Journal: J Cardiovasc Electrophysiol

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Abstract

Short-Term Natural Course of Esophageal Thermal Injury After Ablation for Atrial Fibrillation.

Ishidoya Y, Kwan E, Dosdall DJ, Macleod RS, ... Jared Bunch T, Ranjan R
Purpose
To provide insight into the short-term natural history of esophageal thermal injury (ETI) after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) by esophagogastroduodenoscopy (EGD).
Methods
We screened patients who underwent RFCA for AF and EGD based on esophageal late gadolinium enhancement (LGE) in post ablation MRI. Patients with ETI diagnosed with EGD were included. We defined severity of ETI according to Kansas City classification (KCC): type 1: erythema; type 2: ulcers (2a: superficial; 2b deep); type 3 perforation (3a: perforation; 3b: perforation with atrioesophageal fistula). Repeated EGD was performed within 1-14 days after the last EGD if recommended and possible until any certain healing signs (visible reduction in size without deepening of ETI or complete resolution) were observed.
Results
ETI was observed in 62 of 378 patients who underwent EGD after RFCA. Out of these 62 patients with ETI, 21% (13) were type 1, 50% (31) were type 2a and 29% (18) were type 2b at the initial EGD. All esophageal lesions, but one type 2b lesion that developed into an atrioesophageal fistula (AEF), showed signs of healing in repeated EGD studies within 14 days after the procedure. The one type 2b lesion developing into an AEF showed an increase in size and ulcer deepening in repeat EGD 8 days after the procedure.
Conclusion
We found that all ETI which didn\'t progress to AEF presented healing signs within 14 days after the procedure and that worsening ETI might be an early signal for developing esophageal perforation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 May 2022; epub ahead of print
Ishidoya Y, Kwan E, Dosdall DJ, Macleod RS, ... Jared Bunch T, Ranjan R
J Cardiovasc Electrophysiol: 23 May 2022; epub ahead of print | PMID: 35606341
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Abstract

Durable pulmonary vein isolation with diffuse posterior left atrial ablation using low-flow, median power, short-duration strategy.

Li DL, El-Harasis M, Montgomery JA, Richardson TD, ... John RM, Michaud GF
Introduction
To target posterior wall isolation (PWI) in atrial fibrillation (AF) ablation, diffuse ablation theoretically confers a lower risk of conduction recovery compared to box set. We sought to assess the safety and efficacy of diffuse PWI with low-flow, medium-power, and short-duration (LF-MPSD) ablation, and evaluate the PVI and PWI durability among patients undergoing repeat ablations.
Methods
We retrospectively studied patients undergoing LF-MPSD ablation for AF (PVI + diffuse PWI) between 8/2017 and 12/2019. Clinical characteristics were collected. Kaplan-Meier survival analysis was performed to study AF/atrial flutter (AFL) recurrence. Ablation data were analyzed in patients who underwent a repeat AF/AFL ablation.
Results
Of the 463 patients undergoing LF-MPSD AF ablation (PVI alone, or PVI + diffuse PWI), 137 patients had PVI + diffuse PWI. Acute PWI with complete electrocardiogram elimination was achieved in 134 (97.8%) patients. Among the 126 patients with consistent follow up, 38 (30.2%) patients had AF/AFL recurrence during a median duration of 14 months. Eighteen patients underwent a repeat AF/AFL ablation after PVI + diffuse PWI, and 16 (88.9%) patients had durable PVI, in contrast to 10 of 45 (23.9%) patients who had redo ablation after LF-MPSD PVI alone. Seven patients (38.9%) had durable PWI, while 11 patients had partial electrical recovery at the posterior wall. The median percentage of area without electrical activity at the posterior wall was 70.7%. Conduction block across the posterior wall was maintained in 16 (88.9%) patients.
Conclusion
There was a high rate of PVI durability in patients undergoing diffuse PWI and PVI. Partial posterior wall electrical recovery was common but conduction block across the posterior wall was maintained in most patients. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
Li DL, El-Harasis M, Montgomery JA, Richardson TD, ... John RM, Michaud GF
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598280
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Abstract

Can All Stakeholders Benefit from Same Day Discharge Following Catheter Ablation of Atrial Fibrillation?

Musat D, Mittal S
Same-day discharge after AF ablation procedure is becoming the preferred trend. Vascular closure devices use have shortened the post-procedural bedrest, associated with increased patient satisfaction. Although this approach comes with a cost, it might also beneficial to the healthcare system. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
Musat D, Mittal S
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598283
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Abstract

Initial experience of left bundle branch area pacing using stylet-driven pacing leads: a multicenter study.

De Pooter J, Ozpak E, Calle S, Peytchev P, ... Wauters A, le Polain de Waroux JB
Background
Left bundle branch area pacing (LBBAP) has been performed exclusively using lumen-less pacing leads (LLL) with fixed helix design. This registry study explores the safety and feasibility of LBBAP using stylet-driven leads (SDL) with extendable helix design in a multicenter patient population.
Methods
This study prospectively enrolled consecutive patients who underwent LBBAP for bradycardia pacing or heart failure indications at eight Belgian hospitals. LBBAP was attempted using SDL (Solia S60, Biotronik) delivered through dedicated delivery sheath (Selectra3D). Implant success, complications, procedural and pacing characteristics were recorded at implant and follow-up.
Results
The study enrolled 353 patients (mean age 76±39 years, 43% female). The mean number of implants per center was 25 (range 5-162). Overall, LBBAP with SDL was successful in 334/353 (94%), varying from 93 to 100% among centers. Pacing response was labeled as left bundle branch pacing in 73%, whereas 27% were labeled as myocardial capture. Mean paced QRS duration and stimulus to left ventricular activation time measured 126±21ms and 74±17. SDL LBBAP resulted in low pacing thresholds (0.6±0.4V at 0.4ms), which remained stable at 12 months follow-up (0.7±0.3, p=0.291). Lead revisions for SDL LBBAP occurred in 5(1.4%) patients occurred during a mean follow up of 9±5 months. Five (1.4%) septal coronary artery fistulas and 8(2%) septal perforations occurred, none of them causing persistent ventricular septal defects.
Conclusion
The use of SDL to achieve LBBAP is safe and feasible, characterized by high implant success in low and high volume centers, low complication rates, and stable low pacing thresholds. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
De Pooter J, Ozpak E, Calle S, Peytchev P, ... Wauters A, le Polain de Waroux JB
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598298
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Abstract

Characteristics of Successful Reactive Atrial-based Antitachycardia Pacing in Patients with Cardiac Implantable Electronic Devices: History of Catheter Ablation of Atrial Fibrillation as a Predictor of High Treatment Efficacy.

Nakagomi T, Inden Y, Yanagisawa S, Suzuki N, ... Shibata R, Murohara T
Introduction
Reactive atrial-based antitachycardia pacing (rATP) in patients with cardiac implantable electronic devices (CIEDs) suppresses the progression of atrial fibrillation (AF) to the persistent form. However, the clinical factors associated with successful rATP treatment are unknown. This study aimed to examine the predictors of high rATP efficacy in patients with CIEDs.
Methods
The data of 101,325 rATP-treated atrial tachyarrhythmia (AT/AF) episodes in 51 patients, obtained through remote monitoring and device interrogation, were analyzed. The study population was divided into the high and low efficacy groups based on the overall median success rate of rATP. Clinical characteristics were compared between the two groups.
Results
During a follow-up period of 28.6±8.6 months, the median success rate was 43.7% (31.5-64.9%). The prevalence of a history of catheter ablation of AF was significantly higher in the high efficacy group than in the low efficacy group (73.0% vs. 44.0%, p=0.048) and was the only independent predictor of high rATP efficacy (odds ratio, 3.45; p=0.038). The rATP success rate in patients with (n=30) and without (n=21) a history of catheter ablation was 53.9% (40.0-67.5%) and 36.4% (22.2-47.7%), respectively (p=0.012). The effect of rATP after ablation was more pronounced in patients with long cycle length episodes (≥75% of AT/AF sequences having a cycle length of 200-449 ms) (67.3% [46.0-73.6%] vs. 30.6% [18.1-60.3%], p=0.027). The high efficacy group had a significantly lower incidence of AT/AF lasting ≥1, ≥7, and ≥30 days than the low efficacy group.
Conclusion
rATP combined with catheter ablation therapy is effective in suppressing AT/AF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
Nakagomi T, Inden Y, Yanagisawa S, Suzuki N, ... Shibata R, Murohara T
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598302
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Abstract

Patient-reported Outcomes and Costs Associated with Vascular Closure and Same-Day Discharge following Atrial Fibrillation Ablation.

Steinberg BA, Woolley S, Li H, Crawford C, ... Zhang Y, Jared Bunch T
Background
We aimed to measure patient reported outcomes (PROs) and costs associated with same day discharge (SDD) for AF ablation and vascular closure device implantation in clinical practice.
Methods
PROs were prospectively measured in 50 AF ablation patients, comparing complete vascular device closure (n=25) versus manual compression hemostasis (n=25). Health-system costs for SDD patients receiving vascular device closure were compared to matched controls with one-night stays who did not receive any closure device.
Results
Prospectively-enrolled patients receiving vascular device closure for AF ablation had mean age of 65 years, 17% were female, with a mean CHA2 DS2 -VASc score 3. Mean number of venous sheaths was higher among patients receiving vascular device closure (3.8 vs. 3.1,p<0.001), and there was 1 case of re-bleeding in a patient receiving vascular closure device (no other complications). Same-day discharge rates (76% vs. 8.3%,p<0.001), patient satisfaction with bedrest time (8.5 vs. 6,p=0.004) and with pain (8 vs. 5.1,p=0.009) were significantly better among patients receiving vascular closure. In matched analyses of health-system costs, patients with vascular closure had mean age 66, 32% were female, and mean CHA2 DS2 -VASc score was 2 (p=NS vs. controls). SDD with vascular closure was associated with significantly lower facility, pharmacy, and disposable costs, but higher implant costs. Overall costs for ablation were not significantly different (mean difference 1.10%, 95% CI -3.03-5.42).
Conclusions
Vascular closure for AF ablation improves patient experience in routine care. Use of vascular closure and SDD after AF ablation reduces several components of healthcare system costs, without an overall increase. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
Steinberg BA, Woolley S, Li H, Crawford C, ... Zhang Y, Jared Bunch T
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598310
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Abstract

Left Atrial Posterior Wall Isolation - The Conundrum of Safety versus Efficacy.

Calvert P, Gupta D
The study by Worck et al. raises interesting findings with regard to left atrial posterior wall ablation. The utility of ablation at the CRZ - which may represent epicardial connection via the septopulmonary bundle - warrants future research. Upcoming trials utilising existing technology, along with increased availability of pulsed field ablation, will advance our knowledge of the impact of left atrial posterior wall isolation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
Calvert P, Gupta D
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598312
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Abstract

Posterior Wall Isolation in Persistent Atrial Fibrillation Feasibility, Safety, Durability and Efficacy.

Worck R, Sørensen SK, Johannessen A, Ruwald M, Haugdal M, Hansen J
Introduction
Posterior wall isolation (PWI) added to pulmonary vein isolation (PVI) is increasingly used despite limited evidence of clinical benefit. We investigated the feasibility, durability, and efficacy of index-procedure PVI + PWI radio frequency ablation (RFA) in patients with persistent atrial fibrillation (PeAF).
Methods and results
Twenty-four patients with PeAF participated in the prospective PeAF-Box study and underwent RFA with wide area circumferential ablation (WACA), roof- and inferior lines to achieve PVI + PWI at index procedure. Follow-up included monitoring by an implantable cardiac monitor (ICM), esophagoscopy and mandated invasive lesion-reassessment at six months. PWI was achieved at minor procedural cost in all patients following PVI. In 33% of patients a median of three ablations in the narrow zone between the center of the posterior wall (PW) and the posterior right carina was pivotal for swift achievement of PWI. At the 6-months reassessment procedure 85% (95% CI: 77-92%) of pulmonary veins (PV´s) and 46% (95% CI: 26-67%) of PW´s remained durably isolated. AF recurred in 25% and was associated with PV-reconnection (P = 0.02) but not PW-reconnection (P = 0.27). AF-burden was 0% (IQR: 0% to 0%) overall and after recurrence 1% (IQR: 0 % - 7 %)
Conclusion:
Index procedure PVI + PWI for PeAF was feasible when recognizing that limited ablation in a PW center-to-right-carina zone was required in a subset of patients. Despite limited chronic PWI durability this strategy was followed by low AF-burden. A PVI + PWI strategy appears promising in ablation for PeAF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print
Worck R, Sørensen SK, Johannessen A, Ruwald M, Haugdal M, Hansen J
J Cardiovasc Electrophysiol: 22 May 2022; epub ahead of print | PMID: 35598313
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Abstract

The wall of unintended consequences: is the main benefit of posterior LA wall isolation simply more durable pulmonary vein isolation?

Zei PC
Medicine is rife with therapies originally developed for a specific purpose, yet after some time, the true benefit is determined to lie elsewhere - examples of the \"law of unintended consequences\". This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 May 2022; epub ahead of print
Zei PC
J Cardiovasc Electrophysiol: 19 May 2022; epub ahead of print | PMID: 35589553
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Abstract

Catheter Ablation for Atrial Fibrillation in the Elderly > 75 Years old: Systematic Review and Meta-Analysis.

Prasitlumkum N, Tokavanich N, Trongtorsak A, Cheungpasitporn W, ... Jared Bunch T, Navaravong L
Introduction
Atrial fibrillation (AF) ablation is increasingly performed worldwide. As comfort with AF ablation increases, the procedure is increasingly used in patients that are older and in those with more comorbidities. However, it is not well established whether AF ablation in the elderly, especially those >75 years old, has comparable safety and efficacy to younger populations.
Objective
To compare the efficacy and safety profiles in patients older than 75years undergoing AF ablation with younger patients.
Methods
Databases from EMBASE, Medline, PubMed and Cochrane, were searched from inception through September 2021. Studies that compared the success rates in AF catheter ablation and all complications rates between patients who were older vs under 75 years were included. Effect estimates from the individual studies were extracted and combined using random effect, generic inverse variance method of DerSimonian and Laird.
Results
Twenty-seven observational studies were included in the analysis consisting of 363,542 patients who underwent AF ablation. Comparing patients older than 75 years old to younger patients, there was no difference in the success of ablation rates between elderly and younger patients (pooled OR 0.85: 95% CI:0.69 - 1.05, p=0.131). On the other hand, AF ablation in the elderly was associated with higher complication rates (pooled OR 1.43: 95% CI:1.21 - 1.68, p<0.001)
Conclusion:
As AF ablation is expanded to elderly populations, our study found that AF ablation success rates were similar in both elderly and younger patients. However, older patients experience higher rates of complications that should be considered when offering the procedure and as a means to improve outcomes with future innovations. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 May 2022; epub ahead of print
Prasitlumkum N, Tokavanich N, Trongtorsak A, Cheungpasitporn W, ... Jared Bunch T, Navaravong L
J Cardiovasc Electrophysiol: 19 May 2022; epub ahead of print | PMID: 35589557
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Abstract

DURABILITY OF LEFT BUNDLE BRANCH AREA PACING.

Mehta NA, Saqi B, Sabzwari SRA, Gupta R, ... Freudenberger R, Bozorgnia B
Background
Left bundle branch area pacing (LBBAP) is a form of conduction system pacing. Long term data on the safety and performance of LBBAP one year post device implantation has not been well described.
Methods and results
Sixty-five patients (49% females) who received LBBAP for bradycardia indications using the SelectSecure 3830 lead (Medtronic, Minneapolis, MN) were retrospectively evaluated. Clinical variables were examined. Lead parameters were obtained at implant and during regular follow-up. Mean age of patients was 75.7±10.1 years with left ventricular ejection fraction 59.8±10.4%. Indications for pacing were atrioventricular block 55%, sinus node dysfunction 19%, tachy-brady syndrome 15%, atrioventricular node ablation 8%, and bail out CRT 3%. Mean baseline QRS measured 120±38ms, paced QRS duration was 138±22ms. Paced QRS narrowed by 24ms in those with preexisting left bundle branch block (BBB), increased by 1ms in those with preexisting right BBB, and increased by 42ms in those with no BBB. LBBAP threshold at implant was 0.521±0.153V @0.4ms, and increased to 0.654±0.186V at 3 months (+26%), 0.707±0.186 V at 6 months (+36%), and 0.772±0.220V at 12 months (+48%). Patients with left BBB showed the maximum benefit with QRS narrowing 24ms. Pacing impedance remained unchanged with no procedure related complications.
Conclusion
LBBAP is a durable form of conduction system pacing with pacing thresholds remaining relatively stable over 12 months post device implantation. Patients with left BBB display the narrowest paced QRS. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 May 2022; epub ahead of print
Mehta NA, Saqi B, Sabzwari SRA, Gupta R, ... Freudenberger R, Bozorgnia B
J Cardiovasc Electrophysiol: 18 May 2022; epub ahead of print | PMID: 35586896
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Abstract

Seize the day, …s(e)ize the device: the emerging imaging modality to improve left atrial appendage device sizing.

