Journal: J Cardiovasc Electrophysiol

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<div><h4>Coronary arterial injury during right ventricular outflow tract ablation: Know your neighbors.</h4><i>Sridharan A, Hutchinson MD</i><br /><AbstractText>Left anterior descending (LAD) coronary arterial injury is an underappreciated and rare consequence of ablation in the right ventricular outflow tract (RVOT). The authors present five cases of acute or subacute LAD injury after RVOT ablation. Most patients had fairly extensive ablation and two had coincident cardiac perforation. The patients reported also had a strikingly similar ECG morphology of their spontaneous ventricular arrhythmias. The authors\' report serves an important cautionary tale regarding ablation of intramural septal VAs This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print</small></div>
Sridharan A, Hutchinson MD
J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print | PMID: 36709466
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<div><h4>Temporal association between drops in thoracic impedance and malignant ventricular arrhythmia: A longitudinal analysis of remote monitoring trends.</h4><i>Rodio G, Iacopino S, Pisanò EC, Calvi V, ... Gargaro A, D\'Onofrio A</i><br /><b>Introduction</b><br />Thoracic impedance (TI) drops measured by implantable cardioverter-defibrillators (ICDs) have been reported to correlate with ventricular tachycardia/fibrillation (VT/VF). The aim of our study was to assess temporal association of decreasing TI trends with VT/VF episodes through a longitudinal analysis of daily remote monitoring data from ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds).<br /><b>Methods and results</b><br />Retrospective data from 2,384 patients were randomized 1:1 into a derivation or validation cohort. The TI decrease rate was defined as the percentage of rolling weeks with a continuously decreasing TI trend. The derivation cohort was used to determine a TI decrease rate threshold for a ≥99% specificity of arrhythmia prediction. The associated risk of VT/VF episodes was estimated in the validation cohort by dividing the available follow-up into 60-day assessment intervals. Analyses were performed separately for 1,354 ICD and 1,030 CRT-D patients. During a median follow-up of 2.0 years, 727 patients (30.4%) experienced 3,298 confirmed VT/VF episodes. In the ICD group, a TI decrease rate of >60% was associated with a higher risk of VT/VF episode in a 60-day assessment interval (stratified hazard ratio, 1.42; 95% CI, 1.05-1.92; p=0.023). The TI decrease preceded (40.8%) or followed (59.2%) the VT/VF episodes. In the CRT-D group, no association between TI decrease and VT/VF episodes was observed (p=0.84).<br /><b>Conclusion</b><br />In our longitudinal analysis, TI decrease was associated with VT/VF episodes only in ICD patients. Preventive interventions may be difficult since episodes can occur before or after TI decrease. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print</small></div>
Rodio G, Iacopino S, Pisanò EC, Calvi V, ... Gargaro A, D'Onofrio A
J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print | PMID: 36709469
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<div><h4>Lesion Size Index-guided high-power ablation for atrial fibrillation: opening the therapeutic window.</h4><i>Hanley A</i><br /><AbstractText>Radiofrequency (RF) ablation for the treatment of atrial fibrillation has gained widespread acceptance since the concept was introduced by Haissaguerre et al a quarter of a century ago. High power short duration ablation has been widely adopted in the management of atrial fibrillation. Evidence for combining lesion size index and high power short duration ablation is lacking. In this issue of the journal, Cai et al evaluated the combination of HPSD with LSI with a focus on long-term efficacy. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print</small></div>
Hanley A
J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print | PMID: 36709478
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<div><h4>Network Meta-Analysis and Systematic Review Comparing Efficacy and Safety between Very high Power Short Duration, High Power Short Duration, and Conventional Radiofrequency Ablation of Atrial Fibrillation.</h4><i>Tokavanich N, Prasitlumkum N, Kewcharoen J, Chokesuwattanaskul R, ... Bunch TJ, Navaravong L</i><br /><b>Background</b><br />High-power short-duration (HPSD) atrial fibrillation (AF) ablation with a power of 40-50 watts was proved to be safe and effective. Very high-power short-duration (vHPSD) AF ablation is a novel method using >50 watts to obtain more durable AF ablation. This study aimed to evaluate the efficacy and safety of vHPSD ablation compared with HPSD ablation and conventional power ablation.<br /><b>Methods</b><br />A literature search for studies that reported AF ablation outcomes, including short-term freedom from atrial arrhythmia, first-pass isolation (FPI) rate, procedure time, and major complications, was conducted utilizing MEDLINE, EMBASE, and Cochrane databases. All relevant studies were included in this analysis. A random-effects model of network meta-analysis and surface under cumulative ranking curve (SUCRA) were used to rank the treatment for all outcomes.<br /><b>Results</b><br />A total of 29 studies with 9,721 patients were included in the analysis. According to the SUCRA analysis, HPSD ablation had the highest probability of maintaining sinus rhythm. Point estimation showed an odds ratio of 1.5 (95% confidence interval [CI] 1.2-1.9) between HPSD ablation and conventional power ablation and an odds ratio of 1.3 (95% CI 0.78-2.2) between vHPSD ablation and conventional power ablation. While the odds ratio of FPI between HPSD ablation and conventional power ablation was 3.6 (95% CI 1.5-8.9), the odds ratio between vHPSD ablation and conventional power ablation was 2.2 (95% CI 0.61-8.6). The procedure times of vHPSD and HPSD ablations were comparable and, therefore, shorter than that of conventional power ablation. Major complications were low in all techniques.<br /><b>Conclusion</b><br />vHPSD ablation did not yield higher efficacy than HPSD ablation and conventional power ablation. With the safety concern, vHPSD ablation outcomes were comparable with those of other techniques. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print</small></div>
Tokavanich N, Prasitlumkum N, Kewcharoen J, Chokesuwattanaskul R, ... Bunch TJ, Navaravong L
J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print | PMID: 36691892
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<div><h4>Substrate Modification of Ventricular Tachycardia: Can Ripple Mapping help improve success rates by identifying critical channels?</h4><i>Katritsis G, Linton NW, Kanagaratnam P</i><br /><AbstractText>Ablation of ventricular tachycardia (VT) has been shown to reduce VT recurrence more favourably than drug therapy in a number of trials This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print</small></div>
Katritsis G, Linton NW, Kanagaratnam P
J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print | PMID: 36691897
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<div><h4>In which patients with heart failure should ablation of atrial fibrillation not be performed?</h4><i>Hachiya H</i><br /><AbstractText>Catheter ablation of atrial fibrillation (AF) in patients with heart failure associated with a reduced EF (HFrEF) was associated with a significantly lower rate of a composite endpoint of death from any cause or hospitalization for worsening heart failure (HF) than medical therapy in the CASTLE-AF trial. In patients with HF and also with a preserved EF (HFpEF), AF is known to be associated with increased mortality. Although the particular benefit in patients with an EF >35% may suggest the need for prospective randomized control trial data in patients with HF to assess the role of ablation as a first-line therapy as Sessions AJ, et al. stated, we believe at present that 1) whether there is structural heart disease detected by cardiac images and 2) whether the left atrial voltage is generally low, should be assessed \"before ablation\" in each patient with HF to achieve a successful ablation. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print</small></div>
Hachiya H
J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print | PMID: 36691910
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<div><h4>Rationale For and Use of the Lumenless 3830 Pacing Lead.</h4><i>Richardson TD, Adam Himes MS, Marshall M, Crossley GH</i><br /><b>Introduction</b><br />Most currently available pacing and defibrillation leads utilize a stylet-based design that facilitates implantation. This has advantages, but also increases the lead diameter and adds the potential for metal fatigued-based conductor failure.<br /><b>Methods</b><br />A systematic literature search was conducted, and the authors add their twenty-year experience with this lead design.<br /><b>Results</b><br />The global experience with lumenless leads was reviewed both for \"standard\" positioning and with conduction system pacing. Methods for both placement and system modification are reviewed.<br /><b>Conclusions</b><br />Lumenless leads have the potential to improve the durability of endocardial pacing and facilitate conduction system pacing. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print</small></div>
Richardson TD, Adam Himes MS, Marshall M, Crossley GH
J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print | PMID: 36682066
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<div><h4>Evaluating Temperature Gradients Across the Posterior Left Atrium with Radiofrequency Ablation.</h4><i>Sandhu A, Holman B, Lammers S, Cerbin L, ... Sauer WH, Tzou WS</i><br /><b>Introduction</b><br />Esophageal injury is a well-known complication associated with catheter ablation. Though novel methods to mitigate esophageal injury have been developed, few studies have evaluated temperature gradients with catheter ablation across the posterior wall of the left atrium, interstitium and esophagus.<br /><b>Methods</b><br />To investigate temperature gradients across tissue, we developed a porcine heart-esophageal model to perform ex vivo catheter ablation on the posterior wall of the LA, with juxtaposed interstitial tissue and esophagus. Circulating saline (5 L/min) was used to mimic blood flow along the LA and alteration of ionic content to modulate impedance. Thermistors along the region of interest were used to analyze temperature gradients. Varying time and power, radiofrequency (RF) ablation lesions were applied with an externally irrigated ablation catheter. Ablation strategies were divided into standard approaches (SA, 10-15g, 25-35W, 30s) or high-power short duration (HPSD, 10-15g, 40-50W, 10s). Temperature gradients, time to maximum measured temperature and the relationship between measured temperature as a function of distance from the site of ablation were analyzed.<br /><b>Results</b><br />In total, 5 experiments were conducted each utilizing new porcine posterior LA wall-esophageal specimens for RF ablation (n=60 lesions each for SA and HPSD). For both SA and HPSD, maximum temperature rise from baseline was markedly higher at the anterior wall (AW) of the esophagus compared to the esophageal lumen (SA: 4.29°C vs. 0.41°C, p<0.0001 and HPSD: 3.13°C vs. 0.28°C, p<0.0001). Across ablation strategies, the average temperature rise at the anterior wall of the esophagus was significantly higher with SA relative to HPSD ablation (4.29°C vs. 3.13°C, p=0.01). From start of ablation, the average time to reach maximum temperature as measured at the anterior wall of the esophagus with SA was 36.49 +/- 12.12 sec, compared to 16.57 +/- 4.54 sec with HPSD ablation, p<0.0001. Fit to a linear scale, a 0.37°C drop in temperature was seen for every 1 cm increase in distance from the site of ablation and thermistor location at the anterior wall of the esophagus.<br /><b>Conclusion</b><br />Both SA and HPSD ablation strategies resulted in markedly higher temperatures measured at the anterior wall of the esophagus compared to the esophageal lumen, raising concern about the value of clinical intraluminal temperature monitoring. The temperature rise at the anterior wall was lower with HPSD. Significant time delay was seen to reach maximum measured temperature and a modest increase in distance between site of ablation and thermistor location impacted accuracy of monitored temperatures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print</small></div>
Sandhu A, Holman B, Lammers S, Cerbin L, ... Sauer WH, Tzou WS
J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print | PMID: 36682068
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<div><h4>Comparison of Warfarin with Direct Oral Anticoagulants for Thromboembolic Prophylaxis after Catheter Ablation of Ventricular Tachycardia.</h4><i>Deshmukh A, Gunda S, Ghannam M, Liang J, ... Morady F, Bogun F</i><br /><b>Introduction</b><br />Thromboembolic events after catheter ablation of ventricular tachycardia (VT) can result in significant morbidity. Thromboembolic prophylaxis after catheter ablation can be achieved by the use of antiplatelet agents, vitamin K antagonists, or direct oral anticoagulants (DOACs). The relative safety and efficacy of these modes of prophylaxis are uncertain. We sought to compare the outcomes of patients who received warfarin or DOACs for thromboembolic prophylaxis after catheter ablation of VT.<br /><b>Methods and results</b><br />Anticoagulation with DOACS was started after left ventricular VT ablation in a series of 42 consecutive patients with structural heart disease (67±11 years, 3 women, ejection fraction 32±14%). Duration of hospital stay, bleeding episodes, and thromboembolic events were compared to a historic consecutive group of patients (n=38, 65±13 years, 14 women, ejection fraction 36±13%) in whom anticoagulation with a formerly described protocol of heparin and vitamin K antagonist was used after VT ablation procedures. Hospital stay was significantly shorter in the group where DOACs were used as compared to vitamin K antagonists (3.3±1.8 vs. 5.0 ±2.5 days post ablation; p=0.001) without an increase of bleeding or thromboembolic events.<br /><b>Conclusion</b><br />Anticoagulation with DOACs is safe and shortens hospital stay in patients with structural heart disease undergoing left ventricular VT ablation procedures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Jan 2023; epub ahead of print</small></div>
Deshmukh A, Gunda S, Ghannam M, Liang J, ... Morady F, Bogun F
J Cardiovasc Electrophysiol: 19 Jan 2023; epub ahead of print | PMID: 36655538
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<div><h4>You won\'t see me: can pacing correlation maps be used to assess scar location?</h4><i>Gianni C, Burkhardt JD</i><br /><AbstractText>In ventricular tachycardia (VT) ablation, substrate-based approaches have emerged as an alternative approach to activation-based VT ablation, which is often limited when clinical arrhythmias are non-inducible, non-sustained, and/or hemodynamically compromising. Traditionally, substrate mapping is performed in sinus or paced rhythm, and comprises of annotation of abnormal electrograms, including low voltage, fractionated, and late potentials This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Gianni C, Burkhardt JD
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651345
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<div><h4>A novel practical algorithm using machine learning to differentiate outflow tract ventricular arrhythmia origins.</h4><i>Shimojo M, Inden Y, Yanagisawa S, Suzuki N, ... Tsuji Y, Murohara T</i><br /><b>Introduction</b><br />Diagnosis of outflow tract ventricular arrhythmia (OTVA) localization by an electrocardiographic complex is key to successful catheter ablation for OTVA. However, diagnosing the origin of OTVA with a precordial transition in lead V3 (V3TZ) is challenging. This study aimed to create the best practical electrocardiogram algorithm to differentiate the left ventricular outflow tract (LVOT) from the right ventricular outflow tract (RVOT) of OTVA origin with V3TZ using machine learning.<br /><b>Methods</b><br />Of 498 consecutive patients undergoing catheter ablation for OTVA, we included 104 patients who underwent ablation for OTVA with V3TZ and identified the origin of LVOT (n=62) and RVOT (n=42) from the results. We analyzed the standard 12-lead electrocardiogram preoperatively and measured 128 elements in each case. The study population was randomly divided into training group (70%) and testing group (30%), and decision tree analysis was performed using the measured elements as features. The performance of the algorithm created in the training group was verified in the testing group.<br /><b>Results</b><br />Four measurements were identified as important features: the aVF/II R-wave ratio, the V2S/V3R index, the QRS amplitude in lead V3, and the R-wave deflection slope in lead V3. Among them, the aVF/II R-wave ratio and the V2S/V3R index had a particularly strong influence on the algorithm. The performance of this algorithm was extremely high, with an accuracy of 94.4%, precision of 91.5%, recall of 100%, and an F1-score of 0.96.<br /><b>Conclusions</b><br />The novel algorithm created using machine learning is useful in diagnosing the origin of OTVA with V3TZ. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Shimojo M, Inden Y, Yanagisawa S, Suzuki N, ... Tsuji Y, Murohara T
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651347
