval 1.005-1.267) in multivariable analysis. Moreover, FAF had a significant higher impact on AT recurrence in the subgroup of patients diagnosed with AF at age 50 years or younger (p for interaction = .036).
Conclusion
FAF is a risk factor for postablation AT recurrence. This is especially true in those with AF diagnosed at 50 years or younger.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Jan 2021; epub ahead of print
Wu Z, Jiang C, Li J, Du J, ... Ma C, Dong J
J Cardiovasc Electrophysiol: 28 Jan 2021; epub ahead of print | PMID: 33512061
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Abstract

Patch monitors for arrhythmia monitoring in patients for suspected inherited arrhythmia syndrome.

Cheung CC, Davies B, Gibbs K, Laksman ZW, Krahn AD
Introduction
Patients undergoing evaluation for an inherited arrhythmia syndrome undertake a series of ambulatory investigations including 24-h Holter monitor, exercise treadmill testing (ETT), and others. Patch monitors may simplify the evaluation, providing accurate arrhythmia evaluation and QT assessment.
Methods and results
Patients referred for evaluation of an inherited arrhythmia syndrome underwent standard investigations, including 12-lead electrocardiography (ECG), 24-h Holter monitoring, ETT, along with supplemental monitoring using a 7-day ECG patch monitor. Heart rates (HR), corrected QT intervals (QTc), and ectopic burden were compared across monitoring modalities. Among 35 patients that wore the patch monitor, the median age was 39 years (54% male). There was intermediate correlation between resting HR across modalities (r = .58-.66) and poor correlation of peak HR (r = .27-.39). There was intermediate correlation between resting QTc intervals across modalities (r = .72-.77) but negligible correlation between QTc intervals at peak HR across modalities (r = -.01 to -.06). There was good correlation in PAC and PVC ectopic burden across the Holter and patch monitor.
Conclusion
Patch monitors may simplify the evaluation of patients for an inherited arrhythmia syndrome and provide resting QT assessment over time. However, QTc interval comparison at peak HRs remains variable, and may be limited by the single-lead ECG vector when using the patch monitor. Apart from QTc intervals at peak HR, patch monitors demonstrated good correlation with the ECG and Holter monitor for other parameters.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Jan 2021; epub ahead of print
Cheung CC, Davies B, Gibbs K, Laksman ZW, Krahn AD
J Cardiovasc Electrophysiol: 28 Jan 2021; epub ahead of print | PMID: 33512057
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