Tondo C
There is still uncertainity about the use of CT-scan for LAAO device sizing. The main reason for this disappointing position is likely to relate to the scarcity of robust data, since there is still difference among institutions with regards how to perform measurement of the devices. Dallan et al. (1) report their own experience on the use of a novel computed tomography angiography-based (CTA) for sizing the Watchman Flex device for left atrial appendage occlusion (LAAO). The authors through the TruPlan software package that a pre-procedural CTA sizing protocol can be applied successfully with ICE guidance and provide excellent procedural outcomes.The applied CTA protocol is safe and can provide high success rates with the WatchmanTM FLX device reducing the number of deployment attempts and reducing the risk of complications. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 May 2022; epub ahead of print
Tondo C
J Cardiovasc Electrophysiol: 18 May 2022; epub ahead of print | PMID: 35586897
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Abstract

Novel Computed Tomography Angiography-Based Sizing Methodology for WATCHMAN FLX Device in Left Atrial Appendage Closure.

Dallan LAP, Arruda M, Yoon SH, Rana MA, ... Rajagopalan S, Filby SJ
Background
While there is recent data suggesting an advantage of Computed Tomography Angiography (CTA) over transesophageal echocardiography (TEE) for pre-procedural left atrial appendage closure (LAAC) planning, there is limited published experience for sizing strategies. Device sizing for LAAC may be challenging and non-invasive algorithms that improve this selection process are warranted.
Objectives
We sought to evaluate the safety and the feasibility for the implementation of a novel CTA-based sizing methodology for WATCHMAN FLX device in a series of patients undergoing LAAC using the TruPlan™ software package.
Methods
A prospective analysis of 136 consecutive patients who underwent LAAC over a 12-month period in a single, large academic hospital in the United States was conducted. CTA-guided pre-procedural planning and intracardiac echocardiography (ICE) was performed in all. Procedural success, adverse events, length of procedure, number of devices used, and length of stay were evaluated.
Results
A total of 136 patients who underwent LAAC procedure with WATCHMAN FLX platform between October 1, 2020 until September 30, 2021 were included. The pre-specified protocol using CTA and ICE was implemented in all patients (100%). Mean CHA2 DS2 VASc score was 4.4 ± 1.3 and the mean HAS-BLED score was 3.9 ± 0.8. ICE-guided 100% transseptal puncture success rate was 100% with 98.5% of overall procedural success rate. Pre-procedural CTA sizing strategy accurately predicted the implanted size in 91.1% of patients. Ten patients (7.4%) required another sized device and 2 cases were aborted. At 45-day follow-up, only 1 patient (0.7%) had significant peri-device leak (≥ 5mm) on TEE.
Conclusions
CTA-based pre-procedural sizing methodology for WATCHMAN FLX in LAAC was safe, feasible and associated with excellent procedural outcomes. Further studies are warranted to confirm if the features specific to TruPlan may reduce the number of deployment attempts, the number of devices utilized in the procedure, and the risk of complications. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 May 2022; epub ahead of print
Dallan LAP, Arruda M, Yoon SH, Rana MA, ... Rajagopalan S, Filby SJ
J Cardiovasc Electrophysiol: 18 May 2022; epub ahead of print | PMID: 35586899
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Abstract

Lowering the Threshold for Left Bundle Branch Area Pacing.

Cerbin LP, Garg L
Cardiac pacing remains the mainstay of therapy for conduction system disease and irreversible bradyarrhythmias. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 May 2022; epub ahead of print
Cerbin LP, Garg L
J Cardiovasc Electrophysiol: 16 May 2022; epub ahead of print | PMID: 35578129
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Abstract

Contact Force Guided Radiofrequency Current Application at Developing Myocardium: Summary and Conclusions.

Backhoff D, Müller MJ, Betz T, Arnold A, ... Paul T, Krause U
Background
Catheter contact is one key determinant for lesion size in radiofrequency catheter ablation (RFA). Monitoring of contact force (CF) during RFA has been shown to improve efficacy of RFA in experimental settings as well as in adult patients. Coronary artery narrowing after RFA has been described in experimental settings as well as in children and adults and may be dependent from catheter contact. Value of CF monitoring concerning these issues has not been systematically yet.
Objective
Value of high versus low CF during RFA in piglets was studied to assess lesion size and potential coronary artery involvement mimicking RFA in small children.
Animals and methods
RFA with continuous CF monitoring was performed in 24 piglets (median weight 18.5 kg) using a 7F TactiCath Quartz RF ablation catheter (Abbott, Illinois, USA). A total of 7 lesions were induced in each animal applying low (10-20 g) or high (40-60 g) CF. RF energy was delivered with a target temperature of 65 °C at 30 W for 30 seconds. Coronary angiography was performed prior and immediately after RF application. Animals were assigned to repeat coronary angiography followed by heart removal after 48 h (n=12) or 6 months (n=12). Lesions with surrounding myocardium were excised, fixated and stained. Lesion volumes were measured by microscopic planimetry.
Results
A total of 148 RF lesions were identified in the explanted hearts. Only in the subset of lesions at the AV annulus 6 month after ablation, lesion size and number of lesions exhibiting transmural extension were higher in the high CF group compared to low CF. In all other locations CF had no impact on lesion size and mural extension after 48 h as well as after 6 months. Additional parameters as Lesion Size Index and Force Time Integral were also not related to lesion size. Coronary artery damage was present in 2 animals after 48 h and in 1 after 6 months and was not related to CF. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 16 May 2022; epub ahead of print
Backhoff D, Müller MJ, Betz T, Arnold A, ... Paul T, Krause U
J Cardiovasc Electrophysiol: 16 May 2022; epub ahead of print | PMID: 35578015
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Abstract

AMEN and ALARA - Remembering the dangers of the (new) technology of lesion formation.

Alexander ME, O\'leary ET
Catheter ablation in children has evolved to become a highly effective and safe therapy. Each iterative improvement in ablation technology provides another opportunity to investigate how much incremental benefit can be made without sacrificing safety. Contact force sensing catheters represent an example of such technology that has become commonplace in adult ablation. Its capability in predicting lesion size and collateral damage to critical structures has not been meticulously explored. Backhoff and colleagues describe an animal ablation model where they quantitate lesion characteristics at the atrium, atrioventricular groove, and ventricle using low and high contact force targets, with a specific focus on assessing for coronary arterial injury. In this controlled experiment, chronic lesion characteristics were widely variable (~0-8 mm diameter) yet there was a statistically significant (albeit small) increase in lesion diameter for high (vs low) contact force lesions delivered to the atrioventricular groove. The risk of chronic sub-clinical coronary artery injury was 1-2%. The remarkably weak association between contact force and lesion size suggests that delivery of clinical lesions needs to have both principles of As much as effectively needed (AMEN) and as low as reasonably achievable (ALARA), mirroring radiation exposure This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 16 May 2022; epub ahead of print
Alexander ME, O'leary ET
J Cardiovasc Electrophysiol: 16 May 2022; epub ahead of print | PMID: 35578108
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Abstract

Dielectric-based Tissue Thickness Measured During Radiofrequency Catheter Ablation.

Schillaci V, Stabile G, Arestia A, Shopova G, ... De Simone A, Solimene F
A new dielectric-based method (KODEX-EPD mapping system, EPD Solutions, a Philips company) for measuring tissue thickness at the catheter-tissue interface has recently been developed. We reported preliminary data on real-time catheter-based measuring myocardial wall thickness in vivo, during typical atrial flutter radiofrequency ablation. The atrial wall thickness was significantly higher close to the tricuspid annulus than close to the inferior vena cava (3.6±0.5 mm vs 2.4±0.3 mm, p<0.001) and a trend towards a progressive decrease of atrial wall thickness was observed moving the mapping catheter from the tricuspid valve to the inferior vena cava. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 12 May 2022; epub ahead of print
Schillaci V, Stabile G, Arestia A, Shopova G, ... De Simone A, Solimene F
J Cardiovasc Electrophysiol: 12 May 2022; epub ahead of print | PMID: 35557022
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Impact:
Abstract

Dielectric concept: \"A Magnification Lens in EP Lab?\"

Tondo C
It is well recognized that radiofrequency (RF) energy effect, is dependent upon several variables that impact lesion size and transmurality including catheter stability, contact force, power output, temperature, duration of RF output, and tissue characteristics and thickness This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 12 May 2022; epub ahead of print
Tondo C
J Cardiovasc Electrophysiol: 12 May 2022; epub ahead of print | PMID: 35559585
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Abstract

Predictors of Conduction Disturbances after Transcatheter Aortic Valve Implantation with Balloon-expandable Valve for Bicuspid Aortic Valve Stenosis.

Miyashita H, Moriyama N, Yamanaka F, Saito S, ... Niemelä M, Laine M
Objective
Implantation depth and membranous septum (MS) length have been established as the predictors of new-onset conduction disturbance (CD) after transcatheter aortic valve replacement (TAVR) for tricuspid aortic valve (TAV) stenosis. However, little is known about the predictors with bicuspid aortic valve (BAV). This study investigated the role of MS length and implantation depth in predicting CD following TAVR with a balloon-expandable valve in patients with BAV.
Methods and results
This retrospective study analyzed 169 patients who underwent TAVR for BAV with balloon-expandable valve, and TAV cohort was established as a control group using propensity score (PS) matching. The primary endpoints were in-hospital new permanent pacemaker implantation (PPI) new-onset CD (the composite outcome of new-onset left bundle branch block and new PPI). PPI developed in 14 patients (8.3%) and new-onset CD in 37 patients (21.9%) in BAV cohort. Multivariate analysis revealed severe LVOT calcification (Odds ratio [OR]: 5.83, 95% confidence interval [CI]: 1.08 - 31.5, p = 0.0407) and implantation depth - MS length (OR: 1.30, 95% CI: 1.12 - 1.51, p = 0.0005) as the predictors of new-onset CD within the BAV cohort. The matched comparison between BAV and TAV groups showed similar MS length (3.0 vs 3.2mm, p = 0.5307), but valves were implanted more deeply in the BAV group than in the TAV group (3.9 vs 3.0mm, p < .0001). New-onset CD was more frequent in patients who had BAV (22.3% vs 13.9%, p = 0.0458).
Conclusion
The implantation depth - MS length, and severe LVOT calcification predicted new-onset CD following TAVR in BAV with balloon-expandable valve. Among BAV patients, THV were implanted more deeply compared to THV patients. High deployment technique could be considered to avoid new-onset CD in BAV anatomy. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 11 May 2022; epub ahead of print
Miyashita H, Moriyama N, Yamanaka F, Saito S, ... Niemelä M, Laine M
J Cardiovasc Electrophysiol: 11 May 2022; epub ahead of print | PMID: 35543515
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Abstract

Targeted ablation of residual pulmonary vein potentials in atrial fibrillation ablation through ultra-high-density mapping: insights from the CHARISMA registry.

Solimene F, Stabile G, Segreti L, Malacrida M, ... De Simone A, Garcia-Bolao I
Introduction
Low-voltage activity beyond pulmonary veins (PVs) may contribute to the failure of ablation of atrial fibrillation (AF) in the long term. We aimed to assess the presence of gaps (PVG) and residual potential (RAP) within the antral scar by means of an ultra-high density mapping (UHDM) system.
Methods
We studied consecutive patients from the CHARISMA registry who were undergoing AF ablation and had complete characterization of residual PV antral activity. The LumipointTM (Boston Scientific) map-analysis tool was used sequentially on each PV component. The ablation endpoint was PV isolation (PVI) and electrical quiescence in the antral region.
Results
Fifty-eight cases of AF ablation were analyzed. A total of 86 PVGs in 34 (58.6%) patients and 44 RAPs in 34 patients (58.6%) were found. In 16 (27.6%) cases, we found at least one RAP in patients with complete absence of PV conduction. RAPs showed a lower mean voltage than PVG (0.3±0.2mV vs 0.7±0.5mV, p<0.0001), whereas the mean number of EGM peaks was higher (8.4±1.4 vs 3.2±1.5, p<0.0001). The percentage of patients in whom RAPs were detected through LumipointTM was higher than through propagation map analysis (58.6% vs 36.2%, p=0.025). Acute procedural success was 100%, with all PVs successfully isolated and RAPs completely abolished in all study patients. During a mean follow-up of 453±133 days, 6 patients (10.3%) suffered an AF/AT recurrence.
Conclusion
Local vulnerabilities in antral lesion sets were easily discernible by means of the UHDM system in both de novo and redo patients when no PV conduction was present.
Clinical trial registration
Catheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice (CHARISMA). URL: http://clinicaltrials.gov/Identifier: NCT03793998 This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print
Solimene F, Stabile G, Segreti L, Malacrida M, ... De Simone A, Garcia-Bolao I
J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print | PMID: 35524404
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Abstract

Transient changes in QRS morphology during a narrow complex tachycardia: What is the mechanism?

Kara M, Cetin EHO, Korkmaz A, Ozeke O, ... Aras D, Topaloglu S
The observation of electrograms and electrocardiograms recorded in sinus rhythm can offer important initial information about the mechanism of arrhythmia. Some patients may have both bundle branch aberrancy or a bystander pathway or multiple pathways, giving rise to varying degrees of QRS fusion. There is need to focus on any change in cycle length of the tachycardia and morphology of QRS during tachycardia. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print
Kara M, Cetin EHO, Korkmaz A, Ozeke O, ... Aras D, Topaloglu S
J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print | PMID: 35524413
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Abstract

Anatomical variations in Coronary Venous Drainage: Challenges and Solutions in Delivering Cardiac Resynchronisation Therapy.

Akhtar Z, Sohal M, Kontogiannis C, Harding I, ... Beeton I, Gallagher MM
Aims
To investigate the abnormalities of the coronary venous system in candidates for cardiac resynchronization therapy (CRT) and describe methods for circumventing the resulting difficulties.
Methods
From 4 implanting institutes, data of all CRT implants between October 2008-October 2020 were screened for abnormal cardiac venous anatomy, defined as an anatomical variation not conforming to the accepted \'normal\' anatomy. Patient demographics, procedural detail and subsequent left ventricle (LV) lead pacing indices were collected.
Results
From a total of 3548 CRT implants, 15 (0.42%) patients (80% male) of 72.2±10.6 years in age with a LV ejection fraction of 34±10.3% were identified to have had an abnormal cardiac venous anatomy over the study period. There were 13 cases of persistent left side superior vena cava (pLSVC), 5 of which had coronary sinus ostium atresia (CSOA) including 2 with an \'unroofed\' coronary sinus (CS); 1 patient had a unique anomalous origin of the CS and 1 patient had an isolated CSOA. In total 14 patients (60% repeat attempt) had successful percutaneous implant under general anaesthesia (46.7%) via the cephalic vein (59.1%), using the femoral approach (53.3%) for levophase venography and/or pull-through, including 1 case of endocardial LV implant. Pacing follow-up over 37.64±37.6 months demonstrated LV lead threshold between 0.62-2.9 volts (pulsewidth 0.4-1.5 milliseconds) in all cases; 5 patients died within 2.92±1.6 years of successful implant.
Conclusion
CRT devices can be implanted percutaneously even in the presence of substantial abnormalities of coronary venous anatomy. Alternative routes of venous access may be required. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print
Akhtar Z, Sohal M, Kontogiannis C, Harding I, ... Beeton I, Gallagher MM
J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print | PMID: 35524414
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Abstract

Use of extendable helix leads for conduction system pacing: differences in lead handling and performance: Conclusion.

Tan ES, Lee JY, Boey E, Soh R, ... Seow SC, Kojodjojo P
Introduction
Pacing leads with extendable-retractable helix (EHL) are alternatives to fixed-helix leads (FHL) for conduction system pacing (CSP), but data on handling characteristics are limited. This study evaluated a dual-center experience of lead handling and performance during CSP.
Methods and results
Consecutive patients with His-bundle pacing (HBP) or left bundle branch pacing (LBBP) were evaluated for the primary outcome of lead failure, defined as structural damage to the lead necessitating lead replacement. Differences in pacing characteristics were compared. Among 280 patients (mean age 74±11 years, 44% male, 50% LBBP), 246 (88%) received FHL and 34 (12%) received EHL. Of 299 leads used, lead failure occurred more frequently among patients with EHL than FHL (29% vs 2%, p<0.001), regardless of CSP modality. Majority of damaged leads (89%) in the form of helix deformation were successfully removed, with failure occurring in only 2 patients, both EHL, leading to helix fracture and retention within the septal myocardium. EHL, compared to FHL, was associated with 25-fold increased odds of lead failure (odds ratio 25.21, 95% confidence interval 7.35-86.51), and persisted after adjustment in turn for age, pacing modality and indication. CSP implant success rates did not differ by lead design (FHL 80% vs EHL 71%, p=0.18), with similar pacing thresholds at implant and follow-up. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print
Tan ES, Lee JY, Boey E, Soh R, ... Seow SC, Kojodjojo P
J Cardiovasc Electrophysiol: 06 May 2022; epub ahead of print | PMID: 35524417
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Abstract

Pulsed-Field Ablation: What Are the Unknowns and When Will They Cease to Concern Us?

Steiger NA, Romero JE
Catheter ablation (CA) is the mainstay therapy for the maintenance of sinus rhythm in patients with paroxysmal and persistent atrial fibrillation (AF). This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 May 2022; epub ahead of print
Steiger NA, Romero JE
J Cardiovasc Electrophysiol: 05 May 2022; epub ahead of print | PMID: 35510406
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Abstract

In-vivo porcine characterization of atrial lesion safety and efficacy utilizing a circular pulsed-field ablation catheter including assessment of collateral damage to adjacent tissue in supratherapeutic ablation applications.