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<div><h4>Damage to the left descending coronary artery due to radiofrequency ablation in the right ventricular outflow tract: Clinical case series and anatomical considerations.</h4><i>Dilling-Boer D, Nof E, Beinaert R, Wakili R, ... Didenko M, Vijgen J</i><br /><AbstractText>The purpose of this paper was to highlight the importance of the anatomy of the right ventricular outflow tract (RVOT) and the proximity of the mid segment of the left anterior descending coronary artery (LAD) to the RVOT in the setting of ablation of ventricular arrhythmias in the RVOT. During the period from 2014 till 2017, five patients with injury to the LAD during ablation within RVOT were identified in three centers, in Belgium, Germany and Israel. The clinical characteristics, procedural data and follow up data, where available, are reported. The literature review over coronary artery damage during radiofrequency ablation procedures is provided and the anatomy of the RVOT and the neighboring vascular structures is discussed. We present five patients who underwent radiofrequency ablation of ventricular arrhythmias mapped to the inferior and anterior part of the RVOT, at the insertion of the right ventricular wall to the septum, whereby ablation resulted in occlusion in four and severe stenosis in one, of the mid segment of the LAD coronary artery. All patients underwent percutaneous coronary intervention and stenting, four of them immediately during the same procedure and one 3 days later because of lack of signs and symptoms of acute coronary occlusion. In conclusion, the mid segment of the LAD at the level of the second septal perforator/second diagonal branch runs in very close proximity to the endocardial aspect of the lower part of the RVOT and care should be taken during ablation of ventricular arrhythmias in this region. Additional imaging such as intracardiac echocardiography and coronary angiography may be helpful in avoiding complications.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Dilling-Boer D, Nof E, Beinaert R, Wakili R, ... Didenko M, Vijgen J
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651349
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<div><h4>Catheter Ablation of Idiopathic Left Fascicular Ventricular Tachycardia: Implications of False Tendons for Mapping and Ablation.</h4><i>Ma W, Qiu J, Lu F, Michael Shehata MD, ... Wang Z, Xu J</i><br /><b>Background</b><br />The anatomical substrate for idiopathic left ventricular tachycardia (ILVT) remains speculative. Purkinje networks surrounding false tendons (FTs) might be involved in the reentrant circuit of ILVT.<br /><b>Objectives</b><br />The objective was to evaluate the anatomical and electrophysiological features of false tendons FTs in relation to ILVT.<br /><b>Methods</b><br />Intracardiac echocardiography (ICE) was conducted on patients with ILVT. The relationship of the FTs with ILVT was determined using electro-anatomical mapping.<br /><b>Results</b><br />Electrophysiological evaluation and radiofrequency ablation were conducted in 23 consecutive patients with ILVT. FTs were identified in 19/23 cases (82.6%) with P1 potentials during VT recorded at the FT in fourteen of these patients (73.7%). Three FT types were identified. In type 1, the FT attached the septum to the base of the posteromedial papillary muscle (PPM) (4/19); type 2 FTs ran between the septum and the PPM apex (3/19), while in type 3, the connection occurred between the septum and apex (11/19) or between the septum and the LV free wall (1/19). The effective ILVT ablation sites were situated at the FT-PPM (3/19) and the FT-septum (16/19) attachment sites.<br /><b>Conclusions</b><br />This series demonstrates the association between Purkinje fibers and FTs during catheter ablation of ILVT and verifies that left ventricular FTs are an important substrate in this type of tachycardia. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Ma W, Qiu J, Lu F, Michael Shehata MD, ... Wang Z, Xu J
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651353
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<div><h4>Implementation of an Intravenous Sotalol Initiation Protocol: Implications for Feasibility, Safety, and Length of Stay.</h4><i>Liu AY, Charron J, Fugaro D, Spoolstra S, ... Knight BP, Verma N</i><br /><b>Introduction</b><br />Oral sotalol initiation requires a multiple-day, inpatient admission to monitor for QT prolongation during loading. A one-day intravenous (IV) sotalol loading protocol was approved by the FDA in March 2020, but limited data on clinical use and administration currently exists. This study describes implementation of an IV sotalol protocol within an integrated health system, provides initial efficacy and safety outcomes, and examines length of stay compared to oral sotalol initiation.<br /><b>Methods</b><br />IV sotalol was administered according to a pre-specified initiation protocol to adult patients with refractory atrial or ventricular arrhythmias. Baseline characteristics, safety and feasibility outcomes, and length of stay (LOS) were compared to patients receiving oral sotalol over a similar time period.<br /><b>Results</b><br />From January 2021 to June 2022, a total of 29 patients (average age 66.0 ± 8.6 years, 27.6% women) underwent IV sotalol load and 20 patients (average age 60.4 ± 13.9 years, 65.0% women) underwent oral sotalol load. The load was successfully completed in 22/29 (75.9%) patients receiving IV sotalol and 20/20 (100%) of patients receiving oral sotalol, although 7/20 of the oral sotalol patients (35.0%) required dose reduction. Adverse events interrupting IV sotalol infusion included bradycardia (7 patients, 24.1%) and QT prolongation (3 patients, 10.3%). No patients receiving IV or oral sotalol developed sustained ventricular arrhythmias prior to discharge. LOS for patients completing IV load was 2.6 days shorter (mean 1.0 vs 3.6, p < 0.001) compared to LOS with oral load.<br /><b>Conclusion</b><br />Intravenous sotalol loading has a safety profile that is similar to oral sotalol. It significantly shortens hospital LOS, potentially leading to large cost savings. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Liu AY, Charron J, Fugaro D, Spoolstra S, ... Knight BP, Verma N
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640424
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<div><h4>A Single-Lead ECG Algorithm to Differentiate Right from Left Manifest Accessory Pathways: A Reappraisal of the P-Delta Interval.</h4><i>Ali H, De Lucia C, Cristiano E, Lupo P, ... Francia P, Cappato R</i><br /><b>Background</b><br />Despite numerous ECG algorithms being developed to localize the site of manifest accessory pathways (AP), they often require stepwise multiple-lead analysis with variable accuracy, limitations, and reproducibility.<br /><b>Objectives</b><br />The study aimed to develop a single-lead ECG algorithm incorporating the P-Delta interval (PDI) as an adjunct criterion to discriminate between right and left manifest AP.<br /><b>Methods</b><br />Consecutive WPW patients undergoing electrophysiological study (EPS) were retrospectively recruited and split into a derivation and validation group (1:1 ratio). Sinus rhythm ECG analysis in lead V1 was performed by three independent investigators blinded to the EPS results. Conventional ECG parameters and PDI were assessed through the global cohort.<br /><b>Results</b><br />140 WPW patients were included (70 for each group). A score-based, single-lead ECG algorithm was developed through derivation analysis incorporating the PDI, R/S ratio, and QRS onset polarity in lead V1. The validation group analysis confirmed the proposed algorithm\'s high accuracy (95%), which was superior to the previous ones in predicting the AP side (P-values <0.05). A score of ≤+1 was 96.5% accurate in predicting right AP while a score of ≥+2 was 92.5% accurate in predicting left AP. The new algorithm maintained optimal performance in specific subgroups of the global cohort showing an accuracy rate of 90%, 92%, and 96% in minimal preexcitation, posteroseptal AP, and pediatric patients, respectively.<br /><b>Conclusions</b><br />A novel single-lead ECG algorithm incorporating the PDI interval with previous conventional criteria showed high accuracy in differentiating right from left manifest AP comprising pediatric and minimal preexcitation subgroups in the current study. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Ali H, De Lucia C, Cristiano E, Lupo P, ... Francia P, Cappato R
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640425
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<div><h4>Effect of Contact Force on Pulsed Field Ablation Lesions in Porcine Cardiac Tissue.</h4><i>Mattison L, Verma A, Tarakji KG, Reichlin T, ... Miklavčič D, Sigg DC</i><br /><b>Background</b><br />Contact force has been used to titrate lesion formation for radiofrequency ablation. Pulsed Field Ablation (PFA) is a field-based ablation technology for which limited evidence on the impact of contact force on lesion size is available.<br /><b>Methods</b><br />Porcine hearts (n=6) were perfused using a modified Langendorff set-up. A prototype focal PFA catheter attached to a force gauge was held perpendicular to the epicardium and lowered until contact was made. Contact force was recorded during each PFA delivery. Matured lesions were cross-sectioned, stained, and the lesion dimensions measured.<br /><b>Results</b><br />A total of 82 lesions were evaluated with contact forces between 1.3 g and 48.6 g. Mean lesion depth was 4.8 ± 0.9 mm (standard deviation), mean lesion width was 9.1 ± 1.3 mm and mean lesion volume was 217.0. ± 96.6 mm<sup>3</sup> . Linear regression curves showed an increase of only 0.01 mm in depth (Depth = 0.01*Contact Force + 4.41, R<sup>2</sup> = 0.05), 0.03 mm in width (Width = 0.03*Contact Force + 8.26, R<sup>2</sup> = 0.13) for each additional gram of contact force, and 2.20 mm<sup>3</sup> in volume (Volume = 2.20*Contact Force + 162, R<sup>2</sup> = 0.10).<br /><b>Conclusions</b><br />Increasing contact force using a bipolar, biphasic focal PFA system has minimal effects on acute lesion dimensions in an isolated porcine heart model and achieving tissue contact is more important than the force with which that contact is made. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Mattison L, Verma A, Tarakji KG, Reichlin T, ... Miklavčič D, Sigg DC
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640426
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<div><h4>Risk Factors Associated with Higher Mortality in Patients with Cardiac Implantable Electronic Device Infection.</h4><i>Kalot MA, Bahuva R, Pandey R, Farooq W, ... Amuthan R, Sharma UC</i><br /><b>Background</b><br />Cardiac Implantable Electronic Devices (CIEDs) are widely used for the management of advanced heart failure and ventricular arrhythmias. CIED-Infection (CIED-I) has very high mortality, especially in the subsets of patients with limited health-care access and delayed presentation. The purpose of this study is to identify the risk-predictors mortality in subjects with CIED-I.<br /><b>Methods</b><br />We performed a retrospective cohort study of a regional database in patients presenting with CIED infections to tertiary care medical centers across Western New York, USA from 2012 - 2020. The clinical outcomes included recurrent device infection (any admission for CIED-I after the first hospitalization for device infection), septic complications (pulmonary embolism, respiratory failure, septic shock, decompensated HF, acute kidney injury) and mortality outcomes (death during hospitalization, within 30 days from CIED-I, and within 1 year from CIED-I). We studied associations between categorical variables and hard outcomes using chi-square tests and used one-way analysis of variance to measure between-groups differences.<br /><b>Results</b><br />We identified 296 patients with CIED-I, among which 218 (74%) were male, 237 (80%) were white and the mean age at the time of infection was 69.2±13.7 years. One-third of the patients were referred from the regional facilities. Staphylococcus aureus was responsible for most infections, followed by Enterococcus fecalis. On multivariate analysis, the covariates associated with significantly increased mortality risk included referral from regional facility (OR: 2.0;1.0-4.0), hypertension (Odds ratio, OR: 3.2;1.3-8.8), right ventricular dysfunction (OR: 2.6;1.2-5.1), end-stage renal disease (OR: 2.6;1.1-6.2), immunosuppression (OR: 11.4;2.5-53.3), and septic shock as a complication of CIED-I (OR: 3.9;1.3-10.8).<br /><b>Conclusion</b><br />Hypertension, right ventricular dysfunction, immunosuppression, and end-stage renal disease are associated with higher mortality after CIED-I. Disproportionately higher mortality was also noted in subjects referred from the regional facilities. This underscores the importance of early clinical risk-assessment, and the need for a robust referral infrastructure to improve patient outcomes. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Kalot MA, Bahuva R, Pandey R, Farooq W, ... Amuthan R, Sharma UC
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640427
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<div><h4>Performance of an Implantable Cardioverter Defibrillator Lead Family.</h4><i>Klampfleitner S, Mundel M, Schinke K, Neuberger HR</i><br /><b>Background</b><br />Lead failure is the major limitation in implantable cardioverter-defibrillator (ICD) therapy. Long-term follow-up data for Biotronik Linox ICD leads are limited. Therefore, we analyzed the performance of all these leads implanted at our institution.<br /><b>Materials & methods</b><br />All Linox and Linox Smart ICD leads implanted between 2006 and 2015 were identified. Lead failure was defined as electrical dysfunction (oversensing, abnormal impedance, exit-block). Lead survival was described, according to Kaplan-Meier. Associations between lead failure and specific variables were examined. P-value <0.05 was considered significant.<br /><b>Results</b><br />We included 417 ICD leads. The median follow-up time for Linox (n=205) was 81 months and for Linox Smart (n=212) 75 months. During that follow-up time 30 Linox (14.6%) and 16 Linox Smart leads (7.6 %) showed a malfunction. The 5-year lead survival probability was 97.4% for Linox and 95.2% for Linox Smart (log-rank test, p=0.19). The 6- and 8-year lead survival probability for Linox was 93.6% and 84.6%, and for Linox Smart 93% and 91.9%. The only factor significantly associated with lead failure was younger patient age at implantation (HR/year: 0.97, 95% KI: 0.95-0.99, p=0.005).<br /><b>Conclusion</b><br />This relatively large study with a long follow-up period highlights a relevant failure rate of Biotronik Linox leads. The performance of Linox vs. Linox Smart ICD leads was comparable. Although we show an acceptable 5-year lead survival probability, we observed a marked drop after just one more year of follow-up. In an era of improving heart failure survival probability a prolonged follow-up of ICD leads is increasingly clinically relevant. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Klampfleitner S, Mundel M, Schinke K, Neuberger HR
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640428
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<div><h4>Clinical Outcome of Lesion Size Index-Guided High-Power Radiofrequency Catheter Ablation for Pulmonary Vein Isolation in Patients with Atrial Fibrillation: 2-Year Follow-Up.</h4><i>Cai C, Wang J, Niu HX, Chu JM, ... Zhang S, Yao Y</i><br /><b>Background</b><br />The long-term efficacy of high-power (50 W) ablation guided by lesion size index (LSI-guided HP) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) remains undetermined. Our study sought to assess the clinical efficacy of LSI-guided HP ablation for PVI in patients with AF and explore the potential predictors associated with clinical outcomes.<br /><b>Methods</b><br />We consecutively included 186 patients with AF who underwent LSI-guided HP (50 W) ablation at Fuwai Hospital from June 2019 to October 2021. The target LSI values of 4.5-5.5 and 4.0-4.5 at the anterior and posterior walls, respectively, were used in our study. The baseline clinical characteristics, procedural and ablation data, and clinical outcomes were evaluated. The independent potential predictors associated with AF recurrence were further evaluated.<br /><b>Results</b><br />The incidence rate of first-pass PVI was 83.9% (156/186). A total of 11883 lesions were analyzed, and compared with posterior walls of pulmonary veins, anterior walls had significantly lower mean contact force (8.2 ± 3.0 vs. 8.3 ± 2.3 g, P =0.015), longer mean radiofrequency duration (16.9 ± 7.2 vs. 12.9 ± 4.5 s, P <0.001) and higher mean LSI (4.8 ± 0.2 vs. 4.4 ± 0.2, P <0.001). The overall incidence of periprocedural complications was 3.7%, and steam pops without pericardial effusion occurred in three patients (1.6%). During a mean follow-up of 24.0 ± 8.4 months, the overall AF recurrence-free survival was 87.1% after a single procedure. Patients with paroxysmal AF had a higher incidence of freedom from AF recurrence than those with persistent AF (91.2% vs. 80.8%, log-rank P =0.034). Higher LSI (HR 0.50, P <0.001) and paroxysmal AF (HR0.39, P =0.029) were significantly associated with decreased AF recurrence. By receiver operating characteristic analysis, the LSI of 4.7 and 4.3 for the anterior and posterior walls of the PVs had the highest predictive value for AF recurrence, respectively.<br /><b>Conclusion</b><br />LSI-guided HP (50 W) ablation for PVI was an efficient and safe strategy and led to favorable single-procedure 2-year AF recurrence-free survival in patients with AF. Higher LSI and paroxysmal AF were independent predictors of decreased 2-year AF recurrence. The LSI of 4.7 for the anterior wall and 4.3 for the posterior wall of the PVs were the best cutoff values for predicting AF recurrence after LSI-guided HP ablation. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Cai C, Wang J, Niu HX, Chu JM, ... Zhang S, Yao Y
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640429
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<div><h4>Differential Gap Location after Radiofrequency versus Cryoballoon Pulmonary Vein Isolation: Insights from a Randomized Trial with Protocol-Mandated Repeat Procedure.</h4><i>Sørensen SK, Johannessen A, Worck R, Hansen ML, Ruwald MH, Hansen J</i><br /><b>Background</b><br />Reconnections to pulmonary vein (PV) triggers of atrial fibrillation (AF) are the primary cause of AF recurrence after PV isolation (PVI) with radiofrequency (RF) or cryoballoon (CRYO) catheter ablation, but method-specific contributions to PV reconduction pattern and conductive gap location are incompletely understood.<br /><b>Objective</b><br />The objective of this RACE-AF sub-study was to determine procedure-specific patterns of PV reconduction in a randomized population with protocol-mandated repeat procedures, irrespective of AF recurrence.<br /><b>Methods</b><br />Each PV was assessed in turn and PV reconnection sites were identified by high-density electroanatomical mapping and locating the earliest activation site. Gap locations were verified by PV re-isolation.<br /><b>Results</b><br />In 98 patients, 81% vs. 76% previously isolated PVs remained isolated after CRYO vs. RF (RR: 1.06; 95% CI: 0.96-1.18; p=0.28). There were no significant differences for any PV: left superior PV: 90% vs. 80%; left inferior PV: 80% vs. 78%; right superior PV: 81% vs. 80%, and right inferior PV: 76% vs. 73%. For each reconnected PV, 34% of ipsilateral PVs were also reconnected after CRYO compared to 64% after RF (RR: 0.54; 95% CI: 0.32-0.90; p=0.01). After RF, gaps were clustered by the carina and adjacent segments, whereas they were more heterogeneously distributed after CRYO.<br /><b>Conclusion</b><br />Although RF and CRYO produce similar proportions of durably isolated PVs, gap locations appear to develop in procedure-specific patterns. After RF, ipsilateral PV reconduction is more frequent and gap sites cluster by the carina, suggesting that this region should be selectively ablated for more durable PVI. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Sørensen SK, Johannessen A, Worck R, Hansen ML, Ruwald MH, Hansen J
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640430
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<div><h4>Ripple mapping in ventricular tachycardia substrate mapping and ablation of nonischemic ventricular tachycardia.</h4><i>Gilge JL, Joshi SA, Nair GV, Clark BA, Prystowsky EN, Patel PJ</i><br /><b>Introduction</b><br />Substrate based ablation for ventricular tachycardia (VT) using ripple map (RM) is an effective treatment strategy for patients with ischemic cardiomyopathy but has yet to be evaluated in patients with nonischemic cardiomyopathy (NICMO). The aim of this study is to determine the feasibility and effectiveness of a RM based ablation for NICMO patients.<br /><b>Methods and results</b><br />This was a single center, retrospective study including all NICMO patients undergoing VT ablation at St Vincent Hospital between 1/1/2018 to 12/1/2019. Retrospective RM analysis was performed on those that had a substrate-based ablation to identify the location and number of ripple channels as well as their proximity to ablation lesions. Thirty-three patients met the inclusion criteria and had a median age of 65 (58, 73.5) with 15.2% of the population being female and were followed for a median duration of 451 (217.5, 586.5) days. Of these patients, 23 (69.7%) had a substrate-based ablation with a median procedural duration of 196.4 (186.8, 339) minutes, 1946 (517, 2750) point collected per map and 277 (141, 554) points were within scar. Two (8.6%) procedural complications occurred, and 7 (30.4%) patients had VT recurrence during follow-up. Ripple map analysis revealed an average of 2 ripple channels and the patients without VT recurrence had ablation performed closer to the ripple channels: 0 (0, 4.7) cm vs 14.3 (0, 23.5) cm; p = 0.02.<br /><b>Conclusion</b><br />A RM based substrate ablation can be performed in NICMO patients and ablation within ripple channels is a predictor of VT freedom. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Gilge JL, Joshi SA, Nair GV, Clark BA, Prystowsky EN, Patel PJ
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640431
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<div><h4>Correlation of spatial patterns of endocardial pace mapping to underlying scar topography in patients with scar-related ventricular tachycardia.</h4><i>Kotake Y, Bennett R, Silva K, Bhaskaran A, ... Kumar S, Campbell T</i><br /><b>Introduction</b><br />Endocardial pace-mapping (PM) can identify conducting channels for VT circuits in patients with structural heart disease (SHD). Recent findings show the temporal and spatial pattern of PM may aid identification of the surface harboring VT isthmii. The specific correlation of PM patterns to scar topography has not been examined.<br /><b>Objective</b><br />To correlate the pattern of endocardial PMs to underlying scar topography in SHD patients with VT.<br /><b>Methods</b><br />Data from patients undergoing VT ablation from August 2018 to February 2022 were reviewed.<br /><b>Results</b><br />Sixty-three patients with SHD-related VT (mean age 65±14 years) with 83 endocardial PM correlation maps were analysed. Two main correlation patterns were identified, an \"abrupt-change correlation pattern (AC-pattern)\" and \"centrifugal-attenuation correlation pattern (CA-pattern)\". AC-pattern had lower scar ratio (unipolar/bipolar % scar area; 1.1 vs 1.5, P<0.001), had longer maximal stimulus-QRS intervals (97.5ms vs 68ms, P=0.002), and higher likelihood of endocardial dominant scar (11/21 [52%] vs 3/38 [8%], P<0.001) than CA-pattern seen on intracardiac echocardiography (ICE). In contrast, CA-pattern was more likely to have epicardial dominant scar or mid-intramural scar on ICE (epicardial dominant scar; CA-pattern: 12/38 [32%] vs AC-pattern: 1/21 [5%], P=0.02, mid-intramural scar; CA-pattern: 15/38 [39%] vs AC-pattern: 1/21 [5%], P=0.005).<br /><b>Conclusions</b><br />The spatial pattern of endocardial PM in SHD-related VT directly correlates with scar topography. AC-pattern is associated with endocardial dominant scar on ICE with lower scar ratio and longer stimulus-QRS intervals, whereas CA-pattern is strongly associated with epicardial dominant or mid-intramural scar with higher scar ratio and shorter stimulus-QRS intervals. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Kotake Y, Bennett R, Silva K, Bhaskaran A, ... Kumar S, Campbell T
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640432
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<div><h4>Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes in patients with and without structural heart disease.</h4><i>Sessions AJ, May HT, Crandall BG, Day JD, ... Steinberg BA, Jared Bunch T</i><br /><b>Background</b><br />Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown.<br /><b>Methods</b><br />All patients that received a catheter ablation for AF(n=9,979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF≤35% (n=1024) and EF>35% (n=8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n=1747), 3:546-1825(n=2941), and 4:>1825(n=2602) days.<br /><b>Results</b><br />The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF >35%: 3.5±3.8 years, EF <35%: 3.4±3.8 years, p=0.66). In the EF >35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p<0.0001), 2.62(p<0.0001), and 4.39(p<0.0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:2-01-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24).<br /><b>Conclusion</b><br />Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Sessions AJ, May HT, Crandall BG, Day JD, ... Steinberg BA, Jared Bunch T
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640433
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<div><h4>Trends and Disparities in Ventricular Tachycardia Mortality in the United States.</h4><i>Ibrahim R, Sroubek J, Nakhla S, Lee JZ</i><br /><b>Introduction</b><br />We aimed to evaluate trends and disparities in mortality from ventricular tachycardia in patients with underlying cardiovascular disease.<br /><b>Methods and results</b><br />We performed cross-sectional analyses using publicly available data from the CDC Wide-Ranging Online Data for Epidemiologic Research database. We identified a total of 7,025 deaths from ventricular tachycardia between the years 2007 and 2020. Overall age-adjusted mortality rates increased from 0.22 in 1999 to 0.32 in 2020 [p <0.05]. Black female and male adults had higher age-adjusted mortality rates compared to White female and male adults, respectively [p <0.05]. Disproportionate age-adjusted mortality rates among male populations and Southern residents were also observed.<br /><b>Conclusion</b><br />This study demonstrated an increase in deaths related to ventricular tachycardia since 2007. Significant differences in mortality exist across racial, gender, and geographic subgroups. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Ibrahim R, Sroubek J, Nakhla S, Lee JZ
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640434
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<div><h4>Pulmonary Vein Isolation-induced Vagal Nerve Injury and Gastric Motility Disorders detected by Electrogastrography - The Side Effects of Pulmonary Vein Isolation in Atrial Fibrillation (SEPIA) Study: Discussion and Conclusion.</h4><i>Meininghaus DG, Freund R, Kleemann T, Christoph Geller J, Matthes H</i><br /><b>Background</b><br />Safety of pulmonary vein isolation (PVI) has been established in clinical studies. However, despite prevention efforts the incidence of damage to (peri)-esophageal tissue has not decreased, and the pathophysiology is incompletely understood.<br /><b>Objective</b><br />Damage to vagal nerve branches may be involved in lesion progression to atrio-esophageal fistula. Using electrogastrography, we assessed the incidence of periesophageal vagal nerve injury (VNI) following atrial fibrillation ablation and its association with procedural parameters and endoscopic results.<br /><b>Methods</b><br />Patients were studied using electrogastrography, endoscopy, and endoscopic ultrasound before and after cryoballoon (CB) or radiofrequency (RF) PVI. The incidence of ablation-induced neuropathic pattern (indicating VNI) in pre- and postprocedural electrogastrography was assessed and correlated with endoscopic results and ablation data.<br /><b>Results</b><br />Between February 2021 und January 2022, 85 patients (67±10 years, 53% male) were included, 33 were treated with CB and 52 with RF (38 with moderate power moderate duration [25-30W] and 14 with high power short duration [50W]). blation-induced VNI was detected in 27/85 patients independent of the energy form. Patients with VNI more frequently had postprocedural endoscopically detected pathology (8% mucosal esophageal lesions, 36% periesophageal edema, 33% food retention) but there was incomplete overlap. Preexisting esophagitis increased the likelihood of VNI. Ablation data and esophageal temperature data did not predict VNI. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Meininghaus DG, Freund R, Kleemann T, Christoph Geller J, Matthes H
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640436
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<div><h4>Assisted Reality Device to Guide Cardiac Implantable Device Programming in Distant Rural Areas.</h4><i>Diaz JC, Cañas F, Duque M, Aristizabal J, ... Martin DT, Romero J</i><br /><b>Background</b><br />Patients with cardiac implantable electronic devices (CIEDs) living in rural areas have difficulty obtaining follow-up visits for device interrogation and programming in specialized healthcare facilities.<br /><b>Objective</b><br />To describe the use of an assisted reality device designed to provide front-line workers with real-time online support from a remotely located specialist (Realwear HTM-1; Realwear, Vancouver, WA) during CIED assistance in distant rural areas.<br /><b>Methods</b><br />This is a prospective study of patients requiring CIED interrogation using the Realwear HMT-1 in a remote rural population in Colombia between April 2021 and June 2022. CIED interrogation and device programming were performed by a general practitioner and guided by a cardiac electrophysiologist. Non-CIED-related medical interventions were allowed and analyzed. The primary objective was to determine the incidence of clinically significant CIED alerts. Secondary objectives were the changes medical interventions used to treat the events found in the device interrogations regarding non-CIED related conditions.<br /><b>Results</b><br />A total of 205 CIED interrogations were performed on 139 patients (age 69±14 years; 54% female). Clinically significant CIED alerts were reported in 42% of CIED interrogations, consisting of the detection of significant arrhythmias (35%), lead malfunction (3%), and device in elective replacement interval (3.9%). OAC was initiated in 8% of patients and general medical/cardiac interventions unrelated to the CIED were performed in 52% of CIED encounters.<br /><b>Conclusion</b><br />Remote assistance using a commercially available assisted reality device has the potential to provide specialized health care to patients in difficult-to-reach areas, overcoming current difficulties associated with RM including the inability to change device programming. Additionally, these interactions provided care beyond CIED-related interventions, thus delivering significant social and clinical impact to remote rural populations. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Diaz JC, Cañas F, Duque M, Aristizabal J, ... Martin DT, Romero J
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640437
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<div><h4>Managing Peri-Mitral Flutter.</h4><i>Lim MW, Kistler PM</i><br /><AbstractText>The exponential rise in the incidence of peri-mitral flutter has paralleled the increasing use of more extensive atrial substrate ablation for atrial fibrillation (AF). Given the relative paucity of randomised evidence to support its role in AF management, mitral isthmus ablation should largely be reserved for patients with peri-mitral flutter. Catheter ablation for peri-mitral flutter is challenging due to complex anatomic relationships. The aim of this report is to review the anatomic considerations and approaches to catheter ablation for peri-mitral flutter. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Lim MW, Kistler PM
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598419
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<div><h4>ATRIOVENTRICULAR CONDUCTION MODULATION AND ABLATION: BETTER AT A DISTANCE FROM THE NODE?</h4><i>Criado JLI, Almendral J</i><br /><AbstractText>New therapeutic possibilities open up in the nonpharmacological rate control of patients with atrial fibrillation, and an approach with an ablation line around the AVN could be useful both for modulating the ventricular response and for safer AV ablation if this is finally required. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Criado JLI, Almendral J
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598421
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<div><h4>Catheter ablation of Atrial Fibrillation with a Multi-electrode Radiofrequency balloon; First and early two centre experience in Europe.</h4><i>Kanthasamy V, Breitenstein A, Schilling R, Hofer D, ... Creta A, Finlay M</i><br /><b>Introduction</b><br />The Heliostar™ ablation system is a novel RF balloon ablation technology with an integrated three-dimensional mapping system. Here, we describe our early experience and procedural outcomes using this technology for atrial fibrillation catheter ablation.<br /><b>Methods</b><br />We sought to comprehensively assess the first 60 consecutive patients undergoing pulmonary vein isolation using the novel HELISOTAR™ RF balloon technology including procedural outcomes. A comparison of the workflow between two different anaesthetic modalities (conscious sedation; CS vs general anaesthesia; GA) was made. Procedural data were collected prospectively from two high-volume centres (Barts Heart Centre, UK and University Hospital of Zurich, Zurich). A standardised approach for catheter ablation was employed.<br /><b>Results</b><br />A total of 35 patients had the procedure under CS and the remaining under GA. Mean procedural and fluoroscopy times were 84 ± 33 min and 1.1min. The median duration of RF energy application was 7 (5-9.8) mins per patient. All veins were successfully isolated, and the median isolation time was 10 (7-15) seconds. Our cohort\'s rate of procedural complications was low, with no mortality within 30 days post-procedure.<br /><b>Conclusion</b><br />Our early experience shows that catheter ablation using the Heliostar™ technology can be performed efficiently and safely; however, long-term data is yet to be established. Low fluoroscopy requirements, short learning curves and use of this technology with conscious sedation is possible, including the use of an oesophageal temperature probe. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Kanthasamy V, Breitenstein A, Schilling R, Hofer D, ... Creta A, Finlay M