Hsu JC, Gibson D, Banker R, Doshi SK, ... Govari A, Natale A
Introduction
Pulsed field ablation (PFA), an ablative method that causes cell death by irreversible electroporation, has potential safety advantages over radiofrequency ablation and cryoablation. Pulmonary vein (PV) isolation was performed in a porcine model to characterize safety and performance of a novel, fully-integrated biphasic PFA system comprising a multi-channel generator, variable loop circular catheter, and integrated PFA mapping software module.
Methods
Eight healthy porcine subjects were included. To evaluate safety, multiple ablations were performed, including sites not generally targeted for therapeutic ablation, such as the right inferior PV lumen, right superior PV ostium, and adjacent to the esophagus and phrenic nerve. To evaluate efficacy, animals were recovered, followed for 30(±3) days, then re-mapped. Gross pathological and histopathological examinations assessed procedural injuries, chronic thrombosis, tissue ablation, penetration depth, healing, and inflammatory response.
Results
All 8 animals survived follow-up. PV narrowing was not observed acutely nor at follow-up, even when ablation was performed deep to the PV ostium. No injury was seen grossly or histologically in adjacent structures. All PVs were durably isolated, confirmed by bidirectional block at re-map procedure. Histological examination showed complete, transmural necrosis around the circumference of the ablated section of right PVs.
Conclusion
This pre-clinical evaluation of a fully-integrated PFA system demonstrated effective and durable ablation of cardiac tissue and PV isolation without collateral damage to adjacent structures, even when ablation was performed in more extreme settings than those used therapeutically. Histological staining confirmed complete transmural cell necrosis around the circumference of the PV ostium at 30 days. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 May 2022; epub ahead of print
Hsu JC, Gibson D, Banker R, Doshi SK, ... Govari A, Natale A
J Cardiovasc Electrophysiol: 05 May 2022; epub ahead of print | PMID: 35510408
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Abstract

Preliminary study on left bundle branch area pacing in children:clinical observation of 12 cases.

Wenlong D, Baojing G, Chencheng D, Jianzeng D
Objective
To explore the safety and feasibility of left bundle branch area pacing (LBBAP) in children.
Methods
This study observed 12 children attempted LBBAP from January 2019 to January 2021 in the department of pediatric cardiology of Anzhen Hospital prospectively.Clinical data, pacing parameters, electrocardiograms, intracardiac electrograms, echocardiographic measurements and complications were recorded at implant and during follow-up.
Results
The 12 patients aged between 3 and 14 years old and weighted from 13 to 48kg. Eleven patients were diagnosed with third-degree atrioventricular block and 1 patient (case 4) suffered from cardiac dysfunction due to right ventricular apical pacing (RVAP). Left bundle branch area pacing was successfully achieved in all patients with narrow QRS complexes and V1 lead showed changes like right bundle branch block in the pacing electrocardiogram. Left ventricular ejection fraction in case 4 recovered on the 3rd day after LBBAP. The median of left ventricular end diastolic diameter Z score of the 12 patients decreased from 1.75 to1.05 3 months after implantation (p<0.05). The median of paced QRS duration was 103ms. The median of pacing threshold, R-wave amplitude and impedance were 0.85V, 15mV and 717Ω respectively and remained stable during follow-up. No complications such as loss of capture, lead dislodgement or septal perforation occurred.
Conclusions
Left bundle branch area pacing can be performed safely in children with narrow QRS duration and stable pacing parameters. Cardiac dysfunction caused by long-term RVAP can be corrected by LBBAP quickly. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 May 2022; epub ahead of print
Wenlong D, Baojing G, Chencheng D, Jianzeng D
J Cardiovasc Electrophysiol: 04 May 2022; epub ahead of print | PMID: 35508760
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Abstract

A frozen decade: Ten years outcome of atrial fibrillation ablation using a single shot device for pulmonary vein isolation.

Bergau L, Sciacca V, Nesapiragasan V, Rubarth K, ... Sommer P, Christian Sohns MD
Aims
Cryoballoon-guided pulmonary vein isolation (CB-PVI) for symptomatic atrial fibrillation (AF) has become an established treatment option with encouraging results in terms of safety and efficacy. Data reporting on long-term data beyond a follow-up (FU) period of five years is scarce. This prospective study aimed to evaluate very long-term outcome after CB-PVI for AF.
Methods
Data from consecutive patients treated with CB-PVI for symptomatic and drug refractory AF between 2005 and 2012 were analyzed. Patients with a FU of ≥9 years after index CB-PVI were included. All patients were continuously followed-up in our outpatient clinic. Arrhythmia recurrence was defined as AF or atrial tachycardia (AT) lasting >30s beyond a three-month blanking period.
Results
A total of 385 patients (71% male) were included. Mean age was 58±10 years and paroxysmal AF was present in 93% of patients. Mean FU duration was 124±24 months. At the end of the observational period, 73% of all patients were in stable sinus rhythm after a mean of 2±0.8 ablation procedures. Patients with AF/AT recurrence were older (60±8vs.57±10 years; p=0.019), had a higher CHA2 DS2 -Vasc Score (2.47±1.46vs.1.98±1.50; p=0.01) and presented with a larger LA-diameter (43±5.6vs40±5.1 mm; p=0.002). The LA-diameter was also a significant predictor for AF/AT recurrence after CB-PVI (Odds Ratio: 0.939,95% CI [0.886, 0.992], p=0.03).
Conclusions
CB-PVI as index procedure for AF ablation resulted in favorable long-term outcome in symptomatic AF. CB-PVI might be recommended as interventional therapy in patients with lower LA remodeling. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 03 May 2022; epub ahead of print
Bergau L, Sciacca V, Nesapiragasan V, Rubarth K, ... Sommer P, Christian Sohns MD
J Cardiovasc Electrophysiol: 03 May 2022; epub ahead of print | PMID: 35502754
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Impact:
Abstract

Association between implantable defibrillator-detected sleep apnea and atrial fibrillation: the DASAP-HF study.

Boriani G, Diemberger I, Pisanò EC, Pieragnoli P, ... Ricci RP, D\'Onofrio A
Aim
The Respiratory Disturbance Index (RDI) computed by an implantable cardioverter defibrillator (ICD) algorithm accurately identifies severe sleep apnea (SA). In the present analysis we tested the hypothesis that RDI could also predict AF burden.
Methods
Patients with ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. One month after implantation, patients underwent a polysomnographic study. The weekly mean RDI value was considered, as calculated during the entire follow-up period and over a 1-week period preceding the sleep study. The endpoints were: daily AF burden of ≥5 minutes, ≥6 hours, ≥23 hours.
Results
164 patients had usable RDI values during the entire follow-up period. Severe SA (RDI≥30 episodes/h) was diagnosed in 92 (56%) patients at the time of the sleep study. During follow-up, AF burden ≥5 minutes/day was documented in 70 (43%), ≥6 hours/day in 48 (29%), and ≥23 hours/day in 33 (20%) patients. Device-detected RDI≥30 episodes/h at the time of the polygraphy, as well as the polygraphy-measured apnea hypopnea index ≥30 episodes/h, were not associated with the occurrence of the endpoints, using a Cox regression model. However, using a time-dependent model, continuously measured weekly mean RDI≥30episodes/h was independently associated with AF burden ≥5 minutes/day (HR:2.13, 95%CI:1.24-3.65, p=0.006), ≥6 hours/day (HR:2.75, 95%CI:1.37-5.49, p=0.004), and ≥23 hours/day (HR:2.26, 95%CI:1.05-4.86, p=0.037).
Conclusions
In heart failure patients, ICD-diagnosed severe SA on follow-up data review identifies patients who are from two- to three-fold more likely to experience an AF episode, according to various thresholds of daily AF burden. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 May 2022; epub ahead of print
Boriani G, Diemberger I, Pisanò EC, Pieragnoli P, ... Ricci RP, D'Onofrio A
J Cardiovasc Electrophysiol: 02 May 2022; epub ahead of print | PMID: 35499267
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Abstract

Vein of Marshall alcohol ablation for dormant pulmonary vein conduction: A case report.

Janga C, Madhavan M, Siontis KC, Killu AM
We report a case of alcohol ablation into a vein of Marshall for recurrent dormant conduction into the pulmonary veins with adenosine testing in a patient where two prior ablation attempts failed to isolate the left vein.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Apr 2022; 33:1070-1071
Janga C, Madhavan M, Siontis KC, Killu AM
J Cardiovasc Electrophysiol: 30 Apr 2022; 33:1070-1071 | PMID: 35332624
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Abstract

Outcomes of leadless pacemaker implantation in patients with mechanical heart valves.

Loughlin G, Pachón M, Martínez-Sande JL, Ibáñez JL, ... Cuesta J, Arias MA
Introduction
Device infections constitute a major complication of transvenous pacemakers. Mechanical heart valves (MHV) increase the risk of infective endocarditis (IE) and pacemaker infection, requiring lifelong vitamin K-antagonists (VKA), which may affect patient management. Leadless pacemakers (LP) are associated with low infection rates, posing an attractive option in MHV patients requiring permanent pacing. This study describes outcomes following LP implantation in patients with MHV.
Methods
This is a multicenter, observational, retrospective study including consecutive patients implanted with an LP at 5 centers between June 2015 and January 2020. Procedural outcomes, antithrombotic management, complications, performance during follow-up and episodes of bacteremia and IE were compared between patients with and without an MHV (MHV and non-MHV groups).
Results
Four hundred fifty-nine patients were included (74 in the MHV group, 16.1%, and 385 in the non-MHV group, 83.9%). Procedural outcomes and acute electrical performance were comparable between groups. Vascular complications and cardiac perforation occurred in 2.7 versus 2.3% (p = 1) and 0% versus 0.8% (p = 1) in the MHV group and non-MHV group. One case of IE occurred in the MHV group and 2 in the non-MHV group. In MHV patients, uninterrupted VKA was used in 83.8%, whereas 16.2% were heparin-bridged. Vascular complication or tamponade occurred in 1 (8.3%) MHV heparin-bridged patient versus 1 (1.6%) MHV uninterrupted VKA patient (p = .3).
Conclusion
LP implantation outcomes in MHV patients are comparable to the general LP population. Device-related infections are rare following LP implantation, including in patients with MHV. In the MHV group, periprocedural anticoagulation management was not associated with significantly different rates of tamponade or vascular complication.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Apr 2022; 33:997-1004
Loughlin G, Pachón M, Martínez-Sande JL, Ibáñez JL, ... Cuesta J, Arias MA
J Cardiovasc Electrophysiol: 30 Apr 2022; 33:997-1004 | PMID: 35322490
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Impact:
Abstract

Initial clinical experience of pulmonary vein isolation using the ultra-low temperature cryoablation catheter for patients with atrial fibrillation.

Tohoku S, Schmidt B, Bordignon S, Chen S, Bologna F, Julian Chun KR
Background
The iCLAS ultra-low temperature cryoablation (ULTC) system has recently brought to the market. A combination of a newly exploited cryogen and interchangeable stylet enables flexible and continuous lesion creation in atrial fibrillation (AF) ablation. The use of an esophageal warming balloon is recommended when using the system to reduce the potential for collateral esophageal injury.
Objective
To describe the initial clinical experience when using ULTC in the AF treatment without general anesthesia (GA).
Methods
Consecutive patients undergoing AF ablation using ULTC under deep sedation without GA were enrolled. We assessed the procedural data focusing on \"single-shot isolation\" defined as successful pulmonary vein (PV) isolation after the first application. Esophagogastroduodenoscopy was systematically performed the day after ablation.
Results
A total of 27 AF patients (67% paroxysmal AF) were analyzed. One-hundred-four out of 106 PVs (98.1%) were isolated solely using ULTC. The mean procedure time was 79 ± 30 min. The mean number of applications per PV was 2.6 ± 1.0. Single-shot isolation was achieved in 57 PVs (54%) varying across PVs from left superior- to inferior PVs (40-64%). Single procedure six-month recurrence free rate was 84%. No major complication (cerebrovascular event, pericardial effusion/tamponade, esophageal damage on esophagogastroduodenoscopy) occurred. A single transient phrenic nerve palsy occurred during the right superior PV ablation which had recovered by the 3-month follow up appointment.
Conclusions
AF ablation using the novel ULTC system seemed feasible without GA and enabled >50% single-shot isolation rate. The promising safety profile has to be confirmed in large-scaled studies. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print
Tohoku S, Schmidt B, Bordignon S, Chen S, Bologna F, Julian Chun KR
J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print | PMID: 35488736
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Impact:
Abstract

Mexiletine effectively prevented refractory Torsades de Pointes and ventricular fibrillation in a patient with congenital type 2 long QT syndrome.

Nakashima R, Takase S, Kai K, Sakamoto K, Tsutsui H
We report a 28-year-old female patient with congenital type 2 long QT syndrome (LQTS) in which mexiletine shortened QTc and effectively prevented refractory Torsade de Pointes (TdP) and ventricular fibrillation (VF). She developed TdP and VF, and was subsequently diagnosed as congenital type 2 LQTS type 2. She had refractory TdP and VF every day despite medical therapy including β-blocker. They were completely suppressed after the initiation of mexiletine with shorting of QTc interval. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print
Nakashima R, Takase S, Kai K, Sakamoto K, Tsutsui H
J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print | PMID: 35488741
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Impact:
Abstract

Esophago-gastric Complications in Radiofrequency and Cryoballoon Catheter Ablation of Atrial Fibrillation.

Oikawa J, Fukaya H, Wada T, Kishihara J, ... Kusano C, Ako J
Background
Direct comparison studies about the incidence of esophago-gastric complications between radiofrequency (RF) and cryoballoon (CB) catheter ablation (CA) for atrial fibrillation (AF) have been scarce. We sought to elucidate the relationship between the pulmonary vein isolation (PVI) modalities and esophago-gastric complications.
Methods
The study population consisted of 254 patients who underwent CA for AF from November 2017 to October 2018. Finally, 160 patients were enrolled and divided into the RF and CB groups. Esophageal ulcers, gastric hypomotility, and exfoliative esophagitis detected by esophago-gastro-duodenoscopy were defined as esophago-gastric complications in this study.
Results
The median age was 68 years old, with 34% being females. Esophago-gastric complications were observed in 42.5% of patients who underwent CA. According to the detailed esophago-gastric complications, the RF group had a higher prevalence of esophageal ulcers than the CB group (19% vs. 0%, p <0.0001). There was no significant difference between the two groups regarding gastric hypomotility and exfoliative esophagitis (18% vs. 28%; p = 0.15, 16% vs. 21%; p = 0.42, respectively).
Conclusions
Asymptomatic esophago-gastric complications were common in catheter ablation for atrial fibrillation. The incidence of esophageal ulcers was higher in the radiofrequency group than cryoballoon group, whereas the other esophago-gastric complications did not significantly differ. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print
Oikawa J, Fukaya H, Wada T, Kishihara J, ... Kusano C, Ako J
J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print | PMID: 35488745
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Impact:
Abstract

A frozen decade: Ten years outcome after cryoballoon pulmonary vein isolation.

Rottner L, Metzner A
Cryoballoon (CB) ablation has emerged as an established gold standard for PVI. Since its introduction into clinical practice, more than one million patients worldwide suffering from symptomatic AF have been treated with different versions of this first real single-shot device. High acute and midterm clinical success, a very beneficial safety profile, short learning curves and high procedural reproducibility are strongly associated with CB guided PVI. Though there is a great amount of data on acute efficacy and short- as well as midterm clinical outcome available, studies reporting on long-term arrhythmia-free survival and on long-term safety of CB-PVI is lacking. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print
Rottner L, Metzner A
J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print | PMID: 35488746
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Impact:
Abstract

Frozen, Gone in 60 Seconds!

Saouma S, Kowalski M
The field of electrophysiology has seen the development of a novel ultralow temperature cryoablation (ULTC) system. The data presented in this manuscript shows that the ULTC system is feasible, safe, and effective in acute PVI under sedation and by using angiography only This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print
Saouma S, Kowalski M
J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print | PMID: 35488748
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Impact:
Abstract

Clinical Outcomes Of Left Bundle Branch Area Pacing Compared To His Bundle Pacing.

Vijayaraman P, Rajakumar C, Naperkowski AM, Subzposh FA
Background
His bundle pacing (HBP) is the most physiologic form of pacing and has been associated with reduced risk for heart failure hospitalization (HFH) and mortality compared to right ventricular pacing. Left bundle branch area pacing (LBBAP) is a safe and effective alternative option for patients needing ventricular pacing.
Objective
The aim of this study was to compare the clinical outcomes between LBBAP and HBP among a large cohort of patients undergoing permanent pacemaker implantation.
Methods
This observational registry included consecutive patients with AV block/AV node ablation who underwent de novo permanent pacemaker implantations with successful LBBAP or HBP between April 2018 to October 2020. The primary outcome was the composite endpoint of time to death from any cause or HFH. Secondary outcomes included the composite endpoint among patients with prespecified ventricular pacing burden and individual outcomes.
Results
The study population included 359 patients who met the inclusion criteria (163 in the HBP and 196 in the LBBAP group). Paced QRSd during LBBAP was similar to HBP (125 ± 20.2 vs 126 ± 23.5 ms, p=0.643). There were no statistically significant differences in the primary composite outcome in LBBAP (17.3%) compared to HBP (24.5%) (HR 1.15, CI 0.72-1.82, p = 0.552). Secondary outcomes of death (10 vs 17%; HR 1.3, CI 0.73-2.33, p=0.38) and HFH (10 vs 12%; HR 1.02,CI 0.54-1.94, p=0.94) were not different among both groups.
Conclusions
There were no statistically significant differences in the clinical outcomes of death or HFH in LBBAP when compared to HBP. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print
Vijayaraman P, Rajakumar C, Naperkowski AM, Subzposh FA
J Cardiovasc Electrophysiol: 30 Apr 2022; epub ahead of print | PMID: 35488749
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Abstract

The Development of the Extravascular Defibrillator with Substernal Lead Placement: A New Frontier for Device-Based Treatment of Sudden Cardiac Arrest.