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598422
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<div><h4>Characterization and Identification of Atrial Fibrillation Drivers in Patients with Non-Paroxysmal Atrial Fibrillation using Simultaneous Amplitude Frequency Electrogram Transform.</h4><i>Lin CY, Chiang CH, Te ALD, Lin YJ, ... Liao JN, Chen SA</i><br /><b>Aims</b><br />We hypothesized that real-time simultaneous amplitude frequency electrogram transform (SAFE-T) during sinus rhythm (SR) is able to identify and characterize the drivers of atrial fibrillation (AF) in nonparoxysmal (NP) AF.<br /><b>Methods</b><br />Twenty-one NPAF patients (85.71% males, mean age 52 years old) underwent substrate mapping during SR (SAFE-T and voltage) and during AF (complex fractionated atrial electrograms [CFAE] and similarity index, SI). After pulmonary veins isolation, extensive substrate ablation was performed with the endpoint of procedural termination or elimination of all SI sites (>63% similarities). Sites with procedural termination and non-termination sites were tagged for post-ablation SR analysis using SAFE-T.<br /><b>Results</b><br />In 74 CFAE sites identified (average of 3 ± 2 sites per person), 28 (37.84%) were identified as termination sites demonstrating a high SI compared with the non-termination sites (80.11 ± 9.57 vs. 45.96 ± 13.38%, p<0.001) during AF. During SR, these termination sites have high SAFE-T values and harbor a highly resonant, localized, repetitive high frequency components superimposed in the low frequency components compared with non-termination sites (5.70 ± 3.04 vs. 1.49 ± 1.66 Hz·mV, p<0.001). In the multivariate analysis, the termination sites have higher SAFE-T and SI value (p<0.001).<br /><b>Conclusions</b><br />AF procedural termination sites harbored signal characteristics of repetitive, high frequency component of individualized electrogram during sinus rhythm, which can be masked by the low frequency fractionated electrogram and are difficult to see from the bipolar electrogram. Thus, SAFE-T mapping is feasible in identifying and characterizing sites of AF drivers. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Lin CY, Chiang CH, Te ALD, Lin YJ, ... Liao JN, Chen SA
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598424
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<div><h4>Lifestyle Changes in Atrial Fibrillation Management and Intervention.</h4><i>Yang L, Chung MK</i><br /><AbstractText>Atrial fibrillation (AF) is one of the most common arrhythmias in adults, and its continued rise in the United States is complicated by the increased incidence and prevalence of several AF risk factors, such as obesity, physical inactivity, hypertension, obstructive sleep apnea, diabetes mellitus, coronary artery disease, and alcohol, tobacco, or caffeine use. Lifestyle and risk factor modification has been proposed as an additional pillar of AF therapy, added to rhythm control, rate control, and anticoagulation, to reduce AF burden and risk. Although emerging evidence largely supports the integration of lifestyle and risk factor management in clinical practice, randomized clinical trials investigating the long-term sustainability and reproducibility of these benefits remain sparse. The purpose of this review is to discuss potentially reversible risk factors on AF, share evidence for the impact on AF by modification of these risk factors, and then provide an overview of the effects of reversing or managing these risk factors on the success of various AF management strategies, such as antithrombotic, rate control, and rhythm control therapies. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Yang L, Chung MK
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598428
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<div><h4>Early dose of Adenosine, postRadiofrequency abLation of accessory pathwaY in determining acute procedural Success (EARLY Study).</h4><i>Manickavasagam A, Guttikonda SNR, Bootla D, Patloori SCS, ... Selvaraj R, Jacob JR</i><br /><b>Introduction</b><br />Post ablation of the accessory pathway (AP), the patient is observed in the catheterization laboratory for a variable period for resumption of pathway conduction. Aim of the study was to determine whether the administration of intravenous adenosine at 10 minutes after ablation of accessory pathway (AP) would have the same diagnostic accuracy as waiting for 30 minutes in predicting the resumption of AP conduction.<br /><b>Methods</b><br />This was a prospective interventional study conducted in two centers. Post ablation of the AP, intravenous adenosine was administered at 10 minutes to look for dormant pathway conduction. The response was recorded as positive (presence of pathway conduction), negative (absence), or indeterminate (not able to demonstrate AV and VA block and inability to ascertain AP conduction).<br /><b>Results</b><br />The study included 110 procedures performed in 109 patients. Adenosine administration at 10 minutes showed positive result in 3 cases (2.7%), negative result in 99 cases (90%) and indeterminate result in 8 cases (7.3%). Reconnection of accessory pathway at 30 minutes post ablation was seen in 8 cases (7.3%). Of these 8 cases, 10minutes adenosine administration showed positive test in 3 patients and negative test in 5 patients. Adenosine test at 10 minutes has a sensitivity, specificity, positive predictive value, and negative predictive value of 37.5%, 100%, 100% and 94.9% in identifying the recurrence of accessory pathway conduction at 30 minutes, respectively.<br /><b>Conclusion</b><br />Absence of pathway conduction on administration of adenosine 10 minutes post ablation does not help predict the absence of resumption of conduction thereafter. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Manickavasagam A, Guttikonda SNR, Bootla D, Patloori SCS, ... Selvaraj R, Jacob JR
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598429
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<div><h4>Multicenter Experience with Andexanet Alfa for Refractory Pericardial Bleeding during Catheter Ablation of Atrial Fibrillation.</h4><i>Zghaib T, Allison JD, Barrett C, Arkles J, ... Marchlinski FE, Frankel DS</i><br /><b>Introduction</b><br />Pericardial bleeding is a rare but life-threatening complication of atrial fibrillation (AF) ablation. Patients taking uninterrupted oral anticoagulation (AC) may be at increased risk for refractory bleeding despite pericardiocentesis and administration of protamine. In such cases, andexanet alfa can be given to reverse rivaroxaban or apixaban. In this study, we aim to describe the rate of acute hemostasis and thromboembolic complications with andexanet for refractory pericardial bleeding during AF ablation.<br /><b>Methods and results</b><br />In this multicenter, case series, participating centers identified patients who received a dose of apixaban or rivaroxaban within 24 hours of AF ablation, developed refractory pericardial bleeding during the procedure despite pericardiocentesis and administration of protamine and received andexanet. Eleven patients met inclusion criteria, with mean age of 73.5 ± 5.3 years and median CHA<sub>2</sub> DS<sub>2</sub> -VASc score 4 [3-5]. All patients received protamine and pericardiocentesis, and 9 (82%) received blood products. All patients received a bolus of andexanet followed, in all but one, by a 2-hour infusion. Acute hemostasis was achieved in 8 patients (73%) while 3 required emergent surgery. One patient (9%) experienced acute ST-elevation myocardial infarction after receiving andexanet. Therapeutic AC was restarted after a mean of 2.2 ± 1.9 days and oral AC was restarted after a mean of 2.9 ± 1.6 days, with no recurrent bleeding.<br /><b>Conclusion</b><br />In patients on uninterrupted apixaban or rivaroxaban, who develop refractory pericardial bleeding during AF ablation, andexanet can achieve hemostasis thereby avoiding the need for emergent surgery. However, there is a risk of thromboembolism following administration. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Zghaib T, Allison JD, Barrett C, Arkles J, ... Marchlinski FE, Frankel DS
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598431
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<div><h4>The impact of the procedural parameters on the lesion characteristics associated with AF recurrence: late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) analysis.</h4><i>Takahara H, Kiuchi K, Fukuzawa K, Takami M, ... Somiya Y, Hirata KI</i><br /><b>Background</b><br />Lesion gaps assessed by late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) are associated with the atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). Animal studies have demonstrated that the catheter-contact force (CF), stability, and orientation are strongly associated with lesion formation. However, the impact of those procedural factors on the lesion characteristics associated with AF recurrence has not been well discussed.<br /><b>Methods</b><br />A total of 30 patients with paroxysmal AF who underwent catheter ablation were retrospectively enrolled. Radiofrequency (RF) applications were performed with 35W for 30s in a point-by-point fashion under esophageal temperature monitoring. The inter-lesion distance was 4mm. The lesions were visualized by LGE-MRI three months post-procedure and assessed by the LGE volume (ml), gap number (GN), and average gap length (AGL [mm]). The gaps were defined as non-enhancement sites of >4 mm. The procedural factors including the catheter-CF, stability, and orientation were calculated on the NavX system.<br /><b>Results</b><br />Six (20%) of 30 patients had AF recurrences 12 months post-ablation. A univariate analysis demonstrated that the AGL was associated with AF recurrence (hazard ratio [HR]: 1.20, confidence interval [CI]:1.03 - 1.42, p = 0.02). All AF recurrence were found in patients with an AGL of >7 mm. The catheter-CF and stability were associated with an AGL of >7mm, but not the orientation (CF: HR: 0.62, CI: 0.39-0.97, p=0.038; stability: HR: 0.8, CI: 0.66-0.98, p=0.027).<br /><b>Conclusions</b><br />RF ablation with a low CF and poor catheter stability has a potential risk of creating large lesion gaps associated with AF recurrence. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Takahara H, Kiuchi K, Fukuzawa K, Takami M, ... Somiya Y, Hirata KI
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598438
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<div><h4>Reply to editorial letter.</h4><i>Imnadze G, Lemke L, Sommer P</i><br /><AbstractText>Thank you for the editorial letter and your valuable comments. As your group has shown in a recent publication This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print</small></div>
Imnadze G, Lemke L, Sommer P
J Cardiovasc Electrophysiol: 04 Jan 2023; epub ahead of print | PMID: 36598456
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<div><h4>Implantation of a leadless pacemaker in young adults.</h4><i>Strik M, Nicolas C, Mondoly P, Eschalier R, ... Ploux S, Pierre B</i><br /><b>Aims</b><br />Leadless pacing has emerged as an alternative to conventional transvenous pacemakers to mitigate the risks of pocket- and lead-related complications but its use remains controversial in young adults mostly because experience in this patient population is limited. We sought to examine the feasibility and safety of implanting leadless single chamber pacemakers in young adults.<br /><b>Methods</b><br />This multicenter, retrospective, observational study sought to evaluate the safety, efficacy, and electrical performance of the Micra VR Transcatheter Pacemaker System (Medtronic) in patients between 18 and 40 years who underwent implantation of a leadless pacemaker for any indication at the university medical centers of Bordeaux, Clermont-Ferrand, Toulouse, and Tours (France), between 2015 and 2021. The primary safety endpoint was freedom from system-related or procedure-related major complications at 6 months. The primary efficacy endpoint was the combination of a low (≤2 V) and stable (increase within 1.5 V) pacing capture threshold at 6 months.<br /><b>Results</b><br />Leadless pacemaker implantation was successful in all 35 patients. At six months, safety endpoint was met for 35 (100%) and efficacy endpoint for 34 (97%) patients. During a follow-up of 26±15 months (range: 6-60 months), Safety endpoint remained 100% and efficacy endpoint was 94%. Leadless pacemaker retrieval was not required in any patient. Approximately one third of patients (n=13, 37%) had >40% ventricular pacing burdens at one year, including all 10 patients with a complete AV block but also 3 patients with normal AV conduction during implantation. One patient reported symptoms of pacemaker syndrome which was confirmed using Holter recording and successfully treated using reprogramming.<br /><b>Conclusion</b><br />In this observational study, leadless pacemakers demonstrated favorable short- and intermediate-term safety and effectiveness in young adults. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Dec 2022; epub ahead of print</small></div>
Strik M, Nicolas C, Mondoly P, Eschalier R, ... Ploux S, Pierre B
J Cardiovasc Electrophysiol: 30 Dec 2022; epub ahead of print | PMID: 36583963
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<div><h4>Leadless pacing: also an option for the young?</h4><i>Breeman KTN, Knops RE, Tjong FVY</i><br /><AbstractText>Leadless pacemakers (LPs) were designed to overcome lead- and pocket-related complications. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Dec 2022; epub ahead of print</small></div>
Breeman KTN, Knops RE, Tjong FVY
J Cardiovasc Electrophysiol: 30 Dec 2022; epub ahead of print | PMID: 36583965
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<div><h4>New Atrial Arrhythmia Occurrence in Single Chamber Implantable Cardioverter Defibrillator Patients: A Real-World Investigation.</h4><i>Patel D, Rao A, Friedman PA, Deshmukh AJ, ... Lexcen DR, Wilkoff BL</i><br /><b>Background</b><br />A current limitation of single chamber implantable cardioverter defibrillators (ICDs) is the lack of an atrial lead to reliably detect atrial fibrillation (AF) episodes. A novel ventricular based atrial fibrillation (VBAF) detection algorithm was created for single chamber ICDs to assess R-R variability for detection of AF.<br /><b>Objective</b><br />To quantify AF in a real-world multi-center registry cohort using the new VBAF detection algorithm in single chamber ICDs and report on subsequent clinical actions by providers.<br /><b>Methods</b><br />Patients implanted with Visia AF™ ICDs were prospectively enrolled in the Medtronic Product Surveillance Registry from 12/15/2015 to 1/23/2019 and followed with at least 30 days of monitoring with the algorithm. Time to device-detected daily burden of AF >6 minutes, >6 hours, and >23 hours were reported. Clinical actions after device-detected AF were recorded.<br /><b>Results</b><br />A total of 291 patients were enrolled with a mean follow-up of 22.5 ± 7.9 months. Of these, 212 (73%) had no prior history of AF at device implant. However, 38% of these individuals had AF detected with the VBAF algorithm with daily burden of ≥6 minutes within two years of implant. In these 80 patients with newly detected AF by their ICD, 23 (29%) had a confirmed clinical diagnosis of AF by their provider. Of patients with a clinical diagnosis of AF, 9 (39%) were newly placed on anticoagulation, including 5 of 5 (100%) patients having a burden >23 hours.<br /><b>Conclusions</b><br />Continuous AF monitoring with the new VBAF algorithm permits early identification and actionable treatment for patients with undiagnosed AF that may improve patient outcomes. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 28 Dec 2022; epub ahead of print</small></div>
Patel D, Rao A, Friedman PA, Deshmukh AJ, ... Lexcen DR, Wilkoff BL
J Cardiovasc Electrophysiol: 28 Dec 2022; epub ahead of print | PMID: 36579406
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<div><h4>Retrograde fast pathway cryoablation inside the coronary sinus for slow-fast atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava.</h4><i>Arai H, Nakamura R, Sagawa Y, Oda A, ... Aonuma K, Yamauchi Y</i><br /><b>Introduction</b><br />Persistent left superior vena cava (PLSVC) is accompanied by enlarged coronary sinus (CS) and deformation of the triangle of Koch. This makes anatomical evaluation of the atrioventricular nodal pathways difficult.<br /><b>Methods</b><br />We attempted cryoablation of retrograde fast pathway located in the enlarged CS roof of PLSVC for slow-fast atrioventricular nodal reentrant tachycardia (AVNRT) induced by inadvertent antegrade fast pathway elimination during ablation of left atrial tachycardia.<br /><b>Results</b><br />Slow-fast AVNRT was successfully eliminated without atrioventricular block progression.<br /><b>Conclusions</b><br />This is the first case of successful retrograde fast pathway ablation of the CS ostial roof for slow-fast AVNRT with PLSVC. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 28 Dec 2022; epub ahead of print</small></div>
Arai H, Nakamura R, Sagawa Y, Oda A, ... Aonuma K, Yamauchi Y
J Cardiovasc Electrophysiol: 28 Dec 2022; epub ahead of print | PMID: 36579408
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<div><h4>A VERY UNUSUAL WIDE QRS TACHYCARDIA: VT OR SVT?</h4><i>Verbeet T, Nguyen T, Castro J</i><br /><b>Introduction</b><br />A 13 old girl presented with recurrent wide QRS tachycardia since she was 4.<br /><b>Methods</b><br />An electrophysiologic study was performed.<br /><b>Results</b><br />The electrophysiologic study showed that QRS complexes identical to those of the tachycardia could be elicited with premature atrial extrastimuli but with a shorter atrioventricular (AV) delay when the QRS was wide compared with narrow QRS complexes. The tachycardia was ablated at 9 o\'clock on the tricuspid annulus demonstrating the presence of an atriofascicular fiber.<br /><b>Conclusion</b><br />We believe that this atypical behavior can be explained by AV nodal like longitudinal dissociation of a slowly conducting accessory pathway. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print</small></div>
Verbeet T, Nguyen T, Castro J
J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print | PMID: 36571151
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<div><h4>What We Don\'t Know Might Harm Our Patients: AF Detection Utilizing a Single Chamber ICD.</h4><i>Zweibel SL</i><br /><AbstractText>It is well known that patients receiving implantable cardioverter defibrillators are at risk for developing atrial fibrillation (AF) given their increased incidence of structural heart disease, heart failure, and other comorbidities. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print</small></div>
Zweibel SL
J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print | PMID: 36571157
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<div><h4>Elevated Fibrosis Burden as Assessed by MRI Predicts Cryoballoon Ablation Failure.</h4><i>Boyle PM, Sarairah S, Kwan KT, Scott GD, ... Sridhar AR, Akoum N</i><br /><b>Introduction</b><br />Late-gadolinium enhancement magnetic resonance (LGE-MRI) imaging is increasingly used in management of atrial fibrillation (AFib) patients. Here, we assess the usefulness of LGE-MRI-based fibrosis quantification to predict arrhythmia recurrence in patients undergoing cryoballoon ablation. Our secondary goal was to compare two widely used fibrosis quantification methods.<br /><b>Methods</b><br />In 102 AF patients undergoing LGE-MRI and cryoballoon ablation (mean age 62 years; 64% male; 59% paroxysmal AFib), atrial fibrosis was quantified using the pixel intensity histogram (PIH) and image intensity ratio (IIR) methods. PIH segmentations were completed by a third-party provider as part of the standard of care at our hospital; IIR segmentations of the same scans were carried out in our lab using a commercially available software package. Fibrosis burdens and spatial distributions for the two methods were compared. Patients were followed prospectively for recurrent arrhythmia following ablation.<br /><b>Results</b><br />Average PIH fibrosis was 15.6±5.8% of the left atrial (LA) volume. Depending on threshold (IIR<sub>thr</sub> ), the average IIR fibrosis (% of LA wall surface area) ranged from 5.0±7.2% (IIR<sub>thr</sub> =1.2) to 37.4±10.9% (IIR<sub>thr</sub> =0.97). An IIR<sub>thr</sub> of 1.03 demonstrated the greatest agreement between the methods, but spatial overlap of fibrotic areas delineated by the two methods was modest (Sorenson Dice coefficient: 0.49). 42 patients (41.2%) had recurrent arrhythmia. PIH fibrosis successfully predicted recurrence (HR 1.07; p=0.02) over a follow up period of 362±149 days; regardless of IIR<sub>thr</sub> , IIR fibrosis did not predict recurrence.<br /><b>Conclusions</b><br />PIH-based volumetric assessment of atrial fibrosis was modestly predictive of arrhythmia recurrence following cryoballoon ablation in this cohort. IIR-based fibrosis was not predictive of recurrence for any of the IIR<sub>thr</sub> values tested, and the overlap in designated areas of fibrosis between the PIH and IIR methods was modest. Caution must therefore be exercised when interpreting LA fibrosis from LGE-MRI, since the values and spatial pattern are methodology-dependent. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print</small></div>
Boyle PM, Sarairah S, Kwan KT, Scott GD, ... Sridhar AR, Akoum N
J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print | PMID: 36571158
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<div><h4>Initial Experience with Stylet-Driven Versus Lumenless Lead Delivery Systems for Left Bundle Branch Area Pacing.</h4><i>Braunstein ED, Kagan RD, Olshan DS, Gabriels JK, ... Liu CF, Cheung JW</i><br /><b>Introduction</b><br />Left bundle branch area pacing (LBBP) has emerged as an alternative method for conduction system pacing. While initial experience with delivery systems allowing lumenless and stylet-driven lead implantation for LBBP has been described, data comparing outcomes of stylet-driven versus lumenless lead implantation for LBBP are limited. In this study, we compare success rates and outcomes of LBBP with stylet-driven versus lumenless lead delivery systems.<br /><b>Methods</b><br />Eighty-three consecutive patients (mean age 74.1 ± 11.2 years; 56 (68%) male) undergoing attempted LBBP at a single institution were identified. Cases were grouped by lead delivery systems used: stylet-driven (n = 53) or lumenless (n = 30). Baseline characteristics and procedural findings were recorded and compared between the cohorts. Medium term follow-up data on ventricular lead parameters were also compared.<br /><b>Results</b><br />Baseline characteristics were similar between groups. Successful LBBP was achieved in 77% of patients, with similar success rates between groups (76% in stylet-driven, 80% in lumenless, p = 0.79), and rates of adjudicated LBB capture and other paced QRS parameters were also similar. Compared with the lumenless group, the stylet-driven group had significantly shorter procedure times (90 ± 4 vs 112 ± 31 min, p = 0.004) and fluoroscopy times (10 ± 5 vs 15 ± 6 min, p = 0.003). Ventricular lead parameters at medium term follow-up were similar, and rates of procedural complications and need for lead revision were low in both groups.<br /><b>Conclusion</b><br />Delivery systems for stylet-driven and for lumenless leads for LBBP have comparable acute success rates. Long-term follow-up of lead performance following use of the various delivery systems is warranted. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print</small></div>
Braunstein ED, Kagan RD, Olshan DS, Gabriels JK, ... Liu CF, Cheung JW
J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print | PMID: 36571159
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<div><h4>Left atrial epicardial adipose tissue exacerbates electrical conduction disturbance in normal-weight patients undergoing pulmonary vein isolation for atrial fibrillation.</h4><i>Yamada S, Kaneshiro T, Nodera M, Amami K, Nehashi T, Takeishi Y</i><br /><b>Introduction</b><br />Epicardial adipose tissue (EAT) exacerbates both electrical and structural remodeling in obese atrial fibrillation (AF) patients, but the impacts of EAT on atrial arrhythmogenicity remain unclear in normal-weight AF patients. Therefore, we sought to investigate this issue using electroanatomic mapping.<br /><b>Methods and results</b><br />We enrolled drug-refractory 105 paroxysmal AF patients in normal body mass index range (18.5-24.9 kg/m<sup>2</sup> ), who had undergone electroanatomic mapping after pulmonary vein isolation (PVI). One day before PVI, we assessed P-wave duration in 12-lead electrocardiogram and left atrial (LA)-EAT volumes using contrast-enhanced computed tomography. The patients were divided into two groups based on the median LA-EAT volume (16.0 mL); the high LA-EAT group (≥16.0 mL, n=53) and low LA-EAT group (<16.0 mL, n=52). We compared P-wave duration, LA conduction velocity and bipolar voltage, the presence of low-voltage zone (<0.5 mV), and LA volume index on echocardiography between the two groups. The LA bipolar voltage, low-voltage zone and LA volume index were not different between the high and low LA-EAT groups. However, P-wave duration was significantly longer in the high group than in the low group (P<0.001). Additionally, the LA conduction velocity was significantly more depressed in the high group than in the low group (P<0.001). Multivariate linear regression analysis revealed that LA-EAT volume was correlated with P-wave duration (β=0.367, P<0.001) and conduction velocity (β=-0.566, P<0.001), respectively.<br /><b>Conclusions</b><br />Increased LA-EAT volumes were associated with electrical conduction disturbance after PVI in normal weight patients with AF. P-wave duration may be a clinically useful predictor of LA-EAT. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print</small></div>
Yamada S, Kaneshiro T, Nodera M, Amami K, Nehashi T, Takeishi Y
J Cardiovasc Electrophysiol: 26 Dec 2022; epub ahead of print | PMID: 36571163
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<div><h4>Leadless cardiac ventricular pacing using helix fixation: Step-by-step guide to implantation.</h4><i>Laczay B, Aguilera J, Cantillon DJ</i><br /><AbstractText>Leadless cardiac pacemakers are an alternative modality to traditional transvenous pacemaker systems. Recently receiving Food and Drug Administration approval, the AVEIR VR leadless pacemaker system provides a helix based active fixation leadless pacemaker system. This step-by-step review will cover patient selection, pre-procedural planning, device implantation technique, implant site evaluation, troubleshooting, short- and long-term complications as well as future directions for leadless pacing. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 21 Dec 2022; epub ahead of print</small></div>
Laczay B, Aguilera J, Cantillon DJ
J Cardiovasc Electrophysiol: 21 Dec 2022; epub ahead of print | PMID: 36542756
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<div><h4>Letter in Response to The LEADR ICD Lead Study: Is Thinner Better?</h4><i>Anderson C, Olshansky B</i><br /><AbstractText>We appreciate Dr. Crossley and colleagues\' response to our editorial (REF our editorial - we do not have the reference) clarifying the lead design and patient follow-up in the LEADR Study (reference Dr. Crossley\'s letter - we do not have the reference). This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 21 Dec 2022; epub ahead of print</small></div>
Anderson C, Olshansky B
J Cardiovasc Electrophysiol: 21 Dec 2022; epub ahead of print | PMID: 36542761
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<div><h4>Novel methodology for the evaluation of symptoms reported by patients with newly diagnosed atrial fibrillation: application of natural language processing to electronic medical records data.</h4><i>Reynolds MR, Bunch TJ, Steinberg BA, Ronk CJ, ... Wieloch M, Lip GYH</i><br /><b>Introduction</b><br />Understanding symptom patterns in atrial fibrillation (AF) can help in disease management. We report on the application of natural language processing (NLP) to electronic medical records (EMRs) to capture symptom reports in patients with newly diagnosed (incident) AF.<br /><b>Methods and results</b><br />This observational retrospective study included adult patients with an index diagnosis of incident AF during January 1, 2016 through June 30, 2018, in the Optum datasets. The baseline and follow-up periods were 1 year before/after the index date, respectively. The primary objective was identification of the following predefined symptom reports: dyspnea or shortness of breath; syncope, presyncope, lightheadedness, or dizziness; chest pain; fatigue; and palpitations. In an exploratory analysis, the incidence rates of symptom reports and cardiovascular hospitalization were assessed in propensity-matched patient cohorts with incident AF receiving first-line dronedarone or sotalol. Among 30,447 patients with an index AF diagnosis, the NLP algorithm identified at least 1 predefined symptom in 9734 (31.9%) patients. The incidence rate of symptom reports was highest at 0-3 months post-diagnosis and lower at >3-6 and >6-12 months (pre-defined timepoints). Across all time periods, the most common symptoms were dyspnea or shortness of breath, followed by syncope, presyncope, lightheadedness, or dizziness. Similar temporal patterns of symptom reports were observed among patients with prescriptions for dronedarone or sotalol as first-line treatment.<br /><b>Conclusion</b><br />This study illustrates that NLP can be applied to EMR data to characterize symptom reports in patients with incident AF, and the potential for these methods to inform comparative effectiveness. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 21 Dec 2022; epub ahead of print</small></div>
Reynolds MR, Bunch TJ, Steinberg BA, Ronk CJ, ... Wieloch M, Lip GYH
J Cardiovasc Electrophysiol: 21 Dec 2022; epub ahead of print | PMID: 36542764
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<div><h4>In vivo tissue temperatures during 90W/4se c-very high power-short-duration (vHPSD) ablation versus ablation index-guided 50W-HPSD ablation: A porcine study.</h4><i>Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, ... Takahashi R, Taniguchi Y</i><br /><b>Background</b><br />Neither the actual in vivo tissue temperatures reached with 90W/4sec-very high-power short-duration (vHPSD) ablation for atrial fibrillation nor the safety and efficacy profile have been fully elucidated.<br /><b>Methods</b><br />We conducted a porcine study in which, after right thoracotomy, we implanted 6-8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We compared tissue temperatures close to a QDOT MICRO catheter, between during 90W/4sec-vHPSD ablation during ablation index (AI: target 400)-guided 50W-HPSD ablation, both targeting a contact force of 8-15 g.<br /><b>Results</b><br />Maximum tissue temperature reached during 90W/4sec-vHPSD ablation did not differ significantly from that during 50W-HPSD ablation (49.2±8.4ºC versus 50.0±12.1ºC; P=0.69) and correlated inversely with distance between the catheter tip and the thermocouple, regardless of the power settings (r=-0.52 and r=-0.37). Lethal temperature (≥50°C) was best predicted at a catheter tip-to-thermocouple distance cut-point of 3.13 and 4.27 mm, respectively. All lesions produced by 90W/4sec-vHPSD or 50W-HPSD ablation were transmural. Although there was no difference in the esophageal injury rate (50% versus 66%, P=0.80), the thermal lesion was significantly shallower with 90W/4sec-vHPSD ablation than with 50W-HPSD ablation (381.3±127.3 versus 820.0±426.1μm from the esophageal adventitia; P=0.039).<br /><b>Conclusions</b><br />Actual tissue temperatures reached with 90W/4sec-vHPSD ablation appear similar to those with AI-guided 50W-HPSD ablation, with the distance between the catheter tip and target tissue being shorter for the former. Although both ablation settings may create transmural lesions in thin atrial tissues, any resulting esophageal thermal lesions appear shallower with 90W/4sec-vHPSD ablation. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 17 Dec 2022; epub ahead of print</small></div>
Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, ... Takahashi R, Taniguchi Y
J Cardiovasc Electrophysiol: 17 Dec 2022; epub ahead of print | PMID: 36527433
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<div><h4>Hotter? Yes. Faster? Yes. Better? Maybe.</h4><i>Kaul R, Barbhaiya CR</i><br /><AbstractText>Very-High Power Short Duration (vHPSD) is the latest contender in the armamentarium of escalating radiofrequency (RF) power for safe and effective catheter ablation of atrial fibrillation (AF). This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 16 Dec 2022; epub ahead of print</small></div>
Kaul R, Barbhaiya CR
J Cardiovasc Electrophysiol: 16 Dec 2022; epub ahead of print | PMID: 36525459
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<div><h4>Multiple wide QRS tachycardias in the same individual with ischemic cardiomyopathy.</h4><i>Ozcan Cetin EH, Korkmaz A, Kara M, Merovci I, ... Aras D, Topaloglu S</i><br /><AbstractText>The classic teaching over the years has been that all cases of WCT are to be treated as VT until proven otherwise, particularly in patients with structural heart disease. This case highlights an alternative diagnosis is possible This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Ozcan Cetin EH, Korkmaz A, Kara M, Merovci I, ... Aras D, Topaloglu S
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511469
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<div><h4>Efficacy of Intrinsic Antitachycardia Pacing for Ventricular Tachycardia Refractory to Conventional Burst Pacing: A Case Series.</h4><i>Kamakura T, Ueda N, Wada M, Ishibashi K, Kusano K</i><br /><b>Introduction</b><br />Intrinsic antitachycardia pacing (iATP) is a novel automated ventricular ATP algorithm that designs ATP sequences based on the analysis of prior failed ATP. Real-world data on the efficacy and safety of iATP are lacking.<br /><b>Methods</b><br />Among 124 ventricular tachycardia (VT) episodes in 130 consecutive patients (mean age at implantation: 63.8 ± 14.9 years; sex, 95 male and 35 female) for whom implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator equipped with iATP algorithm was implanted, we investigated the efficacy and safety of iATP for VT refractory to conventional burst pacing.<br /><b>Results</b><br />Eight patients had a total of 17 episodes of iATP therapy after failed conventional burst pacing within 11.2 ± 6.6 months of follow-up. Eleven VT episodes (64.7%) in seven patients (87.5%) were successfully terminated by iATP, and only one patient (12.5%) experienced VT acceleration.<br /><b>Conclusion</b><br />iATP might be useful for VTs refractory to conventional burst pacing with a low risk of VT acceleration. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Kamakura T, Ueda N, Wada M, Ishibashi K, Kusano K
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511471