Thompson AE, Atwater B, Boersma L, Crozier I, ... Kuschyk J, DeGroot P
Introduction
The extravascular ICD (EV ICD) system with substernal lead placement is a novel non-transvenous alternative to current commercially available ICD systems. The EV ICD provides defibrillation and pacing therapies without the potential long-term complications of endovascular lead placement but requires a new procedure for implantation with a safety profile under evaluation.
Methods
This paper summarizes the development of the EV ICD, including the pre-clinical and clinical evaluations that have contributed to system and procedural refinements to date.
Results
Extensive pre-clinical research evaluations and 4 human clinical studies with >140 combined acute and chronic implants have enabled the development and refinement of the EV ICD system, currently in worldwide pivotal study.
Conclusion
The EV ICD may represent a clinically valuable solution in protecting patients from sudden cardiac death while avoiding the long-term consequences of transvenous hardware. The EV ICD offers advantages over transvenous and subcutaneous systems by avoiding placement in the heart and vasculature; relative to subcutaneous systems, EV ICD requires less energy for defibrillation, enabling a smaller device, and provides pacing features such as anti-tachycardia and asystole pacing in a single system. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Apr 2022; epub ahead of print
Thompson AE, Atwater B, Boersma L, Crozier I, ... Kuschyk J, DeGroot P
J Cardiovasc Electrophysiol: 28 Apr 2022; epub ahead of print | PMID: 35478368
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Abstract

The role of cardiac surgeon in transvenous lead extraction: experience from 3462 procedures.

Tułecki Ł, Czajkowski M, Targońska S, Polewczyk A, ... Nowosielecka D, Kutarski A
Introduction
The professional society guidelines recommend that transvenous lead extraction (TLE) operating teams collaborate closely with cardiac surgeons in the management of life-threatening complications.
Methods and results
We assessed the role of cardiac surgeons participating in 3462 TLE procedures at a high-volume center between 2006 and 2021. The roles for cardiac surgery in TLE can be categorized into five areas: emergency surgical interventions for the management of cardiac laceration and severe bleeding (1.184%), cardiac surgery complementing partially successful TLE or vegetation removal (0.693%), delayed surgical treatment of TLE-related tricuspid valve dysfunction (0.751%), epicardial pacemaker implantation through sternotomy during emergency, complementing or delayed surgical interventions (0.607%) and delayed epicardial lead implantation (0.491%). Isolated damage to the wall of the right atrium was the most common cause of cardiac tamponade (53.66% of emergency surgeries) followed by injury to the right ventricle and vena cava (both 7.317%).
Conclusions
Emergency cardiac surgery for the management of severe hemorrhagic complications is still the most common treatment option. The remaining areas include surgery complementing partially successful TLE: repair of tricuspid valve or epicardial ventricular lead placement to achieve permanent cardiac resynchronization. The experience at a single high-volume TLE center indicates the necessity of close collaboration with the cardiac surgeons whose roles appear broader than the mere surgical standby. Mortality in patients who survived cardiac surgery during transvenous lead extraction does not differ from the survival of other patients after TLE without complications requiring surgical intervention. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 27 Apr 2022; epub ahead of print
Tułecki Ł, Czajkowski M, Targońska S, Polewczyk A, ... Nowosielecka D, Kutarski A
J Cardiovasc Electrophysiol: 27 Apr 2022; epub ahead of print | PMID: 35474258
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Abstract

Pro-arrhythmia with Anti-arrhythmic Drugs in Patients with Idiopathic Ventricular Arrhythmia: A Common Problem with Vague Definitions and Complex Interactions.

Hasdemir C, Payzin S
Universally accepted, well-described definitions for therapeutic efficacy and pro-arrhythmia with AADs among patients with IVAs are lacking. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 21 Apr 2022; epub ahead of print
Hasdemir C, Payzin S
J Cardiovasc Electrophysiol: 21 Apr 2022; epub ahead of print | PMID: 35445781
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Abstract

Systematic review of electrophysiology procedures in patients with obstruction of the inferior vena cava.

Al-Sinan A, Dip Cardiac G, Chan KH, Young GD, ... Sepahpour A, Sy RW
Aims
The objective of the study was to conduct a systematic review to describe and compare the different approaches for performing cardiac electrophysiology (EP) procedures in patients with interrupted inferior vena cava (IVC) or equivalent entities causing IVC obstruction.
Methods
We conducted a structured search to identify manuscripts reporting electrophysiology (EP) procedures with interrupted IVC or IVC obstruction of any aetiology published up until August 2020. No restrictions were applied in the search strategy. We also included 7 local cases that met inclusion criteria.
Results
The analysis included 142 patients (mean age 48.9y; 48% female) undergoing 143 procedures. Obstruction of the IVC was not known before the index procedure in 54% of patients. Congenital interruption of IVC was the most frequent cause (80%); and, associated congenital heart disease (CHD) was observed in 43% of patients in this setting. The superior approach for ablation was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). Electroanatomical mapping (58%), use of long sheaths (41%), intracardiac echocardiography (19%), transesophageal echocardiography (15%) and remote controlled magnetic navigation (13%) were used as adjuncts to aid performance. Ablation was successful in 135 of 140 procedures in which outcomes were reported. Major complications were only reported in patients undergoing AF ablation, including two patients with pericardial effusion, one of whom required surgical repair, and another patient who died after inadvertent entry into an undiagnosed atrioesophageal fistula from a previous procedure.
Conclusion
The superior approach is most frequent approach for performing EP procedures in the setting of obstructed IVC. Transhepatic approach is a feasible alternative, and may provide a \'familiar approach\' for transseptal access when it is required. Adjunctive use of long sheaths, intravascular echocardiography, electro-anatomical mapping and remote magnetic navigation may be helpful, especially if there is associated complex CHD. With careful planning, EP procedures can usually be successfully performed with a low risk of complications. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 20 Apr 2022; epub ahead of print
Al-Sinan A, Dip Cardiac G, Chan KH, Young GD, ... Sepahpour A, Sy RW
J Cardiovasc Electrophysiol: 20 Apr 2022; epub ahead of print | PMID: 35441755
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Abstract

Calculated Parameters of Luminal Esophageal Temperatures predict Esophageal Injury following Conventional and High-Power Short-Duration Radiofrequency Pulmonary Vein Isolation.

Meininghaus DG, Freund R, Kleemann T, Christoph Geller J
Background
Luminal esophageal temperature (LET) monitoring is not associated with reduced esophageal injury following pulmonary vein isolation (PVI).
Objective
Detailed analysis of (the temporal and spatial gradients of) LET measurements may better predict the risk for esophageal injury.
Methods
Between January 2020 and December 2021, LET maxima, duration of LET rise above baseline, and area under the LET curve (AUC) were calculated offline and correlated with (endoscopy and endoscopic ultrasound detected) esophageal injury (i.e., mucosal esophageal lesions [ELs], periesophageal edema, and gastric motility disorders) following PVI using moderate-power moderate-duration (MPMD [25-30 W/25-30s]) and high-power short-duration (HPSD [50 W/13s]) radiofrequency (RF) settings.
Results
63 patients (69±9 years old, 32 male, 51 MPMD and 12 HPSD) were studied. Esophageal injury was frequent (40% in both groups), mucosal ELs were more common with MPMD, edema was frequently observed following HPSD. RF-duration, total RF-energy at the left atrial (LA) posterior wall, and distance between LA and esophagus were not different between patients with/without esophageal injury. In contrast to LET and LET duration above baseline, AUC was the best predictor and significantly increased in patients with esophageal injury (3,422 vs. 2,444 K. s).
Conclusion
For both ablation strategies, AUC of the LET curves best predicted esophageal injury. HPSD is associated with similar rates of esophageal injury when (mostly subclinical) periesophageal alterations (that are of unclear clinical relevance) are included. Whether integration of these calculated LET parameters is useful to prevent esophageal injury remains to be seen. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 20 Apr 2022; epub ahead of print
Meininghaus DG, Freund R, Kleemann T, Christoph Geller J
J Cardiovasc Electrophysiol: 20 Apr 2022; epub ahead of print | PMID: 35445476
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Abstract

Reply to \"Pro-arrhythmia with Anti-arrhythmic Drugs in Patients with Idiopathic Ventricular Arrhythmia: A Common Problem with Vague Definitions and Complex Interactions\".

Tang JKK, Deyell MW
Drs. Hasdemir and Payzin have cogently brought up one of the primary challenges in studying patients with frequent premature ventricular complexes (PVCs) and evaluating the impact of therapy. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 20 Apr 2022; epub ahead of print
Tang JKK, Deyell MW
J Cardiovasc Electrophysiol: 20 Apr 2022; epub ahead of print | PMID: 35445496
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Abstract

Efficacy and safety of High Power Short Duration atrial fibrillation ablation in elderly patients.

Müller J, Nentwich K, Berkovitz A, Ene E, ... Akin I, Deneke T
Background
Data about atrial fibrillation (AF) ablation using high power short duration (HPSD) radiofrequency ablation in the elderly population is still scarce. The aim of our study was to investigate the efficacy and safety of HPSD ablation in patients over 75 years compared to younger patients.
Methods
Consecutive patients older than 75 years with paroxysmal or persistent AF undergoing a first time AF ablation using 50W HPSD ablation approach were analysed in this retrospective observational analysis and compared to a control group <75 years. Short-term endpoints included intraprocedural reconnection of at least one PV, intrahospital and AF recurrence during 3 months blanking period as well as long-term endpoint of freedom from atrial arrhythmias of antiarrhythmic drugs after 12 months.
Results
A total of 540 patients underwent a first AF ablation with HPSD (66 ± 10 years; 58% male; 47% paroxysmal AF). Mean age was 78 ± 2.4 years and 63 ± 6.3 years (p<0.001), respectively. Elderly patients were significantly more often women (p<0.001). Procedure, fluoroscopy and ablation were comparable. Elderly patients revealed significantly more often extra-PV low voltage areas requiring additional left atrial ablations (p<0.001). Overall complication rates were low, however elderly patients revealed higher major complication rates mainly due to unmasking sick sinus syndrome (p=0.003). Freedom from arrhythmia recurrences was comparable (68% vs. 76%, log-rank p=0.087). Only in the subgroup of paroxysmal AF AF recurrences were more common after 12 months (69% vs. 82%; log-rank p=0.040; HR 1.462, p=0.044) in the elderly patients. In multivariable Cox regression analysis of the whole cohort persistent AF, female gender, diabetes mellitus and presence of LA low-voltage areas, but not age > 75 years were associated with AF recurrences.
Conclusions
HPSD AF ablation of patients >75 years in experienced centres is safe and effective. Therefore, age alone should not be the reason to withhold AF ablation from vital elderly patients due to only slightly worse outcome and safety profile. In paroxysmal AF elderly patients have more recurrences compared to the younger control group. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Müller J, Nentwich K, Berkovitz A, Ene E, ... Akin I, Deneke T
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35441414
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Abstract

Step by Step: How to perform a fluoroless cryoballoon ablation for atrial fibrillation.

Alyesh D, Frederick J, Choe W, Sundaram S
Pulmonary vein isolation (PVI) is the cornerstone of ablation of atrial fibrillation. With widespread use of 3D Electroanatomic Mapping Systems and advances in Intracardiac Echo (ICE) imaging, fluoroless ablation has been possible. Fluoroless ablation with cryoballoon (CB), however, has not been widely performed because of the need to prove occlusion of the vein with contrast dye and fluoroscopy. In this step-by-step guide, the authors will show how a CB ablation can be performed without the use of fluoroscopy. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Alyesh D, Frederick J, Choe W, Sundaram S
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437834
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Abstract

Grid-mapping catheters versus PentaRay catheters for left atrial mapping on Ensite Precision mapping system.

Saito J, Yamashita K, Numajiri T, Gibo Y, ... Isomura N, Ochiai M
Introduction
Areas displaying reduced bipolar voltage are defined as low-voltage areas (LVAs). Moreover, left atrial (LA) LVAs after pulmonary vein isolation (PVI) have been reported as a predictor of recurrent atrial fibrillation (AF). In this study, we compared grid mapping catheter (GMC) with PentaRay catheter (PC) for LA voltage mapping on Ensite Precision mapping system.
Methods
Twenty-six consecutive patients with LVAs and border zone within the LA were enrolled. After achieving PVI, voltage mapping under high right atrial pacing for 600msec was performed twice using each catheter type (GMC first, PC next). Furthermore, LVA was defined as a region with a bipolar voltage of <0.50, and border zone was defined as a region with a bipolar voltage of <1.0, or <1.5 mV.
Results
Compared with PC, using GMC, voltage mapping contained more mapping points (20242[15859, 26013] vs 5589[4088,7649]; P < .0001), and more mapping points per minute(1428[1275, 1803] vs 558[372,783]; P < .0001). In addition, LVA and border zone size using GMC was significantly less than that reported using PC: <1.0 mV (5.9 cm2 [2.9, 20.2] vs. 13.9 cm2 [6.3, 24.1], P = 0.018) and <1.5mV voltage cutoff (10.6 cm2 [6.6, 27.2] vs. 21.6 cm2 [12.6, 35.0], P = 0.005).
Conclusion
Bipolar voltage amplitude estimated by GMC was significantly larger than that estimated by PC on Ensite Precision mapping system. GMC may be able to find highly selective identification of LVAs with lower prevalence and smaller LVA and border zone size. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Saito J, Yamashita K, Numajiri T, Gibo Y, ... Isomura N, Ochiai M
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35441420
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Response to Letter to the Editor regarding \'Characteristics and outcomes of ventricular tachycardia and premature ventricular contractions ablation in patients with prior mitral valve surgery\'.

Khalil F, Killu AM
We would like to thank the authors for their letter and interest in our manuscript. We appreciate their valuable comments. The authors have raised the following important points: 1. The heterogenicity of our cohort with mitral valve surgery (MVS) 2. Elucidating the characteristics and causes of ventricular arrhythmias (VA) in patients with primary versus secondary mitral disease as well as in those with ischemic versus non-ischemic heart disease 3. The paucity of cardiac magnetic resonance imaging (MRI) as a limitation of the study 4. The need for careful evaluation of patients prior to ablation since most arrhythmias did not originate from the perimitral area. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Khalil F, Killu AM
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437854
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Abstract

Insurance Lesions: Does a Second Lesion Make a Difference?

Toloczko A, Buchan S, John M, Post A, Razavi M
Introduction
In radiofrequency ablation procedures for cardiac arrhythmia, the efficacy of creating repeated lesions at the same location (\"insurance lesions\") remains poorly studied. We assessed the effect of type of tissue, power, and time on the resulting lesion geometry during such multiple ablation procedures.
Methods and results
A custom ex vivo ablation model was used to assess lesion formation. An ablation catheter was oriented perpendicular to the tissue and used to create lesions that varied by type of tissue (atrial or ventricular free wall), power (30 or 50 W), and time (30, 40, or 50 s for standard ablations and 5, 10, or 15 s for high-power, short-duration [HPSD] ablations). Lesion dimensions were recorded and then analyzed. Radiofrequency ablations were performed on 57 atrial tissue samples (28 HPSD, 29 standard) and 28 ventricular tissue samples (all standard). With ablation parameters held constant, performing multiple ablations significantly increased lesion depth in ventricular tissue when ablations were performed at 30 W for 50 seconds. No other set of ablation parameters was shown to affect the width or depth of the resulting lesions in either tissue type.
Conclusion
Multiple ablations created with the same power and time, delivered within 30 seconds of each other at the same exact location, offer no meaningful benefit in lesion depth or width over single ablations, with the exception of ventricular ablation at 30 W for 50 s. Given the risks associated with excessive ablation, our results suggest that this practice should be re-evaluated by clinical electrophysiologists. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Toloczko A, Buchan S, John M, Post A, Razavi M
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437855
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Abstract

Case Volume and Procedural Outcomes in Ablation for Atrial Fibrillation: Practice Makes Perfect?

Muthalaly RG, John RM
Ablation for atrial fibrillation (AF) is an established therapy that continues to grow in scope and indication This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Muthalaly RG, John RM
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437861
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Abstract

Radiofrequency ablation- to insure or not to insure is the question.

Sanghai S, Henrikson CA
Radiofrequency (RF) remains the most used energy source for cardiac ablation since its initial clinical use in 1985 mainly because of its ability to create targeted, discrete areas of irreversible coagulation necrosis while maintain safety and patient comfort This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Sanghai S, Henrikson CA
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437896
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The Impact of Hospital Case Volume on the Outcomes after Catheter Ablation for Atrial Fibrillation according to the Ablation Technology.

Kanaoka K, Nishida T, Nishioka Y, Myojin T, ... Imamura T, Saito Y
Introduction
The appropriate hospital case volume for catheter ablation (CA) in patients with atrial fibrillation (AF) according to the ablation technology has not been fully examined. This study aimed to investigate the association between the hospital case volume for AF and peri-procedural complications and AF recurrence.
Methods
In this retrospective cohort study, we used data from the National Database of Health Insurance Claims and Specific Health Checkups, which covers almost all healthcare insurance claims data in Japan. We included patients with AF who underwent first-time CA from April 2014 to March 2020. Using mixed-effect logistic regression, we analyzed the effect of the annual case volume for AF ablation on acute periprocedural complications and one-year success rate off antiarrhythmic drugs according to the ablation technology (radiofrequency ablation or cryoballoon ablation).
Results
Among 270,116 patients, 207,839 (77%) patients underwent radiofrequency ablation and 56,648 (21%) patients underwent cryoballoon ablation. Of all patients, acute complications occurred in 5,411 (2.0%) patients, and the recurrence at 1 year was 71,511 (27%). In the radiofrequency ablation group, acute complications and one-year AF recurrence according to case volume decreased as the annual case volume increased to up to 150-200 cases/year. However, in the cryoballoon ablation group, these outcomes were similar regardless of the case volumes.
Conclusion
The case-volume effect was noted in the radiofrequency ablation group, but not in the cryoballoon ablation group. Our results may affect the selection of ablation technology, especially in smaller case-volume hospitals. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Kanaoka K, Nishida T, Nishioka Y, Myojin T, ... Imamura T, Saito Y
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437814
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Abstract

Low-voltage areas identified with new mapping catheters and technologies.