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<div><h4>Pre-clinical Evaluation of Semi-Automated Laser Ablation for Pulmonary Vein Isolation: A Comparative Study.</h4><i>Kuroki K, Reddy VY, Iwasawa J, Kawamura I, ... Dukkipati SR, Koruth J</i><br /><b>Introduction</b><br />Visually-guided laser balloon ablation (VGLA) currently requires careful manual rotation of the laser to create overlapping lesions. A novel semi-automated VGLA may reduce ablation times and lesion gaps. We aimed to compare semi-automated (SA) VGLA to that of manual (MN) VGLA.<br /><b>Methods</b><br />Acute: 9 swine underwent right superior pulmonary vein isolation (PVI) using either SA (n=3, 13-18W), MN (n=3, 8.5-12W) or radiofrequency (RF, n=3, 25-40W) and were sacrificed acutely. Chronic: 16 swine, underwent PVI using either SA (n=8, 15W) or MN (n=8, 10W), and were survived for one month before sacrifice. All hearts were then submitted for pathological evaluation.<br /><b>Results</b><br />Acute: PVI was successful in all 9/9 swine with lesion counts significantly lower in the SA arm, (5.3±5.9, 33.7±10.0 and 28.0±4.4 in SA, MN and RF arms; p=0.007 for SA and MN). At necropsy, circumferentiality and transmurality were 98% and 94% in SA, 98 and 80% in MN, and 100% and 100% in RF arms. A single steam pop was noted on sectioning in the SA arm swine and occurred in the high dose (18W) strategy. Chronic: PVI was acutely successful in 16/16 swine with no difference in PVI durability rates (62.5 vs. 75.0%), lesion transmurality (95.8±17.4 vs.91.9±25.9%) and circumferentiality (95.8±6.6% vs. 94.8±6.3%) between SA and MN arms. Catheter use time and lesion counts were lower in the SA arm compared to the MN arm (11.5±12.7 vs. 21.8±3.8min, p=0.046 and 4.8±3.83 vs.35.4±4.4, p<0.001).<br /><b>Conclusion</b><br />Motor-assisted semi-automated laser balloon ablation can improve upon procedural efficiency by reducing ablation time. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Kuroki K, Reddy VY, Iwasawa J, Kawamura I, ... Dukkipati SR, Koruth J
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511472
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<div><h4>\"Laser-based therapy: is the right answer for pulmonary vein isolation?\".</h4><i>Tondo C</i><br /><AbstractText>Laser- based PVI has been around for many years and this modality of ablation is to provide a continuous circular overlapping lesions around the PVs\' ostia. In order to ensure the continuity of the lesion, a camera is embedded in the system as to guide the placement of sequential applications with the target to make an adequate overlapping of two contiguous lesions as to reduce the likelihood of gaps. The first version of the system required the operator to manually rotate the catheter as to create a continuous arc of lesion around the PV\'s ostium. This approach is time-consuming, with a substantial overall time for each PV. The evolvement of the technique has been recently offered, with a novel semi-automated VGLA as to improve ablation efficiency by using a motorized system which moves the laser arc continuously in order to reduce the application time and, hopefully, minimize the creation of gaps. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Tondo C
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511473
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<div><h4>Outcomes and Atrial Substrate Analysis in Patients with HIV undergoing Atrial Fibrillation Ablation.</h4><i>Cheng A, Qiu J, Barbhaiya C, Garber L, ... Chinitz L, Aizer A</i><br /><b>Introduction</b><br />Patients with HIV infection have increased risk of atrial fibrillation, but the pathophysiologic mechanisms and the utility of catheter ablation in this population is not well-studied. We aimed to characterize outcomes of atrial fibrillation ablation and left atrial substrate in patients with HIV.<br /><b>Methods</b><br />The study was a retrospective propensity score-matched analysis of patients with and without HIV undergoing atrial fibrillation ablation. A search was performed in the electronic medical record for all patients with HIV who received initial atrial fibrillation ablation from 2011-2020. After calculating propensity scores for HIV, matching was performed with patients without HIV by using nearest neighbor matching without replacement in a 1:2 ratio. The primary outcome was freedom from atrial arrhythmia and secondary outcomes were freedom from atrial fibrillation, freedom from atrial tachycardia, and freedom from repeat ablation, compared by log-rank analysis. The procedures of patients with HIV who underwent repeat ablation at our institution were further analyzed for etiology of recurrence. To further characterize left atrial substrate, a subsequent case-control analysis was then performed for a set of randomly chosen ten patients with HIV matched with ten without HIV to compare minimum and maximum voltage at 9 pre-specified regions of the left atrium.<br /><b>Results</b><br />27 patients with HIV were identified. All were prescribed antiretroviral therapy at time of ablation. These patients were matched with 54 patients without HIV by propensity score. 86.4% of patients with HIV and 76.9% of controls were free of atrial fibrillation or atrial tachycardia at one year (p=0.509). Log-rank analysis showed no difference in freedom from atrial arrhythmia (p-value 0.971), atrial fibrillation (p-value 0.346), atrial tachycardia (p-value 0.306), or repeat ablation (p-value 0.401) after initial atrial fibrillation ablation in patients with HIV compared to patients without HIV. In patients with HIV with recurrent atrial fibrillation, the majority had pulmonary vein reconnection (67%). There were no significant differences in minimum or maximum voltage at any of the nine left atrial regions between the matched patients with and without HIV.<br /><b>Conclusions</b><br />Ablation to treat atrial fibrillation in patients with HIV, but without overt AIDS is frequently successful therapy. The majority of patients with recurrence of atrial fibrillation had pulmonary vein reconnection, suggesting infrequent non-pulmonary vein substrate. In this population the left atrial voltage in patients with HIV is similar to that of patients without HIV. These findings suggest that the pulmonary veins remain a critical component to the initiation and maintenance of atrial fibrillation in patients with HIV. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Cheng A, Qiu J, Barbhaiya C, Garber L, ... Chinitz L, Aizer A
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511474
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<div><h4>The Reuse of Cardiac Pacemakers and Defibrillators. A Convoluted History in an Era of Global Health.</h4><i>Lemery R</i><br /><AbstractText>Following the development of permanent transvenous cardiac pacing in the 1960s, the costs of pacemakers quickly led to their reuse in both developed countries and in Low-and Middle-Income Countries (LMIC). Legal, ethical and industrial factors gradually resulted in the termination of reuse in developed countries. Without health care budgets to pay for costly pacemaker technologies, Non-Governmental Organizations (NGOs) and other groups have provided support to physicians and hospitals treating patients with heart block in LMICs. Multiple other academic and private groups have also assisted such patients in LMICs. Pacemaker companies have provided physicians and hospitals with new devices (that have an expired package date or through charitable donations). Greater care of preparing and cleaning refurbished devices have demonstrated overwhelmingly the safety and effectiveness of reused devices. More recently, cardiac resynchronization therapy and implantable cardioverter-defibrillators (ICDs) have also been reused in patients in LMICs. While the globalization of non-communicable diseases continues, patients with rhythm disorders in LMICs can no longer be left behind. While patients in developed countries only receive new devices to treat rhythm disorders, the practice of reused cardiac implantable electronic devices (CIEDs) will expand in LMICs, until equal access to device technologies be made available to all. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Lemery R
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511478
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<div><h4>Ablation Of Atrial Fibrillation Beyond Pulmonary Vein Isolation: Do Additional Ablation Lesions Impact Left Atrial Function?</h4><i>Reynbakh O, Garcia M, Romero J, Patel H, ... Fazzari M, Di Biase L</i><br /><b>Background</b><br />Electrical isolation of pulmonary veins (PVI) is a cornerstone for Atrial Fibrillation (AF) ablation. The overall effect of AF ablation, and especially lesions beyond PVI, on left atrial (LA) function is currently poorly understood.<br /><b>Objective</b><br />Our aim was to determine if LA function is different in patients after extensive LA ablation compared to PVI only. We performed non-inferiority analysis of LA function after PVI with additional non-pulmonary vein ablation lesions in LA (PVI+) and PVI alone.<br /><b>Methods</b><br />We studied 68 patients consecutive patients who underwent AF ablation and who had complete echocardiograms (TTE) within 12 months prior to AF ablation and 1-12 months after the procedure. Patients were stratified into 2 groups: PVI only and PVI+. Primary outcome was change in LA reservoir strain (LASr). Non-inferiority margin was defined at 6%.<br /><b>Results</b><br />The PVI only group had a higher proportion of patients with paroxysmal AF (70% vs 30%). The PVI + group was observed to have a slightly higher increase in LASr compared to PVI alone (5.0%vs 4.3%, p<0.01 for non-inferiority). LASr non-inferiority was confirmed when adjusted for age, sex, CAD, HLD, AF type, rhythm at pre-procedure TTE in a multivariable linear regression model, 90% CI (-5.46; 2.04), p<0.01.<br /><b>Conclusion</b><br />LA functional improvement evaluated by LASr was non-inferior after PVI with additional LA ablation lesions compared to PVI alone. These findings were confirmed when adjusted for confounding clinical variables, suggesting that more extensive ablation does not negatively affect LA function. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print</small></div>
Reynbakh O, Garcia M, Romero J, Patel H, ... Fazzari M, Di Biase L
J Cardiovasc Electrophysiol: 13 Dec 2022; epub ahead of print | PMID: 36511480
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<div><h4>Validation of the accuracy of contact force measurement by contemporary force-sensing ablation catheters.</h4><i>Kueffer T, Haeberlin A, Knecht S, Baldinger SH, ... Roten L, Reichlin T</i><br /><b>Introduction</b><br />Contact force-sensing catheters are widely used for ablation of cardiac arrhythmias. They allow quantification of catheter-to-tissue contact, which is an important determinant for lesion formation and may reduce the risk of complications. The accuracy of these sensors may vary across the measurement range, catheter-to-tissue angle, and amongst manufacturers and we aim to compare the accuracy and reproducibility of four different force sensing ablation catheters.<br /><b>Methods</b><br />A measurement setup containing a heated saline water bath with an integrated force measurement unit was constructed and validated. Subsequently, we investigated four different catheter models, each equipped with a unique measurement technology: Tacticath Quartz (Abbott), AcQBlate Force (Biotronik/Acutus), Stablepoint (Boston Scientific), and Smarttouch SF (Biosense Webster). For each model, the accuracy of three different catheters was measured within the range of 0-60 grams and at contact angles of 0°, 30°, 45°, 60°, and 90°.<br /><b>Results</b><br />In total, 6685 measurements were performed using 4x3 catheters (median of 568, IQR 511-606 measurements per catheter). Over the entire measurement-range, the force measured by the catheters deviated from the real force by the following absolute mean values: Tacticath 1.29g ±0.99g, AcQBlate Force 2.87g ±2.37g, Stablepoint 1.38g ±1.29g, and Smarttouch 2.26g ±2.70g. For some models, significant under- and overestimation of >10g were observed at higher forces. Mean absolute errors of all models across the range of 10-40g were <3g.<br /><b>Conclusion</b><br />Contact measured by force-sensing catheters is accurate with 1-3g deviation within the range of 10g to 40g. Significant errors can occur at higher forces with potential clinical consequences. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Dec 2022; epub ahead of print</small></div>
Kueffer T, Haeberlin A, Knecht S, Baldinger SH, ... Roten L, Reichlin T
J Cardiovasc Electrophysiol: 09 Dec 2022; epub ahead of print | PMID: 36490307
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<div><h4>Pharmacological inhibition of SK-channels with AP14145 prevents atrial arrhythmogenic changes in a porcine model for obstructive respiratory events.</h4><i>Linz B, Hesselkilde EM, Skarsfeldt MA, Hertel JN, ... Linz D, Jespersen T</i><br /><b>Background</b><br />Obstructive sleep apnea (OSA) creates a complex substrate for atrial fibrillation (AF), which is refractory to many clinically available pharmacological interventions. We investigated atrial antiarrhythmogenic properties and ventricular electrophysiological safety of small-conductance Ca<sup>2+</sup> -activated K<sup>+</sup> (SK)- channel inhibition in a porcine model for obstructive respiratory events.<br /><b>Methods</b><br />In spontaneously breathing pigs, obstructive respiratory events were simulated by intermittent negative upper airway pressure (INAP) applied via a pressure device connected to the intubation tube. INAP was applied for 75 seconds, every 10 minutes, three times before and three times during infusion of the SK-channel inhibitor AP14145. Atrial effective refractory periods (AERP) were acquired before (Pre-INAP), during (INAP) and after (Post-) INAP. AF-inducibility was determined by a S1S2 atrial pacing protocol. Ventricular arrhythmicity was evaluated by heart rate adjusted QT-interval duration (QT-paced) and electromechanical window (EMW) shortening.<br /><b>Results</b><br />During vehicle infusion, INAP transiently shortened AERP (Pre-INAP: 135±10 ms vs. Post-INAP 101±11 ms; p=0.008) and increased AF-inducibility. QT-paced prolonged during INAP (Pre-INAP 270±7 ms vs. INAP 275±7 ms; p=0.04) and EMW shortened progressively throughout INAP and Post-INAP (Pre-INAP 80±4 ms; INAP 59±6 ms, Post-INAP 46±10 ms). AP14145 prolonged baseline AERP, partially prevented INAP-induced AERP-shortening and reduced AF-susceptibility. AP14145 did not alter QT-paced at baseline (Pre-AP14145 270±7 ms vs. AP14145 268±6 ms, p=0.83) or QT-paced and EMW-shortening during INAP.<br /><b>Conclusion</b><br />In a pig model for obstructive respiratory events, the SK-channel-inhibitor AP14145 prevented INAP-associated AERP-shortening and AF-susceptibility without impairing ventricular electrophysiology. Whether SK-channels represent a target for OSA-related AF in humans warrants further study. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Dec 2022; epub ahead of print</small></div>
Linz B, Hesselkilde EM, Skarsfeldt MA, Hertel JN, ... Linz D, Jespersen T
J Cardiovasc Electrophysiol: 08 Dec 2022; epub ahead of print | PMID: 36482155
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<div><h4>Development of a Clinically Relevant Ex Vivo Model of Cardiac Ablation for Testing of Ablation Catheters.</h4><i>Lacko CS, Chen Q, Mendoza V, Parikh V, ... Matonick JP, Sharma T</i><br /><b>Introduction</b><br />Reliable ex vivo cardiac ablation models have the potential to increase catheter testing throughput while minimizing animal usage. The goal of this work was to develop a physiologically relevant ex vivo swine model of cardiac ablation displaying minimal variability and high repeatability and identify and optimize key parameters involved in ablation outcomes.<br /><b>Methods and results</b><br />A root cause analysis was conducted to identify variables affecting ablation outcomes. Parameters associated with the tissue, bath media, and impedance were identified. Variables were defined experimentally and/or from literature sources to best mimic the clinical cardiac ablation setting. The model was validated by performing three independent replicates of ex vivo myocardial ablation and a direct comparison of lesion outcomes of the ex vivo swine myocardial and in vivo canine thigh preparation (TP) models. Replicate experiments on the ex vivo model demonstrated low variance in ablation depth (6.5±0.6 mm, 6.3±0.6 mm, 6.2±0.4 mm) and width (10.4±1.1 mm, 9.7±1.0 mm, 9.9±0.9 mm) and no significant differences between replicates. In a direct comparison of the two models, the ex vivo model demonstrated ablation depths similar to the canine TP model at 35 W (6.9±1.0 mm, and 7.0±0.9 mm) and 50 W (8.0±0.7 mm, and 8.4±0.7 mm), as well as similar power to depth ratios (15% and 19% for the ex vivo cardiac and in vivo TP models, respectively).<br /><b>Conclusion</b><br />The ex vivo model exhibited strong lesion reproducibility and power-to-depth ratios comparable to the in vivo TP model. The optimized ex vivo model minimizes animal usage with increased throughput, lesion characteristics similar to the in vivo TP model, and ability to discriminate minor variations between different catheter designs. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Dec 2022; epub ahead of print</small></div>
Lacko CS, Chen Q, Mendoza V, Parikh V, ... Matonick JP, Sharma T
J Cardiovasc Electrophysiol: 08 Dec 2022; epub ahead of print | PMID: 36482158