Miyazaki S
The development of the electroanatomic mapping technology has allowed us to precisely localize the mapping catheter and recorded electroanatomic information in a 3-dimensional (3D) field. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print
Miyazaki S
J Cardiovasc Electrophysiol: 19 Apr 2022; epub ahead of print | PMID: 35437822
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Abstract

The Hybrid Convergent Procedure for Persistent and Long-Standing Persistent Atrial Fibrillation From an Electrophysiologist\'s Perspective.

DeLurgio DB
In atrial fibrillation (AF), the pulmonary veins (PV) are central to arrhythmogenicity and are targeted by PV isolation (PVI). As AF progresses, triggers become more prevalent in non-PV areas including the left atrial posterior wall (LAPW). Reported benefits of LAPW isolation in Cox-maze IV led to exploration of ablation strategies using endocardial catheters. However, no single approach to endocardial LAPW isolation exists. Relative success in comparison to PVI alone has been mixed. The hybrid convergent procedure was developed to combine minimally invasive surgical and electrophysiology techniques to accomplish effective PVI and LAPW isolation. Epicardial LAPW isolation is performed by a cardiothoracic surgeon followed by endocardial ablation by an electrophysiologist who ensures PVI completion and targets any remaining gaps. Safety and effectiveness of hybrid convergent was evaluated in the prospective, multi-center, randomized controlled trial, Convergence of Epicardial and Endocardial Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE). CONVERGE compared the effectiveness of the hybrid convergent procedure to endocardial catheter ablation for treatment of drug-refractory persistent and longstanding persistent AF and demonstrated primary effectiveness of higher freedom from atrial arrhythmias absent new/increased dose previously failed/intolerant anti-arrhythmic drugs through 12 months compared to endocardial catheter ablation. Greater freedom from AF and proportion of patients experiencing ≥90% burden reduction with hybrid convergent ablation were seen through 18 months follow-up. Improved electrophysiology lab efficiency was demonstrated by the reduction in endocardial ablation time with addition of epicardial ablation. This multi-disciplinary heart team procedure may improve outcomes in difficult-to-treat patients with advanced AF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Apr 2022; epub ahead of print
DeLurgio DB
J Cardiovasc Electrophysiol: 14 Apr 2022; epub ahead of print | PMID: 35420730
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Abstract

Ripple Mapping: A precise tool for atrioventricular nodal reentrant tachycardia ablation.

Howard TS, Valdes SO, Zobeck MC, Lam WW, ... Dan Pham T, Kim JJ
Introduction
Ablation for atrioventricular nodal reentrant tachycardia (AVNRT) classically utilizes evaluation of signal morphology within the anatomic region of the slow pathway (SP), which involves subjectivity. Ripple Mapping (RM) (CARTO-3© Biosense Webster Inc, Irvine, CA) displays each electrogram at its 3-dimensional coordinate as a bar changing in length according to its voltage-time relationship. This allows prolonged, low-amplitude signals to be displayed in their entirety, helping identify propagation in low-voltage areas. We set out to evaluate the ability of RM to locate the anatomic site of the slow pathway and assess its use in guiding ablation for AVNRT.
Methods
Patients ≤18 yrs with AVNRT in the EP laboratory between 2017 and 2021 were evaluated. RM was performed to define region of SP conduction in patients from 2019-2021, whereas standard electro-anatomical mapping was used from 2017-2019. All ablations were performed using cryo-therapy. Demographics, outcomes and analysis of variance in number of test lesions until success were compared between groups.
Results
A total 115 patients underwent AVRNT ablation during the study; 46 patients were in the RM group and 69 were in the control group. There were no demographic differences between groups. All procedures, in both groups, were acutely successful. In RM group, 89% of first successful lesions were within 4mm of the predicted site. There was significantly reduced variability in number of test lesions until success in the RM group (p=0.01).
Conclusions
RM is a novel technique that can help identify slow pathway location, allowing for successful ablation of AVNRT with decreased variability. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 13 Apr 2022; epub ahead of print
Howard TS, Valdes SO, Zobeck MC, Lam WW, ... Dan Pham T, Kim JJ
J Cardiovasc Electrophysiol: 13 Apr 2022; epub ahead of print | PMID: 35419906
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Abstract

Computed tomography imaging-identified location and electrocardiographic characteristics of left bundle branch area pacing in bradycardia patients.

Chen K, Liu XB, Hou X, Qiu Y, ... Cheng A, Zou J
Introduction
Left bundle branch area pacing (LBBAP) is a novel physiological pacing modality. The relationship between the pacing lead tip location and paced electrocardiographic (ECG) characteristics remains unclear. The objectives are to determine the lead tip location within the interventricular septum (IVS) and assess the location-based ECG QRS duration (QRSd) and left ventricular activation time (LVAT).
Methods
This multi-center study enrolled 50 consecutive bradycardia patients who met pacemaker therapy guidelines and received LBBAP implantation via the trans-ventricular septal approach. After at least 3 months post implant, 12-lead ECGs and pacing parameters were obtained. Cardiac computed tomography (CT) imaging was performed to assess the LBBAP lead tip distance from the LV blood pool.
Results
Among the 50 patients, analyzable CT images were obtained in 42. In 23 of the 42 patients, the lead tips were within 2 mm to the LV blood pool (the LV subendocardial (LVSE) group), 13 between 2 mm and 4 mm (the Near-LVSE group), and the remaining 6 beyond 4 mm (the mid-LV septal (Mid-LVS) group). No significant differences in paced QRSd were found among the 3 groups (LVSE, 107±15 ms; Near-LVSE, 106±13 ms; Mid-LVS, 104±15 ms; P=0.87). LVAT in the LVSE (64±7 ms) was significantly shorter than in the Mid-LVS (72±8 ms; P<0.05), but not significantly different from that in the Near-LVSE (69±8 ms; P>0.05).
Conclusion
In routine LBBAP practice, paced narrow QRSd and fast LVAT, indicative of physiological pacing, was consistently achieved for lead tip location in the LV subendocardial or near LV subendocardial region. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 13 Apr 2022; epub ahead of print
Chen K, Liu XB, Hou X, Qiu Y, ... Cheng A, Zou J
J Cardiovasc Electrophysiol: 13 Apr 2022; epub ahead of print | PMID: 35419908
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Abstract

Predictors of appropriate implantable cardiac defibrillator therapy in cardiac sarcoidosis.

Mathijssen H, Bakker ALM, Balt JC, Akdim F, ... Grutters JC, Post MC
Background
Cardiac sarcoidosis (CS) is associated with an increased risk for sudden cardiac death. An implantable cardiac defibrillator (ICD) is recommended in a subgroup of CS patients. However, the recommendations for primary prevention differ between guidelines. The purpose of the study was to evaluate the efficacy and safety of ICDs in CS and to identify predictors of appropriate therapy.
Methods
A retrospective cohort study was performed in CS patients with an ICD implantation between 2010 and 2019. Primary outcome was appropriate ICD therapy. Independent predictors were calculated using Cox proportional hazard analysis.
Results
105 patients were included. An ICD was implanted for primary prevention in 79%. During a median follow-up of 2.8 years, 34 patients (32.4%) received appropriate ICD therapy of whom 24 (22.9%) received an appropriate shock. Three patients (2.9%) received an inappropriate shock due to atrial fibrillation. Independent predictors of appropriate therapy included prior ventricular arrhythmias (hazard ratio [HR]: 10.5 [95% confidence interval (CI): 5.0-21.9]) and right ventricular late gadolinium enhancement (LGE) (HR: 3.6 [95% CI: 1.7-7.6]). Within the primary prevention group, right ventricular LGE (HR: 5.7 [95% CI: 1.6-20.7]) was the only independent predictor of appropriate therapy. Left ventricular ejection fraction did not differ between patients with and without appropriate therapy (44.4% vs. 45.6%, p = .70).
Conclusion
In CS patients with an ICD, a high rate of appropriate therapy was observed and a low rate of inappropriate shocks. Prior ventricular arrhythmias and right ventricular LGE were independent predictors of appropriate therapy.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 11 Apr 2022; epub ahead of print
Mathijssen H, Bakker ALM, Balt JC, Akdim F, ... Grutters JC, Post MC
J Cardiovasc Electrophysiol: 11 Apr 2022; epub ahead of print | PMID: 35411644
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Abstract

Early repolarization syndrome, epilepsy, and atrial fibrillation in a young girl with novel KCND3 mutation managed with quinidine.

Choubey M, Bansal R, Siddharthan D, Naik N, Sharma G, Saxena A
A 6-year-old girl presented with a difficult to control epilepsy syndrome. On evaluation, additional presyncope episodes associated with polymorphic ventricular tachycardia were also noted. A diagnosis of early repolarization syndrome (ERS) was made with an early repolarization pattern on electrocardiogram, documented VT episodes, and clinical presyncope (proposed Shanghai score 7). Paroxysmal atrial fibrillation (AF) was also noted on 24-h Holter recordings. The child was stabilized with isoprenaline infusion and was later discharged with arrhythmia control on quinidine and cilostazol. The genetic evaluation revealed a potassium channel KCND3 gene missense mutation. The case highlights the association of epilepsy syndrome and AF with ERS; the possible association of KCND3 gene mutation with a malignant phenotype; and management issues in a small child.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 07 Apr 2022; epub ahead of print
Choubey M, Bansal R, Siddharthan D, Naik N, Sharma G, Saxena A
J Cardiovasc Electrophysiol: 07 Apr 2022; epub ahead of print | PMID: 35388935
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Abstract

Influence of respiration and tissue contact on ventricular substrate identification during high density mapping: results from an ovine infarct model.

Campbell T, Bennett RG, Anderson RD, Turnbull S, Kumar S
Introduction
Multi-electrode mapping (MEM) and automated point collection are important enhancements to substrate mapping in ventricular tachycardia ablation. The effects of tissue contact and respiration on electrogram voltage with differing depolarisation wavefronts with MEM catheters are unclear.
Methods
Bipolar and unipolar voltages were collected from control (n=5) and infarcted (n=7) animals with a multi-spline MEM catheter. Electro-anatomic maps were created in sinus rhythm, and right and left ventricular pacing. Analysis was performed across three collection settings: standard (SS), respiratory-phase gating (RG), and electrode-tissue proximity (TP). Comparison was made to scar detected by cardiac MRI (cMRI).
Results
Compared to SS and RG acquisition, median bipolar and unipolar voltages were higher using TP, regardless of the depolarization wavefront. In infarct animals, bipolar voltages were 30.7-50.5% higher for bipolar and 8.7-13.8% higher on unipolar voltages with TP, compared to SS. The effect of RG on bipolar and unipolar voltages was minimal. Percentage of local abnormal ventricular activities was not impacted by acquisition settings or wavefront direction in infarct animals. Compared with cMRI defined scar, all three acquisition settings overestimated scar area using standard voltage-based cutoffs. RG improved the low voltage area concordance with MRI by 1.6-5.1% whereas TP improved by 5.9-8.4%.
Conclusions
High density voltage mapping with a MEM catheter is influenced by point collection settings. Tissue contact filters reduced low voltage areas and improved agreement with cMRI fibrosis in infarcted ovine hearts. These findings have critical implications for optimising filter settings for high density substrate mapping in the left ventricle. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Apr 2022; epub ahead of print
Campbell T, Bennett RG, Anderson RD, Turnbull S, Kumar S
J Cardiovasc Electrophysiol: 07 Apr 2022; epub ahead of print | PMID: 35388937
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Abstract

Ventricular tachycardia targeted in the aortic sinuses of Valsalva in patients with prior myocardial infarction.

Siontis KC, Njeim M, Dabbagh GS, Yokokawa M, Morady F, Bogun F
Introduction
Ventricular tachycardia (VT) in structurally normal hearts or nonischemic cardiomyopathy can originate from the aortic sinuses of Valsalva (SoV). It is unknown whether VT can originate from the SoVs in patients with prior myocardial infarction (MI).
Objective
To evaluate the prevalence, arrhythmogenic substrate, and ablation outcomes of postinfarction VT originating from the SoVs.
Methods
Among 217 consecutive patients with postinfarction VT undergoing ablation, we identified 13 (6%) patients who had ≥1 VT mapped in a SoV. Control groups of 13 patients with idiopathic SoV VT and 13 postinfarction patients without SoV VT were included.
Results
In the study group, 17 VTs were mapped in a SoV (right n = 5, left-right commissure n = 6, left n = 6). SoV VT target sites had low bipolar voltage during sinus rhythm [median 0.42 (IQR: 0.16-0.53) mV] which was significantly lower than target sites in patients with idiopathic SoV VTs [median 1.02 (IQR: 0.89-1.52) mV; p < .001]. An area of endocardial low voltage was found below the aortic valve in all patients with postinfarction SoV VTs compared to 9 (69%) of the patients in the postinfarction control group without SoV VT (p = .02). Morphology characteristics of postinfarction SoV VTs differed from idiopathic SoV VTs. None of the postinfarction SoV VTs were inducible after ablation and none recurred after a median follow-up of 14 months.
Conclusion
In patients with prior MI, VT can be targeted in an aortic SoV. The SoVs should be routinely investigated in postinfarction patients with inferior axis VT and an area of low voltage below the aortic valve.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 06 Apr 2022; epub ahead of print
Siontis KC, Njeim M, Dabbagh GS, Yokokawa M, Morady F, Bogun F
J Cardiovasc Electrophysiol: 06 Apr 2022; epub ahead of print | PMID: 35388571
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Abstract

Cardioneuroablation for vasovagal syncope and atrioventricular block: A step-by-step guide.

Aksu T, Gupta D, D\'Avila A, Morillo CA
Catheter-based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal hyperactivity. There is now increasing convergence among enthusiasts on its various aspects, including patient selection, technical steps, and procedural end-points. This pragmatic review aims to take the reader through a step-by-step approach to cardioneuroablation: we begin with a brief overview of the anatomy of intrinsic cardiac autonomic nervous system, before focusing on the indications, preprocedure and postprocedure management, necessary equipment, and its potential limitations.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 01 Apr 2022; epub ahead of print
Aksu T, Gupta D, D'Avila A, Morillo CA
J Cardiovasc Electrophysiol: 01 Apr 2022; epub ahead of print | PMID: 35362165
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Abstract

Longitudinal QT stability and impact of baseline cardiac rhythm on discharge dose in dofetilide-treated patients.

Khan ZA, LaBreck ME, Luli J, Roberts C, ... Amin AK, Chopra N
Introduction
Dofetilide suppresses atrial fibrillation (AF) in a dose-dependent fashion. The protective effect of AF against QTc prolongation induced torsades de pointe and transient post-cardioversion QTc prolongation may result in dofetilide under-dosing during initiation. Thus, the optimal timing of cardioversion for AF patients undergoing dofetilide initiation to optimize discharge dose remains unknown as does the longitudinal stability of QTc . The purpose of this study was to evaluate the impact of baseline rhythm on dofetilide dosing during initiation and assess the longitudinal stability of QTc-all (Bazzett, Fridericia, Framingham, and Hodges) over time.
Methods
Medical records of patients who underwent preplanned dofetilide loading at a tertiary care center between January 2016 and 2019 were reviewed.
Results
A total of 198 patients (66 ± 10 years, 32% female, CHADS2 -Vasc 3 [2-4]) presented for dofetilide loading in either AF (59%) or sinus rhythm (SR) (41%). Neither presenting rhythm, nor spontaneous conversion to SR impacted discharge dose. The cumulative dofetilide dose before cardioversion moderately correlated (r = .36; p = .0001) with discharge dose. Postcardioversion QTc-all prolongation (p < .0001) prompted discharge dose reduction (890 ± 224 mcg vs. 552 ± 199 mcg; p < .0001) in 30% patients. QTc-all in SR prolonged significantly during loading (p < .0001). All patients displayed QTc-all reduction (p < .0001) from discharge to short-term (46 [34-65] days) that continued at long-term (360 [296-414] days) follow-ups. The extent of QTc-all reduction over time moderately correlated with discharge QTc-all (r = .54-0.65; p < .0001).
Conclusion
Dofetilide initiation before cardioversion is equivalent to initiation during SR. Significant QTc reduction proportional to discharge QTc is seen over time in all dofetilide-treated patients. QTc returns to preloading baseline during follow-up in patients initiated in SR.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 01 Apr 2022; epub ahead of print
Khan ZA, LaBreck ME, Luli J, Roberts C, ... Amin AK, Chopra N
J Cardiovasc Electrophysiol: 01 Apr 2022; epub ahead of print | PMID: 35362175
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Abstract

Is prophylactic ablation of the cavotricuspid and peri-incisional isthmus justified in patients with postoperative atrial flutter after right atriotomy?