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<div><h4>Can We Trust the Force?</h4><i>Pelosi F</i><br /><AbstractText>For over 40 years, delivering quality radiofrequency (RF) ablation lesions has been the unending quest for electrophysiology. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Dec 2022; epub ahead of print</small></div>
Pelosi F
J Cardiovasc Electrophysiol: 08 Dec 2022; epub ahead of print | PMID: 36482011
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<div><h4>A novel approach to differentiate post-infarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation.</h4><i>Khanra D, Calvert P, Hughes S, Waktare J, ... Gupta D, Luther V</i><br /><b>Background</b><br />Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate post-infarct scar from conducting borderzone (BZ) during VT ablation.<br /><b>Methods</b><br />15 consecutive patients (LVEF 30±7%) underwent endocardial LV Pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50mV defined the RM-Borderzone (RM-BZ).<br /><b>Results</b><br />RM-scar was significantly smaller than the traditional 0.50mV cutoff (median 4% vs 12% shell area, p<0.001). 65±16% of tissue <0.50mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from borderzone tissue was 0.22±0.07mV, though this ranged widely (from 0.12mV-0.35mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs 347ms, p=0.001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs 1.2, p=0.013) with faster RM-BZ conduction speed (0.72 vs 0.34 m/sec, p=0.001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367±38ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs 3.2, p=0.059), and slower RM-BZ conduction speed (0.36 vs 0.63 m/sec, p=0.036). RM guided ablation collocated within 66±20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes pre-ablation vs 0 post, p<0.001) at 11±6 months follow-up.<br /><b>Conclusion</b><br />Post-infarct scars appear significantly smaller than traditional 0.50mV cut-offs suggest, with voltage thresholds unique to each patient. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 07 Dec 2022; epub ahead of print</small></div>
Khanra D, Calvert P, Hughes S, Waktare J, ... Gupta D, Luther V
J Cardiovasc Electrophysiol: 07 Dec 2022; epub ahead of print | PMID: 36478627
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<div><h4>Outcomes of Transvenous Lead Extraction of Very Old Leads Using Bidirectional Rotational Mechanical Sheaths: Results of a Multicentre Study.</h4><i>Migliore F, Pittorru R, Dall\'Aglio PB, De Lazzari M, ... Carretta D, Mazzone P</i><br /><b>Introduction</b><br />lead dwell time >10 years is a recognized predictor for transvenous lead extraction (TLE) failure and complications.Data on the efficacy and safety of TLE using the bidirectional rotational mechanical sheaths in patients with very old leads are lacking. In this multicenter study, we reported the outcome of transvenous rotational mechanical lead extraction in patients with leads implanted for ≥10 years.<br /><b>Methods</b><br />a total of 441 leads [median 159 months (135-197);range 120-487] in 189 consecutive patients were removed with the Evolution RL sheaths (Cook Medical,Bloomington,IN,USA) and mechanical ancillary tools supporting the procedure.<br /><b>Results</b><br />the main indication for TLE was infection in 74% of cases.Complete procedural success rate, clinical success rate, per lead were 94.8 and 98% respectively.Failure of lead extraction was seen in 1.8% of leads.The additional use of a snare via the femoral approach was required in 9% of patients.Lead dwell time was the only predictor of incomplete led removal (OR 1.009,95%CI 1.003-1.014,P=0.002).Four major complication (2%) were encountered.During a mean time follow-up of 31±27 months, 21 patients (11%) died.No procedure-related mortality occurred.Predictors of mortality included severe systolic dysfunction (HR 8.06;95%CI 2.99-21.73;P=0.001), TLE for infection (HR 8.0;95%CI 1.04-62.5;P=0.045), diabetes (HR 3.7;95%CI 1.48-9.5;P=0.005), and previous systemic infection (HR 3.1;95%CI 1.17-8.24;P=0.022).Incomplete lead removal or failure lead extraction did not impact on survival during follow-up <br /><b>Conclusion:</b><br/>our findings demonstrated that the use of bidirectional rotational TLE mechanical sheaths combined with different mechanical tools and femoral approach allows reasonable success and safety in patients with very old leads at experienced specialised centres. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 07 Dec 2022; epub ahead of print</small></div>
Migliore F, Pittorru R, Dall'Aglio PB, De Lazzari M, ... Carretta D, Mazzone P
J Cardiovasc Electrophysiol: 07 Dec 2022; epub ahead of print | PMID: 36477909
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<div><h4>Low Voltage Area Guided Substrate Modification in Non-Paroxysmal Atrial Fibrillation: A Systematic review and Meta-analysis.</h4><i>Moustafa A, Karim S, Kahaly O, Elzanaty A, ... Eltahawy E, Chacko P</i><br /><b>Background</b><br />Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in non-paroxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results.<br /><b>Methods</b><br />The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with non-paroxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time.<br /><b>Results</b><br />A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus non LVA ablation group [RR 0.63 (27% vs 36%),95% CI 0.48-0.62, P< 0.001]. Also, redo ablation was significantly lower in LVA ablation group [RR 0.52 (18% vs 26.7%),95% CI 0.38-0.69, P< 0.00133]. No difference was found in the overall adverse event [RR 0.7 (4.3% vs 5.4), 95% CI 0.36-1.35, P= 0.29].<br /><b>Conclusion</b><br />LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Dec 2022; epub ahead of print</small></div>
Moustafa A, Karim S, Kahaly O, Elzanaty A, ... Eltahawy E, Chacko P
J Cardiovasc Electrophysiol: 01 Dec 2022; epub ahead of print | PMID: 36453469
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<div><h4>Feasibility and Safety of Zero-Fluoroscopy Left Bundle Branch Pacing: An Initial Experience.</h4><i>Ramos-Maqueda J, Polo JM, Montilla-Padilla I, Arroyo JRR, Cabrera-Ramos M</i><br /><b>Introduction</b><br />Left bundle branch pacing (LBBP) has emerged in recent years as a new pacing modality, providing patients with a narrower paced QRS than conventional pacing and stable pacing parameters. At the same time, there is a growing concern about the use of fluoroscopy in pacemaker implantations, given its harmful effects on both patients and operators. However, there are no prior experiences of zero-fluoroscopy in LBBP procedure.<br /><b>Methods</b><br />We conducted an observational prospective study recruiting consecutive patients that underwent zero-fluoroscopy LBBP pacemaker implantation. A 6-month follow-up visit was programmed for every patient. The main goal of our study was to assess the efficacy, feasibility and safety of the procedure.<br /><b>Results</b><br />From January 2021 to February 2022, we included 10 patients, 8 males. The average age was 63 ± 4 years. The procedure was successful in all patients. We observed a significant reduction in paced QRS width compared with basal QRS width (149±31.9 vs 116±15.6 ms, p=0.02). All device parameters remained stable at 6-month follow-up: no significant differences in mean impedance (700.5±136.4 vs 494±72.7 Ohm, p=0.09), capture threshold (0.67±0.2 vs 0.83±0.2 V @ 0.4 ms, p=0.27) or endocardial V-wave amplitude (10.6±5.2 vs 13.9±6.3 mV, p=0.19). No complications were reported in any case.<br /><b>Conclusion</b><br />Zero-fluoroscopy LBBP is feasible and safe, and it may be considered in cases where radiation exposure is contraindicated or especially undesirable. Future randomized clinical trials are needed for the widespread use of this new technique. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Nov 2022; epub ahead of print</small></div>
Ramos-Maqueda J, Polo JM, Montilla-Padilla I, Arroyo JRR, Cabrera-Ramos M
J Cardiovasc Electrophysiol: 30 Nov 2022; epub ahead of print | PMID: 36448425
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<div><h4>Same-day Discharge Following Catheter Ablation and Venous Closure With VASCADE MVP: A Post-market Registry.</h4><i>Eldadah ZA, Al-Ahmad A, Jared Bunch T, Delurgio DB, ... Wazni OM, Thomas McElderry H</i><br /><b>Introduction</b><br />Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF).<br /><b>Methods</b><br />The AMBULATE SDD Registry is a 2-stage series of post-market studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure.<br /><b>Results</b><br />Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight.<br /><b>Conclusion</b><br />In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Nov 2022; epub ahead of print</small></div>
Eldadah ZA, Al-Ahmad A, Jared Bunch T, Delurgio DB, ... Wazni OM, Thomas McElderry H
J Cardiovasc Electrophysiol: 30 Nov 2022; epub ahead of print | PMID: 36448428
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<div><h4>Propofol dose and efficacy of defibrillation testing during implantation of subcutaneous implantable cardioverter-defibrillators - a retrospective, single center cohort study.</h4><i>Trolese L, Dall\'Aglio PB, Steinfurt J, Gressler A, ... Jäckel M, Study Group</i><br /><b>Introduction</b><br />Defibrillation testing (DFT) is recommended during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Previous studies analyzing the potential interference of propofol with defibrillation threshold are inconsistent. The purpose of this study was to analyze whether propofol affects DFT post S-ICD placement.<br /><b>Methods</b><br />All patients with S-ICD implantation between 01/2017 and 11/2020 at the University Heart Center Freiburg were retrospectively analyzed. Two groups were generated depending on the success of the first shock during DFT. Implantation characteristics and dose of anesthetics were analyzed.<br /><b>Results</b><br />In 12 of the included 80 (15%) patients, first shock during DFT failed. The absolute dose of propofol was significantly higher in patients with first shock failure (median 653mg [IQR 503-855]) compared to patients with first shock termination (376mg [200-600]; p=0.027). Doses of opioids and midazolam as well as type of anesthesia did not differ between the groups. A multivariable binary logistic regression analysis confirmed an independent association of first shock termination and propofol dose (per 100mg: OR 0.73 (95% CI: 0.56-0.95); p=0.021).<br /><b>Conclusion</b><br />There is an independent association of propofol dose and first shock failure in routine S-ICD defibrillation testing. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Nov 2022; epub ahead of print</small></div>
Trolese L, Dall'Aglio PB, Steinfurt J, Gressler A, ... Jäckel M, Study Group
J Cardiovasc Electrophysiol: 29 Nov 2022; epub ahead of print | PMID: 36444777
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<div><h4>Utility of an Automatic Electrogram Fractionation Annotation Algorithm for Detection of Critical Elements in Atrial Flutter Circuits? The search for EP Gold.</h4><i>Anderson RD, Ha ACT, Lee G</i><br /><AbstractText>In the gold rush of the 1840\'s many miners believed they had struck fortune when they had mistaken the naturally abundant iron pyrite for gold given its brass color, metallic luster and overall superficial resemblance of the valuable commodity. Analogous to this, complex fractionated atrial electrograms (CFAE) may be considered as electrophysiologists pyrite This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Nov 2022; epub ahead of print</small></div>
Anderson RD, Ha ACT, Lee G
J Cardiovasc Electrophysiol: 29 Nov 2022; epub ahead of print | PMID: 36444828
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<div><h4>Atrial fibrillation: Epidemiology, pathophysiology, and clinical complications (literature review).</h4><i>Bizhanov KA, Аbzaliyev KB, Baimbetov AK, Sarsenbayeva AB, Lyan E</i><br /><AbstractText>The last 3 decades have been characterised by an exponential increase in knowledge and advances in the clinical management of atrial fibrillation. The purpose of the study is to provide an overview of the pathogenesis of nonvalvular atrial fibrillation and a comprehensive investigation of the epidemiological data associated with various risk factors for atrial fibrillation. The leading research methods are analysis and synthesis, comparison, observation, induction and deduction and grouping method. Research has shown that old age, male gender, and European descent are important risk factors for developing atrial fibrillation. Other modifiable risk factors include a sedentary lifestyle, smoking, obesity, diabetes mellitus, obstructive sleep apnea, and high blood pressure predisposing to atrial fibrillation, and each has been shown to induce structural and electrical atrial remodelling. Both heart failure and myocardial infarction increase the risk of developing atrial fibrillation and vice versa creating feedback that increases mortality. The review is a comprehensive study of the epidemiological data linking nonmodifiable and modifiable risk factors for atrial fibrillation, and the pathophysiological data supporting the relationship between each risk factor and the occurrence of atrial fibrillation. This may be necessary in the practice of treatment of the cardiac system. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print</small></div>
Bizhanov KA, Аbzaliyev KB, Baimbetov AK, Sarsenbayeva AB, Lyan E
J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print | PMID: 36434795
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<div><h4>Cardiac Tamponade complicating Ventricular Arrythmia Ablation: real life data on incidence, management and outcome.</h4><i>Darma A, Dinov B, Bertagnolli L, Torri F, ... Hindricks G, Arya A</i><br /><b>Backround and objective</b><br />Cardiac tamponade during ablation procedures is a life-threatening complication. While the incidence and management of tamponade in atrial fibrillation ablation has been extensively described, the data on tamponade during ventricular ablations are very limited. The purpose of this study is to shed light into the incidence, typical perforation sites and optimal management as observed through real life data in a tertiary referral centre for ventricular ablation.<br /><b>Methods and results</b><br />Consecutive patients with structural heart disease undergoing ventricular tachycardia ablation through 2008 - 2020 were analysed. Of the 1078 patients undergoing 1287 ventricular ablation procedures, 20 procedures (1.5%) were complicated by cardiac tamponade. In all but one patient the tamponade was treated with emergent pericardial drainage, while nine patients eventually underwent surgical repair. The perforation occurred during transseptal or subxiphoid puncture in six patients, during ventricle mapping in two patients and during ablation in five patients (predominantly basal left ventricle). Steam-pop as definite perforation cause could only be established in two patients. Regardless of the management of the complication, all patients survived to discharge.<br /><b>Conclusion</b><br />Cardiac tamponade during ventricular ablation occurred in 1.5% of the procedures. In nine patients cardiac repair was necessary. Perforation was mostly associated with subxiphoid puncture or ablation of the basal left ventricle. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print</small></div>
Darma A, Dinov B, Bertagnolli L, Torri F, ... Hindricks G, Arya A
J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print | PMID: 36434796
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<div><h4>Pulmonary vein isolation Alone or in Combination wIth substrate modulation aFter electrIcal Cardioversion failure in patients with persistent atrial fibrillation: The PACIFIC trial: Study design.</h4><i>Bortone AA, Marijon E, Limite LR, Lagrange P, ... Durand C, Albenque JP</i><br /><b>Introduction</b><br />Pulmonary vein isolation (PVI) is effective at treating 50% of unselected patients with persistent atrial fibrillation (AF). Alternatively, PVI combined with a new ablation strategy entitled the Marshall-PLAN ensures a 78% 1-year sinus rhythm (SR) maintenance rate in the same population. However, a substantial subset of patients could undergo the Marshall-PLAN unnecessarily. It is therefore essential to identify those patients who can be treated with PVI alone versus those who may truly benefit from the Marshall-PLAN before ablation is performed. In this context, we hypothesised that electrical cardioversion (EC) could help to select the most appropriate strategy for each patient.<br /><b>Methods</b><br />In this multicentre, prospective, randomised study, patients with AF recurrence within 4 weeks after EC will be randomised 1:1 to PVI alone or the Marshall-PLAN. Conversely, patients in whom SR is maintained for <mml:math xmlns:mml=\"http://www.w3.org/1998/Math/MathML\"><mml:mo>≥</mml:mo></mml:math> 4 weeks after EC will be treated with PVI only and included in a prospective registry. The primary endpoint will be the 1-year SR maintenance rate after a single ablation procedure.<br /><b>Results and conclusion</b><br />The Marshall-PLAN might be necessary in patients with an advanced degree of persistent AF (i.e., where SR is not maintained for <mml:math xmlns:mml=\"http://www.w3.org/1998/Math/MathML\"><mml:mo>≥</mml:mo></mml:math> 4 uninterrupted weeks after EC). Conversely, in patients with mild or moderate persistent AF (i.e., where SR is maintained for <mml:math xmlns:mml=\"http://www.w3.org/1998/Math/MathML\"><mml:mo>≥</mml:mo></mml:math> 4 weeks after EC), PVI alone might be a sufficient ablation strategy. The PACIFIC trial is the first study designed to assess whether rhythm monitoring after EC could help to identify patients who should undergo adjunctive ablation strategies beyond PVI. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print</small></div>