Benak A, Kupo P, Bencsik G, Makai A, Saghy L, Pap R
Background
The two most common postoperative atrial flutter (AFL) circuits after right atriotomy are the cavotricuspid isthmus (CTI) dependent and the lateral, peri-incisional. We investigated whether radiofrequency ablation (RFA) of both circuits results in more favorable long-term outcomes.
Methods
Single-center retrospective cohort study of consecutive patients who underwent RFA of AFL after open-heart surgery. The effect of surgery type and RFA strategy on AFL recurrence was evaluated.
Results
One hundred and forty-two patients (mean age 64.5 ± 12.7 years, 65.% male) were enrolled. Patients with right atrial (RA) flutter (n = 124) were divided into two groups based on the index RFA procedure: only one RA circuit was ablated (Group 1, n = 84, 67.7%) or both the CTI and the peri-incisional circuit ablated (Group 2, n = 40, 32.3%). The previous open-heart surgery was categorized based on the extension of the RA incision: limited (Type A) or extended (Type B) atriotomy. After a mean follow-up of 36 ± 28 months, flutter recurrence was not different among patients with limited RA atriotomy (25% vs. 22% in Groups 1A and 2A, respectively, p = 1.0). However, after type B surgery, ablation of both AFL circuits was associated with a reduced recurrence rate (63% vs. 26% in Groups 1B and 2B, respectively, p = .002).
Conclusions
In patients with postoperative RA flutter after extended right atriotomy, ablation of both the CTI and the peri-incisional isthmus significantly reduces the AFL recurrence rate. Prophylactic ablation of both isthmi, even if not proven to support reentry, is reasonable in this population.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 31 Mar 2022; epub ahead of print
Benak A, Kupo P, Bencsik G, Makai A, Saghy L, Pap R
J Cardiovasc Electrophysiol: 31 Mar 2022; epub ahead of print | PMID: 35362181
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Abstract

An unprecedented cause of cardiac resynchronization with defibrillator (CRT-D) malfunction \"A beheaded generator assembly\".

Prasitlumkum N, Ding K, Doyle K, Pai RG, Lo R
Cardiac resynchronization with defibrillator (CRT-D) malfunction can be due to various reasons, including wire injury, insulation break, battery problems, or patient factors. Undesired outcomes can be dramatically elevated in those settings, prompting early detection and proper troubleshooting. To diagnose, clinical correlation and device interrogation are vital. However, it is not uncommon to find general troubleshooting options insufficient, as highlighted in this case report. Here, we presented an unusual \"head assembly separation,\" as the main reason for abnormal device parameters.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 31 Mar 2022; 33:769-772
Prasitlumkum N, Ding K, Doyle K, Pai RG, Lo R
J Cardiovasc Electrophysiol: 31 Mar 2022; 33:769-772 | PMID: 35118754
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Abstract

Impact of body mass index on cryoablation of atrial fibrillation: Patient characteristics, procedural data, and long-term outcomes.

Urbanek L, Bordignon S, Chen S, Bologna F, ... Schmidt B, Chun KJ
Introduction
Ablation of atrial fibrillation in the context of obesity can be challenging. We sought to evaluate the role of cryoballoon pulmonary vein isolation (CB-PVI) in obese patients with symptomatic atrial fibrillation (AF).
Methods
Patients with a BMI ≥ 25 kg/m2 and symptomatic AF who underwent CB-PVI were retrospectively enrolled. Three groups were defined (G1: BMI of 25-29 kg/m2 ; G2: BMI of 30-34 kg/m2 ; G3: BMI ≥ 35 kg/m2 ).
Results
600 patients were included (59% male; 66 ± 11 years old); 337, 149, and 114 were assigned to G1, G2, and G3, respectively. Acute procedural success was recorded in 99.7% of patients. Procedural and fluoroscopy time were comparable but the radiation dose was significantly higher in G3. Procedural complications were 3% in G1, 5.4% in G2, and 8.8% in G3 (p = .01). The overall freedom from AF after 1-year was 77%. G3 had a significantly worse 1-year success rate compared to G1 and G2 (G3: 66.5% vs. G1: 78.4%; p = .015 and vs. G2: 82.5%; p = .008) with reduced 1-year success in paroxysmal AF (G1: 84.0%; G2: 86.3%; and G3: 69.6%) but not in persistent AF (G1: 68.7%; G2: 77.4%; and G3: 62.1%). G3 showed similar success rates irrespective of AF form (PAF: 69.6% vs. persAF 62.1%; p = .501).
Conclusion
Cryoballoon ablation in obese patients can be effective with an acceptable safety profile, 77% of patients were in stable SR at 1 year. Severe obese patients (BMI ≥ 35) showed reduced procedural safety and 1-year success rate. In association with life style modification, CB ablation may represent a strategy to enhance rhythm control in the context of obesity.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 Mar 2022; epub ahead of print
Urbanek L, Bordignon S, Chen S, Bologna F, ... Schmidt B, Chun KJ
J Cardiovasc Electrophysiol: 30 Mar 2022; epub ahead of print | PMID: 35355367
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Abstract

A case series of very slow atrioventricular nodal reentrant tachycardia resembling junctional tachycardia.

Higuchi K, Higuchi S, Baranowski B, Wazni O, Scheinman MM, Tchou P
Introduction
The surface electrocardiography of typical atrioventricular nodal reentrant tachycardia (AVNRT) shows simultaneous ventricular-atrial (RP) activation with pseudo R\' in V1 and typical heart rates ranging from 150 to 220/min. Slower rates are suspicious for junctional tachycardia (JT). However, occasionally we encounter typical AVNRT with slow ventricular rates. We describe a series of typical AVNRT cases with heart rates under 110/min.
Methods
A total of 1972 patients with AVNRT who underwent slow pathway ablation were analyzed. Typical AVNRT was diagnosed when; (1) evidence of dual atrioventricular nodal conduction, (2) tachycardia initiation by atrial drive train with atrial-His-atrial response, (3) short septal ventriculoatrial time, and (4) ventricular-atrial-ventricular (V-A-V) response to ventricular overdrive (VOD) pacing with corrected post pacing interval-tachycardia cycle length (cPPI-TCL) > 110 ms. JT was excluded by either termination or advancement of tachycardia by atrial extrastimuli (AES) or atrial overdrive (AOD) pacing.
Results
We found 11 patients (age 20-78 years old, six female) who met the above-mentioned criteria. The TCL ranged from 560 to 782 ms. Except for one patient showing tachycardia termination, all patients demonstrated a V-A-V response and cPPI-TCL over 110 ms with VOD. AES or AOD pacing successfully excluded JT by either advancing the tachycardia in 10 patients or by tachycardia termination in one patient. Slow pathway was successfully ablated, and tachycardia was not inducible in all patients.
Conclusions
This case series describes patients with typical AVNRT with slow ventricular rate (less than 110/min) who may mimic JT. We emphasize the importance of using pacing maneuvers to exclude JT.

© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Mar 2022; epub ahead of print
Higuchi K, Higuchi S, Baranowski B, Wazni O, Scheinman MM, Tchou P
J Cardiovasc Electrophysiol: 29 Mar 2022; epub ahead of print | PMID: 35348267
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Abstract

Optimal ablation strategy for arrhythmia recurrence following persistent atrial fibrillation ablation; anatomy or electrophysiology?

Choudhury M, Mahida S
The optimal strategy for ablation of persistent atrial fibrillation (PsAF) remains to be defined. Established substrate-based ablation techniques, particularly techniques targeting complex electrograms, with complementary linear ablation for organized atrial tachycardias, have been associated with modest success rates. Recently, the development of VoM ethanol ablation (Et-VoM) has facilitated ablation of previously inaccessible arrhythmogenic substrate. This has allowed comparison of a standardized anatomically-guided protocol with Et-VOM to a traditional electrophysiology-guided approach for PsAF ablation.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Mar 2022; epub ahead of print
Choudhury M, Mahida S
J Cardiovasc Electrophysiol: 28 Mar 2022; epub ahead of print | PMID: 35347779
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Abstract

Chest computer tomography is safe without additional interrogation or monitoring for modern cardiac implantable electrical devices.

Tsutsui K, Kato R, Mori H, Kawano D, ... Muramatsu T, Matsumoto K
Introduction
Whether diagnostic computed tomography (CT) scans to cardiac implantable electronic devices (CIED) is safe in recent models remains unknown.
Methods
A two-centers observational study. Over 14 years, consecutive 2362 chest CT scans (1666 pacemakers [PMs], 145 cardiac resynchronization therapy PM, 316 implantable cardioverter-defibrillator, and 233 cardiac resynchronization therapy defibrillator) were interrogated and monitored upon imaging.
Results
Electromagnetic interference occurred only in a few old models: InSync 8040 (n = 14), InSync III Marquis (n = 1), and Kappa (n = 4), which resulted no adverse events.
Conclusion
CIEDs, especially recent ones, are confirmed safe on chest CT.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Mar 2022; epub ahead of print
Tsutsui K, Kato R, Mori H, Kawano D, ... Muramatsu T, Matsumoto K
J Cardiovasc Electrophysiol: 28 Mar 2022; epub ahead of print | PMID: 35347781
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Abstract

Strategy for repeat procedures in patients with persistent atrial fibrillation: Systematic linear ablation with adjunctive ethanol infusion into the vein of Marshall versus electrophysiology-guided ablation.

Nakashima T, Pambrun T, Vlachos K, Goujeau C, ... Jaïs P, Derval N
Introduction
The optimal strategy after a failed ablation for persistent atrial fibrillation (perAF) is unknown. This study evaluated the value of an anatomically guided strategy using a systematic set of linear lesions with adjunctive ethanol infusion into the vein of Marshall (Et-VOM) in patients referred for second perAF ablation procedures.
Methods and results
Patients with perAF who underwent a second procedure were grouped according to the two strategies. The first strategy was an anatomically guided approach using systematic linear ablation with adjunctive Et-VOM, with bidirectional blocks at the posterior mitral isthmus (MI), roof, and cavotricuspid isthmus (CTI) as the procedural endpoint (Group I). The second one was an electrophysiology-guided strategy, with atrial tachyarrhythmia termination as the procedural endpoint (Group II). Arrhythmia behavior during the procedure guided the ablation strategy. Groups I and II consisted of 96 patients (65 ± 9 years; 71 men) and 102 patients (63 ± 10 years; 83 men), respectively. Baseline characteristics were comparable. In Group I, Et-VOM was successfully performed in 91/96 (95%), and procedural endpoint (bidirectional block across all three anatomical lines) was achieved in 89/96 (93%). In Group II, procedural endpoint (atrial tachyarrhythmia termination) was achieved in 80/102 (78%). One-year follow-up demonstrated Group I (21/96 [22%]) experienced less recurrence compared to Group II (38/102 [37%], Log-rank p = .01). This was driven by lower AT recurrence in Group I (Group I: 10/96 [10%] vs. Group II: 29/102 [28%]; p = .002).
Conclusion
Anatomically guided strategy with adjunctive Et-VOM is superior to an electrophysiology-guided strategy for second procedures in patients with perAF at 1-year follow-up.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Mar 2022; epub ahead of print
Nakashima T, Pambrun T, Vlachos K, Goujeau C, ... Jaïs P, Derval N
J Cardiovasc Electrophysiol: 28 Mar 2022; epub ahead of print | PMID: 35347799
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Abstract

Novel \"late potential map\" algorithm: Abnormal potentials and scar channels detection for ventricular tachycardia ablation.

Cortez-Dias N, Lima da Silva G, Nunes-Ferreira A, Nakar E, ... Pinto FJ, de Sousa J
Background
Automated systems for substrate mapping in the context of ventricular tachycardia (VT) ablation may annotate far-field rather than near-field signals, rendering the resulting maps hard to interpret. Additionally, quantitative assessment of local conduction velocity (LCV) remains an unmet need in clinical practice. We evaluate whether a new late potential map (LPM) algorithm can provide an automatic and reliable annotation and localized bipolar voltage measurement of ventricular electrograms (EGMs) and if LCV analysis allows recognizing intrascar conduction corridors acting as VT isthmuses.
Methods
In 16 patients referred for scar-related VT ablation, 8 VT activation maps and 29 high-resolution substrate maps from different activation wavefronts were obtained. In offline analysis, the LPM algorithm was compared to manually annotated substrate maps. Locations of the VT isthmuses were compared with the corresponding substrate maps in regard to LCV.
Results
The LPM algorithm had an overall/local abnormal ventricular activity (LAVA) annotation accuracy of 94.5%/81.1%, which compares to 83.7%/23.9% for the previous wavefront algorithm. The resultant maps presented a spatial concordance of 88.1% in delineating regions displaying LAVA. LAVA median localized bipolar voltage was 0.22 mV, but voltage amplitude assessment had modest accuracy in distinguishing LAVA from other abnormal EGMs (area under the curve: 0.676; p < .001). LCV analysis in high-density substrate maps identified a median of two intrascar conduction corridors per patient (interquartile range: 2-3), including the one acting as VT isthmus in all cases.
Conclusion
The new LPM algorithm and LCV analysis may enhance substrate characterization in scar-related VT.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 26 Mar 2022; epub ahead of print
Cortez-Dias N, Lima da Silva G, Nunes-Ferreira A, Nakar E, ... Pinto FJ, de Sousa J
J Cardiovasc Electrophysiol: 26 Mar 2022; epub ahead of print | PMID: 35338745
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Abstract

Low-voltage-guided ablation of posterior wall improves 5-year arrhythmia-free survival in persistent atrial fibrillation.

Cutler MJ, Sattayaprasert P, Pivato E, Jabri A, AlMahameed ST, Ziv O
Introduction
The posterior wall (PW) has been proposed as a standard target for ablation beyond pulmonary vein antral isolation (PVI) in patients with persistent atrial fibrillation (AF). However, studies have shown inconsistent outcomes with the addition of PW ablation. The presence or absence of low voltage on the PW may explain these inconsistencies. We evaluated whether PW ablation based on the presence or absence of low voltage improves long-term arrhythmia-free outcomes.
Methods
We retrospectively reviewed 5-year follow-up in 152 consecutive patients who received either standard ablation (SA) with PVI alone or PVI + PW isolation based on physician discretion (n = 77) or voltage-guided ablation (VGA) with PVI and addition of PW ablation only if the low voltage was present on the PW (n = 75).
Results
The two groups were well matched for baseline characteristics including left atrial size and duration of AF. At 5-year follow-up, 64% of patients receiving VGA were AT/AF free compared to 34% receiving SA (HR: 0.358, p < .005). PW ablation had similar AF recurrence in SA and VGA groups (0.30 vs. 0.27, p = .96) but significantly higher recurrence of atrial tachycardia in the SA group compared to the VGA group (0.39 vs. 0.15, p = .03). The only procedure-related predictor of arrhythmia-free survival in multivariate analysis was VGA (HR: 0.30; 95% CI: 0.14-0.64, p = .002).
Conclusion
VGA of the PW ablation beyond PVI in persistent AF significantly improves long-term arrhythmia-free survival when compared with non-VGA. PW ablation without voltage guidance reduced AF recurrence but at the cost of a higher incidence of atrial tachycardia.

© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 24 Mar 2022; epub ahead of print
Cutler MJ, Sattayaprasert P, Pivato E, Jabri A, AlMahameed ST, Ziv O
J Cardiovasc Electrophysiol: 24 Mar 2022; epub ahead of print | PMID: 35332610
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Impact:
Abstract

Right atrium to left ventricle puncture for VT ablation in patients with mechanical aortic and mitral valves: A step-by-step approach.

Santangeli P
In patients with mechanical valves in the aortic and mitral positions, percutaneous access to the left ventricle (LV) for catheter ablation (CA) of ventricular tachycardia (VT) is challenging. We have recently described a novel percutaneous trans-right atrial (RA) access to the LV via a femoral venous approach for CA of VT in patients with mechanical aortic and mitral valves. With this approach, an iatrogenic Gerbode-type of ventricular septal defect is created with direct puncture of the inferior and medial aspect of the RA anatomically adjacent to the inferior-septal LV. The technique involves the use of steerable sheaths, dedicated radiofrequency wires, and intracardiac echocardiography guidance. The procedure has been documented feasible and safe in a series of consecutive patients with aortic and mitral mechanical valves and VT related to LV substrate. In this study, the procedural details of this novel approach are described in a step-by-step fashion.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 24 Mar 2022; epub ahead of print
Santangeli P
J Cardiovasc Electrophysiol: 24 Mar 2022; epub ahead of print | PMID: 35332599
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Impact:
Abstract

Will the insulated-tip radiofrequency catheter transform ablation procedures?

Kotake Y, Kanawati J, Kumar S
Radiofrequency (RF) ablation has been the most widely employed energy source for catheter ablation to date. However, most of conventional RF ablation energy dissipates into the bloodstream before reaching the target tissue. Technology that conveys RF energy exclusively toward target tissue may potentially improve the quality, safety, and outcome of the RF ablation procedures. RF ablation using a novel insulated-tip catheter (Sirona Medical Technologies [SMT]) may refine RF ablation in the future to minimize the risk of iatrogenic complications. Although it is still unclear whether the results of the SMT catheter can be translated to a human beating heart, the data for SMT catheter of this study are very promising.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 Mar 2022; epub ahead of print
Kotake Y, Kanawati J, Kumar S
J Cardiovasc Electrophysiol: 23 Mar 2022; epub ahead of print | PMID: 35322476
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Impact:
Abstract

Radiofrequency ablation using a novel insulated-tip ablation catheter can create uniform lesions comparable in size to conventional irrigated ablation catheters while using a fraction of the energy and irrigation.

Aryana A, Irastorza RM, Berjano E, Cohen RJ, ... Reddy VY, d\'Avila A
Introduction
During radiofrequency ablation (RFA) using conventional RFA catheters (RFC), ~90% of the energy dissipates into the bloodstream/surrounding tissue. We hypothesized that a novel insulated-tip ablation catheter (SMT) capable of blocking the radiofrequency path may focus most of the energy into the targeted tissue while utilizing reduced power and irrigation.
Methods
This study evaluated the outcomes of RFA using SMT versus an RFC in silico, ex vivo, and in vivo. Radiofrequency applications were delivered over porcine myocardium (ex vivo) and porcine thigh muscle preparations superfused with heparinized blood (in vivo). Altogether, 274 radiofrequency applications were delivered using SMT (4-15 W, 2 or 20 ml/min) and 74 applications using RFC (30 W, 30 ml/min).
Results
RFA using SMT proved capable of directing 66.8% of the radiofrequency energy into the targeted tissue. Accordingly, low power-low irrigation RFA using SMT (8-12 W, 2 ml/min) yielded lesion sizes comparable with RFC, whereas high power-high irrigation (15 W, 20 ml/min) RFA with SMT yielded lesions larger than RFC (p < .05). Although SMT was associated with greater impedance drops ex vivo and in vivo, ablation using RFC was associated with increased charring/steam pop/tissue cavitation (p < .05). Lastly, lesions created with SMT were more homogeneous than RFC (p < .001).
Conclusion
Low power-low irrigation (8-12 W, 2 ml/min) RFA using the novel SMT ablation catheter can create more uniform, but comparable-sized lesions as RFC with reduced charring/steam pop/tissue cavitation. High power-high irrigation (15 W, 20 ml/min) RFA with SMT yields lesions larger than RFC.

© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 Mar 2022; epub ahead of print
Aryana A, Irastorza RM, Berjano E, Cohen RJ, ... Reddy VY, d'Avila A
J Cardiovasc Electrophysiol: 23 Mar 2022; epub ahead of print | PMID: 35322477
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Impact:
Abstract

Safety of catheter ablation for atrial fibrillation in patients with mechanical prosthetic valves.

Rozen G, Elbaz-Greener G, Andria N, Heist K, ... Amir O, Marai I
Background
Catheter ablation (CA) for atrial fibrillation (AF) is increasingly utilized in recent years, with promising results. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for AF in patients with mechanical prosthetic valves (MPVs).
Methods and results
We drew data from the US National Inpatient Sample (NIS) database to identify cases of AF ablations in patients with MPVs, between 2003 and 2015. Sociodemographic and clinical data were collected, and incidence of procedural complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity-matched cohort of patients without MPVs. The study included a weighted total of 1898 CA for AF cases in patients with MPVs. The median age of the study population was 67 (61-75) years and 53% were males. Despite the increasing age and significant uptrend in the prevalence of individual comorbidities and Deyo-Charlson Comorbidity Index (CCI) over the years, the risk of peri-procedural complications and mortality in the study group did not change between the early (2003-2008) and late (2009-2015) study years. The peri-procedural complication rate (8.4% vs. 10.4%, p = .33) and in-hospital mortality (0.2% vs. 0.2%, p = .9) did not differ significantly between patients with MPVs and 1901 matched patients without MPVs. Length of stay was higher among patients with prior MPVs compared to the controls (4.0 ± 0.2 vs. 3.3 ± 0.2 days, p = .011).
Conclusion
This nationwide analysis shows that AF ablation in patients with mechanical valve prothesis bares a similar risk of periprocedural complications and mortality as in patients without prosthetic valves.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 19 Mar 2022; epub ahead of print
Rozen G, Elbaz-Greener G, Andria N, Heist K, ... Amir O, Marai I
J Cardiovasc Electrophysiol: 19 Mar 2022; epub ahead of print | PMID: 35304926
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Abstract

Cardiovascular risk of energy drinks: Caffeine and taurine facilitate ventricular arrhythmias in a sensitive whole-heart model.

Ellermann C, Hakenes T, Wolfes J, Wegner FK, ... Eckardt L, Frommeyer G
Background
Several case reports have suggested an increased risk of sudden cardiac death due to energy drinks. Therefore, the purpose of this study was to assess acute electrophysiologic effects of caffeine and taurine, two of the main ingredients of energy drinks, in an experimental whole-heart model.
Methods and results
Twenty-five rabbit hearts were excised, retrogradely perfused, and assigned to two groups. Hearts were perfused with caffeine (2, 10, and 50 µM) or taurine (2, 10, and 50 µM) after generating baseline data. Eight monophasic action potentials and electrocardiography recordings showed a significant abbreviation of action potential duration (APD90 ), QT interval, and effective refractory periods (ERP) after caffeine treatment. With taurine, cardiac repolarization duration and ERP were significantly shortened. A ventricular vulnerability was assessed by a predefined pacing protocol. With caffeine, we observed a trend towards more ventricular arrhythmias in a dose-dependent manner. After treatment with taurine, significantly more episodes of ventricular arrhythmias occurred.
Conclusion
In this experimental whole-heart study, treatment with caffeine and taurine provoked ventricular arrhythmias. The underlying mechanism was an abbreviation of cardiac repolarizations and effective refractory periods that may facilitate re-entry and thereby provokes arrhythmias. These findings help to understand the potentially hazardous and fatal outcomes after intoxication with energy drinks.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print
Ellermann C, Hakenes T, Wolfes J, Wegner FK, ... Eckardt L, Frommeyer G
J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print | PMID: 35304782
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Impact:
Abstract

Impact of a time-to-effect-guided ablation protocol in cryoballoon ablation on the durability of pulmonary vein isolation.

Rexha E, Heeger CH, Maack S, Rottner L, ... Kuck KH, Metzner A
Background
Cryoballoon (CB)-based pulmonary vein isolation (PVI) has proven to be as effective as radiofrequency-based ablation. Different ablation protocols took the individual time-to-isolation (TTI) into account aiming at shorter but equally or even more effective freeze cycles. The current study sought to assess the impact of the TTI on PVI durability in patients undergoing a repeat procedure for recurrence of atrial tachyarrhythmia (ATA).
Methods and results
In 205 patients with ATA recurrence after previous CB-based PVI, a total of 806 pulmonary veins (PVs) were identified. A total of 126 out of 806 PVs (16%) were previously treated with a TTI-guided ablation (Protocol #1; TTI + 120 s), in 92/806 (11%) PVs TTI was only monitored (m) but fixed freeze cycles were applied (Protocol #2; mTTI) and in 588/806 (73%) a fixed freeze cycle was applied without mTTI. There was no difference in the PV-reconduction rate between the groups (p = .23). The right inferior pulmonary vein (RIPV) showed overall significantly higher reconduction rates compared to the other PVs (RIPV-left inferior PV p < .003, -left superior PV p < .001, -right superior PV p < .013). Twenty-one patients (10%) were demonstrated to have only electrical reconduction of the RIPV, while all other PVs were still electrically isolated.
Conclusions
The TTI-based CB ablation protocol did not show significant differences regarding PV-reconduction rates compared to the other ablation protocols.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print
Rexha E, Heeger CH, Maack S, Rottner L, ... Kuck KH, Metzner A
J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print | PMID: 35304790
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Abstract

Fluoroscopic predictors of acceptable capture threshold during the implantation of the micra transcatheter pacing system.

Togashi I, Sato T, Maeda A, Mohri T, ... Ueda A, Soejima K
Introduction
Few predictors of low capture threshold before the deployment of the Micra transcatheter pacing system (Micra TPS) have been determined. We aimed to identify fluoroscopic predictors of an acceptable capture threshold before Micra TPS deployment.
Methods
Sixty patients were successfully implanted with Micra TPS. Before deployment, gooseneck appearance of the catheter shaft was quantified using the angle between the tangent line of the shaft and the cup during diastole in the right anterior oblique (RAO) view. The direction of the device cup toward the ventricular septum was evaluated using the angle between the cup and the horizontal plane in the left anterior oblique (LAO) view.
Results
Of the 95 deployments we evaluated, 56 achieved an acceptable capture threshold of ≤2.0 V at 0.24 ms. In this acceptable threshold group, the deflection angle of the gooseneck shaft was significantly larger and the device cup was placed more horizontally with a lower elevation angle compared with those in the high threshold group. A deflection angle of ≥6° and an elevation angle of ≤30° were identified as the predictors of an acceptable capture threshold after deployment. An acceptable capture threshold was achieved in 24/31 (77.4%) patients in whom either angle criterion was satisfied at the first deployment.
Conclusions
Diastolic gooseneck appearance of the delivery catheter in the RAO view or near-horizontal direction in the LAO view predicts an acceptable capture threshold after deployment. The shape of the delivery catheter before deployment should be evaluated using multiple fluoroscopic views to ensure successful implantation of Micra TPS.

© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print
Togashi I, Sato T, Maeda A, Mohri T, ... Ueda A, Soejima K
J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print | PMID: 35304791
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Abstract

Application of Ensite™ LiveView function for identification of scar-related ventricular tachycardia isthmus.

Kao PH, Chung FP, Lin YJ, Chang SL, ... Chhay C, Chen SA
Introduction
Dynamic display of real-time wavefront activation pattern may facilitate the recognition of reentrant circuits, particularly the diastolic path of ventricular tachycardia (VT).
Objective
We aimed to evaluate the feasibility of LiveView Dynamic Display for mapping the critical isthmus of scar-related reentrant VT.
Methods
Patients with mappable scar-related reentrant VT were selected. The characteristics of the underlying substrates and VT circuits were assessed using HD grid multielectrode catheter. The VT isthmuses were identified based on the activation map, entrainment, and ablation results. The accuracy of the LiveView findings in detecting potential VT isthmus was assessed.
Results
We studied 18 scar-related reentrant VTs in 10 patients (median age: 59.5 years, 100% male) including 6 and 4 patients with ischemic and nonischemic cardiomyopathy, respectively. The median VT cycle length was 426 ms (interquartile range: 386-466 ms). Among 590 regional mapping displays, 92.0% of the VT isthmus sites were identified by LiveView Dynamic Display. The accuracy of LiveView for isthmus identification was 84%, with positive and negative predictive values of 54.8% and 97.8%, respectively. The area with abnormal electrograms was negatively correlated with the accuracy of LiveView Dynamic Display (r = -.506, p = .027). The median time interval to identify a VT isthmus using LiveView was significantly shorter than that using conventional activation maps (50.5 [29.8-120] vs. 219 [157.5-400.8] s, p = .015).
Conclusion
This study demonstrated the feasibility of LiveView Dynamic Display in identifying the critical isthmus of scar-related VT with modest accuracy.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print
Kao PH, Chung FP, Lin YJ, Chang SL, ... Chhay C, Chen SA
J Cardiovasc Electrophysiol: 18 Mar 2022; epub ahead of print | PMID: 35304796
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Abstract

Cardiac Implantable Electronic Device Dysfunctions in Patients Undergoing Radiotherapy A Prospective Cohort Study.

Frey P, Irles D, Dompnier A, Akret C, ... Guillon B, Marijon E
Background
Increasing numbers of patients with cardiac implantable electronic devices (CIEDs) are undergoing radiotherapy for cancer. The aim of the study was to prospectively evaluate the incidence, characteristics, and associated factors of CIED dysfunctions related to radiotherapy.
Methods
Between April 2013 and March 2020, all patients with a CIED who underwent ≥1 radiotherapy session were enrolled. Patients were monitored according to a systematic protocol, including device interrogation before the 1st and after each radiotherapy session. The primary endpoint was CIED dysfunction, defined as oversensing, total or partial deprogramming, and/or unrecoverable reset.
Results
We included a total of 92 CIED radiotherapy courses: 77 (83.7%) in patients with a pacemaker and 15 (16.3%) in those with an implantable cardioverter defibrillator. Overall, 13 dysfunctions (14.1%) were observed during 92 courses (1509 sessions), giving an incidence of 0.9 per 100 sessions. These included nine deprogramming (three total resets to back-up pacing mode and six partial deprogramming that were all successfully reprogrammed), three transient oversensing, and one unrecoverable oversensing requiring CIED and leads replacement. There were no adverse clinical events related to device dysfunction. In multivariable analysis, neutron-producing irradiation (odds ratio [OR], 5.59; 95% confidence interval [CI], 1.09-28.65; P=0.039) and cumulative tumor dose (OR, 1.05; 95% CI, 1.01-1.10; P=0.007) remained significantly associated with CIED dysfunction.
Conclusions
In this prospective study, transient or permanent subclinical CIED dysfunction occurred in 14.1% of radiotherapy courses. Our findings emphasize the importance of high-energy beams and neutron-producing irradiation in risk assessment. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Mar 2022; epub ahead of print
Frey P, Irles D, Dompnier A, Akret C, ... Guillon B, Marijon E
J Cardiovasc Electrophysiol: 16 Mar 2022; epub ahead of print | PMID: 35299286
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Abstract

Preoperative Personalization of Atrial Fibrillation Ablation Strategy to Prevent Esophageal Injury: Impact of Changes in Esophageal Position.

Nakatani Y, Nuñez-Garcia M, Cheniti G, Sridi-Cheniti S, ... Jais P, Cochet H
Introduction
Due to changes in esophageal position, preoperative assessment of the esophageal location may not mitigate the risk of esophageal injury in catheter ablation for atrial fibrillation (AF). This study aimed to assess esophageal motion and its impact on AF ablation strategies.
Methods and results
Ninety-seven AF patients underwent 2 computed tomography (CT) scans. The area at risk of esophageal injury (AAR) was defined as the left atrial surface ≤3 mm from the esophagus. On CT1, ablation lines were drawn blinded to the esophageal location to create 3 ablation sets: individual pulmonary vein isolation (PVI), wide antral circumferential ablation (WACA), and WACA with linear ablation (WACA+L). Thereafter, ablation lines for WACA and WACA+L were personalized to avoid the AAR. Rigid registration was performed to align CT1 onto CT2, and the relationship between ablation lines and the AAR on CT2 was analyzed. The esophagus moved by 3.6 [2.7 to 5.5] mm. The AAR on CT2 was 8.6 ± 3.3 cm2 , with 77% overlapping that on CT1. High body mass index was associated with the AAR mismatch (standardized β 0.382, P <0.001). Without personalization, AARs on ablation lines for individual PVI, WACA, and WACA+L were 0 [0-0.4], 0.8 [0.5-1.2], 1.7 [1.2-2.0] cm2 . Despite the esophageal position change, the personalization of ablation lines for WACA and WACA+L reduced the AAR on lines to 0 [0-0.5] and 0.7 [0.3-1.0] cm2 (P <0.001 for both).
Conclusion
The personalization of ablation lines based on a preoperative CT reduced ablation to the AAR despite changes in esophageal position. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 10 Mar 2022; epub ahead of print
Nakatani Y, Nuñez-Garcia M, Cheniti G, Sridi-Cheniti S, ... Jais P, Cochet H
J Cardiovasc Electrophysiol: 10 Mar 2022; epub ahead of print | PMID: 35274776
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Abstract

In vivo Lesion Index (LSI) validation in percutaneous radiofrequency catheter ablation.

Themistoclakis S, Calzolari V, De Mattia L, China P, ... Thiene G, Tondo C
Introduction
Lesion Index (LSI) has been developed to predict lesion efficacy during radiofrequency (RF) catheter ablation. However, its value in predicting lesions size has still to be established. The aim of our study was to assess the lesions size reproducibility for pre-specified values of LSI reached during RF delivery in an in vivo beating heart.
Methods
Ablation lesions were created with different values of LSI in 7 domestic pigs by means of a contact force sensing catheter (TactiCathTM , Abbott). Lesions were identified during RF delivery by means of a 3D mapping system (EnSiteTM Precision, Abbott) and measured after heart explantation. Histology was carried out after gross examination on the first 3 lesions to confirm the accuracy of the macroscopic evaluation.
Results
A total of 64 myocardial lesions were created. Thirty-nine lesions were excluded from the analysis for the following reasons: histological confirmation of macroscopic lesion measurement (n=3), transmurality (n=24), unfavorable anatomic position (n=10), not macroscopically identifiable (n=2). In a final set of 25 non-transmural lesions, injury width and depth were respectively 4.6±0.6 mm and 2.6±0.8 mm for LSI=4, 7.3±0.8 mm and 4.7±0.6 mm for LSI=5, and 8.6±1.2 mm and 7.2±1.1 mm for LSI=6. A strong linear correlation was observed between LSI and lesion width (r=0.87, p<0.00001) and depth (r=0.89, p<0.00001). Multiple linear regression analysis identified LSI as the only ablation parameter that significantly predicted lesion width (p<0.001) and depth (p<0.001).
Conclusion
In our in vivo study, LSI proved highly predictive of lesion size and depth. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print
Themistoclakis S, Calzolari V, De Mattia L, China P, ... Thiene G, Tondo C
J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print | PMID: 35262242
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Abstract

Genetically Based Atrial Fibrillation: Current Considerations for Diagnosis and Management.

Pensa AV, Baman JR, Puckelwartz MJ, Wilcox JE
Atrial fibrillation (AF) is the most common atrial arrhythmia and is subcategorized into numerous clinical phenotypes. Given its heterogeneity, investigations into the genetic mechanisms underlying AF have been pursued in recent decades, with predominant analyses focusing on early onset or lone AF. Linkage analyses, genome wide association studies (GWAS), and single gene analyses have led to the identification of rare and common genetic variants associated with AF risk. Significant overlap with genetic variants implicated in dilated cardiomyopathy syndromes, including truncating variants of the sarcomere protein titin, have been identified through these analyses, in addition to other genes associated with cardiac structure and function. Despite this, widespread utilization of genetic testing in AF remains hindered by the unclear impact of genetic risk identification on clinical outcomes and the high prevalence of variants of unknown significance (VUS). However, genetic testing is a reasonable option for patients with early onset AF and in those with significant family history of arrhythmia. While many knowledge gaps remain, emerging data support genotyping to inform selection of AF therapeutics. In this review we highlight the current understanding of the complex genetic basis of AF and explore the overlap of AF with inherited cardiomyopathy syndromes. We propose a set of criteria for clinical genetic testing in AF patients and outline future steps for the integration of genetics into AF care. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print
Pensa AV, Baman JR, Puckelwartz MJ, Wilcox JE
J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print | PMID: 35262243
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Abstract

Anatomy of the Proximal Septal Vein in Patients with Focal Intramural Ventricular Arrhythmias.

Tam TK, Liang JJ, Ghannam M, Latchamsetty R, ... Morady F, Bogun F
Background
Focal ventricular arrhythmias (VA) originating from the intramural myocardium of the basal septum are difficult to localize and ablate. Proximal septal veins emptying into the great cardiac vein can reach close to the origin of intramural arrhythmias.
Objective
To assess characteristics of proximal septal coronary veins in patients with intramural VAs.
Methods and results
From among 84 consecutive patients with intramural VAs, 29 patients (age 60±11years, 16 males, ejection fraction 47±13%) underwent preprocedural cardiac computed tomographic angiography (CTA). In 14 of these patients the intramural site of origin (SOO) was identified with multipolar catheters. The intramural SOO could not be accessed with mapping catheters in the other 15 patients while mapping the coronary venous system. The CTA identified sizable proximal septal veins in all patients in whom the SOO could be accessed with mapping catheters. In the patients in whom the intramural SOO was not identified, the proximal septal veins were often either small (< 2 mm at branching site) or non-existent (n=9, p=0.001). The proximal septal veins in patients in whom the SOO was identified were larger than in the patients in whom the SOO could not be identified (3.0±0.6 mm vs 2.1±0.9 mm, p=0.01).
Conclusions
Preprocedural imaging with CTAs can be beneficial in identifying the anatomy of proximal septal coronary veins that allow adequate mapping of patients with suspected intramural VAs. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print
Tam TK, Liang JJ, Ghannam M, Latchamsetty R, ... Morady F, Bogun F
J Cardiovasc Electrophysiol: 08 Mar 2022; epub ahead of print | PMID: 35262245
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Impact:
Abstract

Artificial Intelligence and Atrial Fibrillation.

Sehrawat O, Kashou AH, Noseworthy PA
In the context of atrial fibrillation (AF), traditional clinical practices have thus far fallen short in several domains such as identifying patients at risk of incident AF or patients with concomitant undetected paroxysmal AF. Novel approaches leveraging artificial intelligence have the potential to provide new tools to deal with some of these old problems. In this review we focus on the roles of artificial intelligence-enabled ECG pertaining to AF, potential roles of deep learning (DL) models in the context of current knowledge gaps, as well as limitations of these models. One key area where DL models can translate to better patient outcomes is through automated ECG interpretation. Further, we overview some of the challenges facing AF screening and the harms and benefits of screening. In this context, a unique model was developed to detect underlying hidden AF from sinus rhythm and is discussed in detail with its potential uses. Knowledge gaps also remain regarding the best ways to monitor patients with embolic stroke of undetermined source (ESUS) and who would benefit most from oral anticoagulation. The AI-enabled AF model is one potential way to tackle this complex problem as it could be used to identify a subset of high-risk ESUS patients likely to benefit from empirical oral anticoagulation. Role of DL models assessing AF burden from long duration ECG data is also discussed as a way of guiding management. There is a trend towards the use of consumer-grade wristbands and watches to detect AF from photoplethysmography data. However, ECG currently remains the gold standard to detect arrythmias including AF. Lastly, role of adequate external validation of the models and clinical trials to study true performance is discussed. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print
Sehrawat O, Kashou AH, Noseworthy PA
J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print | PMID: 35258136
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Impact:
Abstract

Strategies for Repeat Ablation for Atrial Fibrillation: A Multicentre Comparison of Non-Pulmonary Vein versus Pulmonary Vein Target Ablation.

Mol D, Mulder MJ, Veenstra R, Allaart CP, ... de Groot JR, de Jong JSSG
Introduction
Approximately 18% of patients with atrial fibrillation (AF) undergo a repeat ablation within 12 months after their index ablation. Despite the high prevalence, comparative studies on non-pulmonary vein (PV) target strategies in repeat AF ablation are scarce. Here, we describe 12 months efficacy of non-PV and PV target ablations as repeat ablation strategy.
Methods
A multicentre retrospective, descriptive study was conducted with data of 280 patients who underwent repeat AF ablation. Ablation strategy for repeat ablation was at operators\' discretion. Non-PV target ablation (n=140) included, PV re-isolation, posterior wall isolation, mitral line, roofline and/or complex fractionated atrial electrogram ablation. PV target ablation (n=140), included re-isolation and/or wide atrium circumferential ablation. Patients\' demographics and rhythm outcomes during 12-months follow-up were analysed.
Results
At 12 months, more atrial tachyarrhythmias were observed in the non-PV target group (48.6%) compared to the PV target group (29.3%,p=0.001). Similarly, a significantly higher AF and atrial tachycardia (AT) recurrence rate was observed after non-PV target ablation compared to PV target ablation (36.4% versus 22.1% and 22.9% versus 10.7%). After adjustment, a significantly higher risk of AT recurrence remained in the non-PV target group. Both groups significantly de-escalated anti-arrhythmic drug use, de-escalation was more profound after PV target ablation. Patients with isolated PVs during non-PV target ablation had a significantly higher risk for AF recurrence than those with reconnected PVs.
Conclusion
Compared to PV target ablation, non-PV target repeat ablation did not improve outcomes after 12 months, and was independently associated an increased risk for AT recurrences. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print
Mol D, Mulder MJ, Veenstra R, Allaart CP, ... de Groot JR, de Jong JSSG
J Cardiovasc Electrophysiol: 07 Mar 2022; epub ahead of print | PMID: 35257441
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Abstract

Association Between Biventricular Pacing and Incidence of Ventricular Arrhythmias in the Early Post-Operative Period after Left Ventricular Assist Device Implantation.

Chou A, Larson J, Deshmukh A, Cascino TM, ... Pagani FD, Liang JJ
Introduction
Cardiac resynchronization therapy (CRT) and left ventricular assist devices (LVAD) improve outcomes in heart failure patients. Early ventricular arrhythmias (VA) are common after LVAD and are associated with increased mortality. The association between left ventricular pacing (LVP) with CRT and VAs in the early post-LVAD period remains unclear.
Methods
This was a retrospective study of all patients undergoing LVAD implantation from 1/2016 - 12/2019. Patients were divided into those with CRT and active LVP (CRT-LVP) immediately post-LVAD implant versus those without CRT-LVP. ICD electrograms were reviewed and early VAs were defined as sustained VT/VF occurring within 30 days of LVAD implantation.
Results
Of 186 included patients (mean age 53 years, 75% male, mean BMI 28), 72 had CRT devices, 63 of whom had LV pacing enabled after LVAD implant (CRT-LVP group). Patients with CRT-LVP were more likely to have VA in the early post-operative period (21% vs 4%; p=0.0001). All 9 patients with CRT in whom LVP was disabled had no early VA. Among those with early VA, patients with CRT-LVP were more likely to have monomorphic VT (77% vs 40%; p=0.07). In multiple logistic regression, CRT-LVP pacing remained an independent predictor of early VA after adjustment for history of VA and AF.
Conclusions
Patients with CRT-LVP after LVAD implant had a higher incidence of early VA (specifically monomorphic VT). Epicardial LV pacing may be proarrhythmic in the early post-operative period after LVAD. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 03 Mar 2022; epub ahead of print
Chou A, Larson J, Deshmukh A, Cascino TM, ... Pagani FD, Liang JJ
J Cardiovasc Electrophysiol: 03 Mar 2022; epub ahead of print | PMID: 35245401
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Impact:
Abstract

Remote Programming of Cardiac Implantable Electronic Devices: A Novel Approach to Program Cardiac Devices for Magnetic Resonance Imaging.

Siddamsetti S, Shinn A, Gautam S
Background
Magnetic Resonance imaging (MRI) in patients with MRI-conditional cardiovascular implantable electronic devices (CIED) remain a logistical issue for device programming during the scan. In current practice, a trained person needs to be present on-site to program CIED for MRI scan. This can cause delay in patient care, rescheduling of tests and increase healthcare costs. A novel remote programming (RP) strategy can be utilized to reprogram the CIED remotely. We sought to explore the feasibility and safety of RP of CIEDs in patients undergoing MRI scan.
Methods
We implemented the Medtronic CIED RP software at our institution after ensuring HIPAA compliance. The MRI technician started the session by contacting an off-site remote operator and placing a programmer wand from the 2090 Medtronic programmer over the CIED. The remote operator logged into a remote access software and provided a unique access code to the MRI technician. After entering the access code into the programmer, the remote operator was able to program the device as needed. We conducted a periodic audit of the first 209 patients who underwent RP of CIEDs for MRI. Outcomes analyzed were successful completion of RP sessions and time saved per scan.
Results
Of the 209 MRI scans, 51 scans were performed urgently. There were no connectivity and programming problems or need for MRI rescheduling. In-person reprogramming was not required for any patient. All scans were completed safely in a timely manner, and there were no reports of CIED malfunction. Time saved per scan was estimated to be 28 +/-10 minutes.
Conclusions
Remote programming of CIEDs for MRI scans is a safe and effective strategy. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Mar 2022; epub ahead of print
Siddamsetti S, Shinn A, Gautam S
J Cardiovasc Electrophysiol: 02 Mar 2022; epub ahead of print | PMID: 35243710
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Impact:
Abstract

The Role of Preoperative Venography in Predicting the Difficulty of a Transvenous Lead Extraction Procedure.

Aboelhassan M, Bontempi L, Cerini M, Salghetti F, ... Dell\'Aquila A, Curnis A
Introduction
We hypothesized that an accurate assessment of preoperative venography could be useful in predicting transvenous lead extraction (TLE) difficulty.
Methods and results
A dedicated preoperative venogram was performed in consecutive patients with cardiac implantable electronic device who underwent TLE. The level of stenosis was classified as without significant stenosis, moderate, severe, and occlusion. The presence of extensive lead-venous wall adherence (≥50 mm) was also assessed. A total of 105 patients (median age 71 years; 72% male) with a median of 2(1-2) leads to extract were enrolled. Preoperative venography showed moderate to severe stenosis in 31(30%), complete occlusion in 15(14%), and extensive lead-venous wall adherence in 50 (48%) patients. Complete TLE success was achieved in 103(98%) patients. Fifty-five (52%) were advanced extractions as they required a power mechanical and/or laser sheath. They were more prevalent in the group with extensive lead-venous wall adherence (72% vs. 34%, p<0.001), while no differences were found between patients with and without venous occlusion. In multivariate analysis, the presence of adherence was a predictor of advanced extraction (odds ratio 2.89[1.14-7.32], p=0.025). The fluoroscopy time was also significantly longer (14.0[8.2-18.7] vs. 5.1[2.1-10.0] min, p<0.001). The rate of complications did not differ based on the presence of venous lesions.
Conclusion
Although procedural success and complication rates were similar, patients with extensive lead-venous wall adherence required a longer fluoroscopy time and were 3 times more likely to need advanced extraction tools. Conversely, the presence of total venous occlusion had no impact on the procedure complexity. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Mar 2022; epub ahead of print
Aboelhassan M, Bontempi L, Cerini M, Salghetti F, ... Dell'Aquila A, Curnis A
J Cardiovasc Electrophysiol: 02 Mar 2022; epub ahead of print | PMID: 35243712
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Impact:
Abstract

Safety aspects of very high power very short duration atrial fibrillation ablation using a modified radiofrequency RF-generator: Single-center experience.

Mueller J, Halbfass P, Sonne K, Nentwich K, ... Behnes M, Deneke T
Introduction
High power short duration (HPSD) ablation proved to be an effective and safe ablation technique for atrial fibrillation (AF). In former case series, a significant amount of postablation coagulation at the catheter tip as well as silent cerebral lesions (SCL) in postprocedural cerebral magnetic resonance (cMRI) have been identified in patients undergoing de-novo AF ablations with very high power 90 W short duration (vHPvSD) ablations using the QDot ablation catheter in combination with a novel RF generator (nGEN, Biosense Webster). Therefore, the RF generator software has been recently modified.
Methods and results
Consecutive patients undergoing a first AF ablation including pulmonary vein isolation (PVI) with vHPvSD (90 W, with a predefined ablation time of 3 s at posterior left atrium (LA) wall sites and 4 s at other ablation sites) using the QDOT Micro ablation catheter (Biosense Webster) in conjunction with the technically modified nGEN RF generator (software V1c; Biosense Webster) were included. Procedural characteristics including first-pass isolation per pulmonary vein (PV) pair and early reconnection location within the 30-min waiting period were recorded. In all patients postablation endoscopy to document any thermal esophageal injury (EDEL) and in eligible patients a cMRI to detect silent cerebral events (SCEs)/lesions were performed. All acute procedure-related complications were recorded during the time until hospital discharge. Furthermore, short-term and midterm success after 3 and 6-12 months of follow-up was investigated. In total, 34 consecutive patients (67 ± 9 years; 62% male; 68% paroxysmal AF) were included. First-pass isolation of all PVs was achieved in 6/34 (18%) patients. First-pass isolation was seen in 37/68 (54%) of PV pairs. Early reconnection occurred in 11 (32%) patients (including reconnections at posterior LA wall sites n = 6 and at nonposterior sites n = 5). No patient had an EDEL (0%). In 6/23 (26%) patients undergoing postablation cerebral MRI SCEs were identified. In six patients, coagulation on the catheter tip was detected at the end of the procedure. No further peri- or postprocedural complications were detected. Early AF recurrence before discharge was seen in 1/34 (3%) of the patients included in this study. Within 3 months 10/34 (29%) revealed AF recurrence during blanking period. After a mean follow-up of 7 months, 31/34 (88%) patients revealed sinus rhythm.
Conclusion
AF ablation using 90 W vHPvSD with a specialized ablation catheter in conjunction with a recently modified RF generator was associated with no EDEL in the whole study cohort and 26% SCEs in a subgroup of patients undergoing acute postablation cerebral MRI. Accordingly, to our previously published results, a relevant number of catheter tip coagulations was identified in this patient cohort even after modifications of the RF generator. The vHPvSD ablation technique using the present and the previous generator seems to be associated with a very low rate of esophageal injury. However, the recently revised generator software also produced a relevant number of catheter tip coagulum formation and SCEs.

© 2022 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 01 Mar 2022; epub ahead of print
Mueller J, Halbfass P, Sonne K, Nentwich K, ... Behnes M, Deneke T
J Cardiovasc Electrophysiol: 01 Mar 2022; epub ahead of print | PMID: 35233883
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Abstract

A Real-world Experience of Atrioventricular Synchronous Pacing with Leadless Ventricular Pacemakers.

Kowlgi GN, Tseng AS, Tempel ND, Henrich MJ, ... Cha YM, Mulpuru SK
Aims
The MicraTM transcatheter pacing system (TPS) (Medtronic) is the only leadless pacemaker that promotes atrioventricular (AV) synchrony via accelerometer-based atrial sensing. Data regarding the real-world experience with this novel system are scarce. We sought to characterize patients undergoing MicraTM -AV implants, describe percentage AV synchrony achieved, and analyze the causes for suboptimal AV synchrony.
Methods
In this retrospective cohort study, electronic medical records from 56 consecutive patients undergoing MicraTM -AV implants at the Mayo Clinic sites in Minnesota, Florida, and Arizona with a minimum follow-up of 3 months were reviewed. Demographic data, comorbidities, echocardiographic data, and clinical outcomes were compared among patients with and without atrial synchronous-ventricular pacing (AsVP) ≥70%.
Results
Sixty-five percent of patients achieved AsVP ≥70%. Patients with adequate AsVP had smaller body mass indices, a lower proportion of congestive heart failure, and prior cardiac surgery. Echocardiographic parameters and procedural characteristics were similar across the two groups. Active device troubleshooting was associated with higher AsVP. The likely reasons for low AsVP were small A4-wave amplitude, high ventricular pacing burden, and inadequate device reprogramming. Importantly, in patients with low AsVP, subjective clinical worsening was not noted during follow-up.
Conclusion
With the increasing popularity of leadless PM, it is paramount for device implanting teams to be familiar with common predictors of AV synchrony and troubleshooting with MicraTM -AV devices. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Feb 2022; epub ahead of print
Kowlgi GN, Tseng AS, Tempel ND, Henrich MJ, ... Cha YM, Mulpuru SK
J Cardiovasc Electrophysiol: 28 Feb 2022; epub ahead of print | PMID: 35233867
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Abstract

Transseptal access: A review of contemporary tools.

Kaplan RM, Wasserlauf J, Knight BP
Transseptal left atrial catheterization is routinely used for many common catheter-based interventions. Tools for transseptal catheterization have advanced over the recent years. Such tools include imaging advances with intracardiac echocardiology as well as an array of needles, wires, and dilators to achieve transseptal access with greater ease and safety. This study will discuss the contemporary tools for transseptal catheterization and guidance for difficult cases.

© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Feb 2022; epub ahead of print
Kaplan RM, Wasserlauf J, Knight BP
J Cardiovasc Electrophysiol: 28 Feb 2022; epub ahead of print | PMID: 35229417
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