Bortone AA, Marijon E, Limite LR, Lagrange P, ... Durand C, Albenque JP
J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print | PMID: 36434797
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<div><h4>Automatic identification of areas with low-voltage fragmented electrograms for the detection of the critical isthmus of atypical atrial flutters.</h4><i>Franco E, Granero CL, Cortez-Dias N, Nakar E, ... Zamorano JL, Moreno J</i><br /><b>Introduction</b><br />Critical isthmuses of atypical atrial flutters (AAFLs) are usually located at slow conduction areas that exhibit fractionated electrograms. We tested a novel software, intended for integration with a commercially available navigation system, that automatically detects fractionated electrograms, to identify the critical isthmus in patients with AAFL ablation.<br /><b>Methods and results</b><br />All available patients were analysed; 27 patients with 33 AAFLs were included. The PentaRay NAV catheter (Biosense Webster) was used for mapping. The novel software was retrospectively applied; fractionated points with duration ≥80ms and bipolar voltage between 0.05-0.5mV were highlighted on the surface of maps. In 10 randomly chosen AAFLs, an expert electrophysiologist evaluated the positive predictive value of the algorithm to detect true fractionation: 74.4%. We tested the capacity of the software to identify areas of fractionation (defined as clusters of ≥3 adjacent points with fractionation) at the critical isthmus of the AAFLs (defined using conventional mapping criteria). An area of fractionation was identified at the critical isthmus in 30 cases (91%). Globally, 144 areas of fractionation (median number per AAFL 4 [3-6]) were identified. Duration of the fractionation or the surface of the areas were not different between areas at critical isthmuses and the rest. Setting the fractionation score filter of the software in 9 provided best performance.<br /><b>Conclusions</b><br />The novel software detected areas of fractionation at the critical isthmus in most AAFLs, which may help identify the critical isthmus in clinical practice. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print</small></div>
Franco E, Granero CL, Cortez-Dias N, Nakar E, ... Zamorano JL, Moreno J
J Cardiovasc Electrophysiol: 26 Nov 2022; epub ahead of print | PMID: 36434798
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<div><h4>Spatial relationship of localized sources of persistent atrial fibrillation identified by a unipolar-based automated algorithm to complex fractionated atrial electrocardiograms and atrial low voltage areas.</h4><i>Nagase T, Kato R, Asano S, Fukunaga H, ... Nitta J, Isobe M</i><br /><b>Introduction</b><br />Spatial characteristics of localized sources of persistent atrial fibrillation (AF) identified by unipolar-based panoramic mapping software (CARTOFINDER) remain unclear. We evaluated spatial characteristics of bi-atrial AF localized sources in relation to complex fractionated atrial electrocardiograms (CFAEs) and atrial low voltage area (LVAs) (≤ 0.35 mV during AF).<br /><b>Methods and results</b><br />Twenty consecutive patients with persistent AF underwent bi-atrial voltage, CFAE, and CARTOFINDER mapping before the beginning of ablation (18 [90%] patients, initial procedure; 2 [10%] patients, repeat procedure). CFAEs were recorded using the interval confidence level (ICL) mode and defined as sites with a confidence level of ≥ 80% of maximal ICL number. We elucidated the following: (1) differences in the rate of AF localized sources and CFAEs inside or outside the atrial LVAs; (2) distribution of AF localized sources and CFAEs; and (3) distance between the closest points of AF localized sources and CFAEs. A total of 270 AF localized sources and 486 CFAEs were identified in 20 patients. AF localized sources were confirmed more often outside atrial LVAs than CFAEs (71% vs. 46% outside LVA, P < .001). AF localized sources and CFAEs were diffusely distributed without any tendency in bi-atria. Mean distance between closest AF localized sources and CFAEs was 22 ± 8 mm.<br /><b>Conclusion</b><br />AF localized sources identified by CARTOFINDER are different therapeutic targets as compared to CFAEs and could be confirmed both inside and outside atrial LVAs. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Nov 2022; epub ahead of print</small></div>
Nagase T, Kato R, Asano S, Fukunaga H, ... Nitta J, Isobe M
J Cardiovasc Electrophysiol: 24 Nov 2022; epub ahead of print | PMID: 36423234
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<div><h4>3D-guided and ICE-guided transseptal puncture for cardiac ablations: a propensity score match study.</h4><i>Chokesuwattanaskul R, Ananwattanasuk T, Hughey AB, Stuart EA, ... Morady F, Jongnaransin K</i><br /><b>Background</b><br />Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three-dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system-guided TSP and ICE-guided TSP techniques.<br /><b>Methods</b><br />We conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D-guided TSP with patients undergoing ICE-guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate and complications between the groups.<br /><b>Results</b><br />65 patients underwent 3D-guided TSP, and 151 propensity score-matched patients underwent ICE-guided TSP. The TSP success rate was 100% in both 3D-guided and ICE-guided group. Median needle time was 4.00 min (IQR 2.57-5.08) in patients with 3D-guided TSP compared to 4.02 minutes (IQR 2.83-6.95) in those with ICE-guided TSP (p = 0.22). Mean fluoroscopy time was 0.2 minutes (IQR 0.1-0.4) in patients with 3D-guided TSP compared to 1.2 minutes (IQR 0.7-2.2) in those with ICE-guided TSP (p < 0.001). There were no complications related to TSP in both groups.<br /><b>Conclusions</b><br />3D mapping-guided TSP is as safe and effective as ICE-guided TSP without additional cost. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Nov 2022; epub ahead of print</small></div>
Chokesuwattanaskul R, Ananwattanasuk T, Hughey AB, Stuart EA, ... Morady F, Jongnaransin K
J Cardiovasc Electrophysiol: 24 Nov 2022; epub ahead of print | PMID: 36423239
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<div><h4>Mapping for Non-Pulmonary Vein Atrial Fibrillation Sources: The Road to Improved Ablation Outcomes.</h4><i>Krummen DE, Ho G, Hsu JC</i><br /><AbstractText>Since the publication of seminal work demonstrating ablation of AF triggers within the pulmonary veins, significant focus has been placed upon finding adjunctive AF mapping and ablation strategies to improve the targeted treatment of this arrhythmia. Presently, wide-area circumferential ablation to achieve pulmonary vein isolation has become the standard of care for catheter-based management. However, despite significant work, a comprehensive mechanistic understanding of the sustaining mechanisms of AF remains elusive. The present study from Nagase and colleagues provides important insight derived from a multielectrode catheter-based mapping algorithm regarding the spatial relationships between identified targets, regions of low voltage, and complex fractionated atrial electrograms. Being spatially distinct and distributed in both atria, identified sites may represent novel targets for ablation therapy. Additional studies are required to better assess the impact of elimination of such foci. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Nov 2022; epub ahead of print</small></div>
Krummen DE, Ho G, Hsu JC
J Cardiovasc Electrophysiol: 24 Nov 2022; epub ahead of print | PMID: 36423245
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<div><h4>Performance of Two Tools for Pulmonary Vein Occlusion Assessment with a Novel Navigation System in Cryoballoon Ablation Procedure.</h4><i>Qiao Y, Zhao Z, Fu M, Cai X, ... Guo T, Niu G</i><br /><b>Background</b><br />Optimal occlusion of pulmonary vein (PV) is essential for atrial fibrillation (AF) cryoballoon ablation (CBA). The aim of the study was to investigate the performance of two different tools for the assessment of PV occlusion with a novel navigation system in CBA procedure.<br /><b>Methods</b><br />In consecutive patients with paroxysmal AF who underwent CBA procedure with the guidance of the novel 3-dimentional mapping system, the baseline tool, injection tool and pulmonary venography were all employed to assess the degree of PV occlusion, and the corresponding cryoablation parameters were recorded.<br /><b>Results</b><br />In 23 patients (mean age 60.0 + 13.9 years, 56.5% male), a total of 149 attempts of occlusion and 122 cryoablations in 92 PVs were performed. Using pulmonary venography as the gold standard, the overall sensitivity, specificity of the baseline tool was 96.7% (95% CI 90.0% - 99.1%), and 40.5% (95% CI 26.0% - 56.7%), respectively, while the corresponding value of the injection tool was 69.6% (95% CI 59.7% - 78.1%), and 100.0% (95% CI 90.6% - 100.0%), respectively. Cryoablation with optimal occlusion showed lower nadir temperature (baseline tool: -44.3 + 8.4 °C vs -35.1 + 6.5 °C, p < 0.001; injection tool: -46.7 + 6.4 °C vs -38.3 + 9.2 °C, p < 0.001) and longer total thaw time (baseline tool: 53.3 + 17.0 s vs 38.2 + 14.9 s, p = 0.003; injection tool: 58.5 + 15.5 s vs 41.7 + 15.2 s, p < 0.001) compared with those without.<br /><b>Conclusions</b><br />Both tools were able to accurately assess the degree of PV occlusion and predict the acute cryoablation effect, with the baseline tool being more sensitive and the injection tool more specific. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 22 Nov 2022; epub ahead of print</small></div>
Qiao Y, Zhao Z, Fu M, Cai X, ... Guo T, Niu G
J Cardiovasc Electrophysiol: 22 Nov 2022; epub ahead of print | PMID: 36413675
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<div><h4>Effects of different ablation settings on lesion dimensions in an ex vivo swine heart model: baseline impedance, irrigant and electrode configuration.</h4><i>Jiang X, Li S, Xiong Q, Zhang C, ... Chen S, Ling Z</i><br /><b>Introduction</b><br />Intramural or epicardial locations of the arrhythmogenic substrate are regarded as one of the main reasons for radiofrequency (RF) catheter ablation failure. This study aims to conduct a comprehensive analysis of various factors including baseline impedance, irrigant and electrode configuration at similar ablation index value.<br /><b>Methods</b><br />In 12 ex vivo swine hearts, radiofrequency ablation was performed at a target AI value of 500 and a multistep impedance load (100-180Ω) in 4 settings: (1) conventional unipolar configuration with an irrigant of NS; (2) conventional unipolar configuration with an irrigant of HNS; (3) bipolar configuration with an irrigant of NS.; (4) sequential unipolar configuration with an irrigant of NS. The relationships between lesion dimensions and above factors were examined.<br /><b>Results</b><br />Baseline impedance had a strong negative linear correlation with lesion dimensions at a certain AI. The correlation coefficient between baseline impedance and depth, width, and volume were R =-0.890, R =-0.755 and R =-0.813, respectively (P<0.01). There were 10 (total: 10/100, 10%; bipolar: 10/25, 40%) transmural lesions during the whole procedure. Bipolar ablation resulted in significantly deeper lesion than other electrode configurations. Other comparisons in our experiment did not achieve statistical significance.<br /><b>Conclusion</b><br />There is a strong negative linear correlation between baseline impedance and lesion dimensions at a certain AI value. Baseline impedance has an influence on the overall lesion dimensions among irrigated fluid and ablation configurations. Over a threshold impedance of 150Ω, the predictive accuracy of AI can be compromised. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 20 Nov 2022; epub ahead of print</small></div>
Jiang X, Li S, Xiong Q, Zhang C, ... Chen S, Ling Z
J Cardiovasc Electrophysiol: 20 Nov 2022; epub ahead of print | PMID: 36403284
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<div><h4>Prevalence of atrial fibrillation and procedural outcome in patients undergoing catheter ablation for premature ventricular complexes.</h4><i>Zou F, Di Biase L, Mohanty S, Zhang XD, ... Burkhardt JD, Natale A</i><br /><b>Background</b><br />Atrial fibrillation (AF) and premature ventricular complexes (PVC) are common arrhythmias.<br /><b>Objective</b><br />We aimed to investigate AF prevalence in patients with PVC and its impact on PVC ablation outcomes.<br /><b>Methods</b><br />Consecutive patients undergoing PVC ablation at a single institution between 2016-2019 were included and prospectively followed for 2 years. Patients with severe valvular heart disease, hyperthyroidism, malignancy, alcohol use disorder and advanced renal/hepatic diseases were excluded. Twelve-lead electrocardiograms were used to diagnose AF and assess PVC morphology. All PVCs were targeted for ablation using 4-mm irrigated-tip catheters at standardized radiofrequency power guided by 3-D mapping and intra-cardiac echocardiography. Patients were followed with remote monitoring, device interrogations and office visits every 6 months for 2 years. Detection of any PVCs in follow-up was considered as recurrence.<br /><b>Results</b><br />A total of 394 patients underwent PVC ablation and 96 (24%) had concurrent AF. Patients with PVC and AF were significantly older (68.2±10.8 vs 58.3±15.8 years, p<0.001), had lower LV ejection fraction (43.3±13.3% vs 49.6±12.4%, p<0.001), higher CHA<sub>2</sub> DS<sub>2</sub> -VASc (2.8±1.3 vs 2.0±1.3, p<0.001) than those without. PVCs with ≥2 morphologies were detected in 60.4% and 13.7% patients with vs without AF (p<0.001). At 2-year follow-up, PVC recurrence rate was significantly higher in patients with vs without AF (17.7% vs 9.4%, p=0.02).<br /><b>Conclusion</b><br />AF was documented in 1/4 of patients undergoing PVC ablation and was associated with lower procedural success at long-term follow up. This was likely attributed to older age, worse LV function and higher prevalence of multiple PVC morphologies in patients with concurrent AF. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Nov 2022; epub ahead of print</small></div>
Zou F, Di Biase L, Mohanty S, Zhang XD, ... Burkhardt JD, Natale A
J Cardiovasc Electrophysiol: 15 Nov 2022; epub ahead of print | PMID: 36378783
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<div><h4>Rationale and Design of the Lead EvaluAtion for Defibrillation and Reliability (LEADR) Study: Safety and Efficacy of a Novel ICD Lead Design.</h4><i>Crossley GH, Sanders P, De Filippo P, Tarakji KG, ... Maus B, Holloman K</i><br /><b>Background</b><br />Implantable cardioverter defibrillators (ICD) are indicated for primary and secondary prevention of sudden cardiac arrest. Despite enhancements in design and technologies, the ICD lead is the most vulnerable component of the ICD system and failure of ICD leads remains a significant clinical problem. A novel, small diameter, lumenless, catheter delivered, defibrillator lead was developed with the aim to improve long term reliability.<br /><b>Methods and results</b><br />The Lead Evaluation for Defibrillation and Reliability (LEADR) study is a multi-center, single-arm, Bayesian, adaptive design, pre-market interventional pivotal clinical study. Up to 60 study sites from around the world will participate in the study. Patients indicated for a de novo ICD will undergo defibrillation testing at implantation and clinical assessments at baseline, implant, pre-hospital discharge, 3 months, 6 months, and every 6 months thereafter until official study closure. Patients may be participating for a minimum of 18 months to approximately 3 years. Fracture-free survival will be evaluated using a Bayesian statistical method that incorporates both virtual patient data (combination of bench testing to failure with in-vivo use condition data) with clinical patients. The clinical subject sample size will be determined using decision rules for number of subject enrollments and follow-up time based upon the observed number of fractures at certain time points in the study. The adaptive study design will therefore result in a minimum of 500 and a maximum of 900 patients enrolled.<br /><b>Conclusion</b><br />The LEADR Clinical Study was designed to efficiently provide evidence for short- and long-term safety and efficacy of a novel lead design using Bayesian methods including a novel virtual patient approach. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Nov 2022; epub ahead of print</small></div>
Crossley GH, Sanders P, De Filippo P, Tarakji KG, ... Maus B, Holloman K
J Cardiovasc Electrophysiol: 15 Nov 2022; epub ahead of print | PMID: 36378803
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Abstract
<div><h4>Optimal local impedance parameters for successful pulmonary vein isolation in patients with atrial fibrillation.</h4><i>Fukaya H, Mori H, Oikawa J, Kawano D, ... Kato R, Fukamizu S</i><br /><b>Background</b><br />Local impedance (LI) parameters of IntellaNav STABLEPOINT for successful pulmonary vein isolation (PVI) of atrial fibrillation (AF) remain unclear. The purpose of this study was to seek LI data achieving successful PVI.<br /><b>Methods</b><br />Consecutive AF patients who underwent catheter ablation with STABLEPOINT were prospectively enrolled in two centers. PVI was performed under a constant 35-or 40-watt power, 20-second duration, and >5-gram contact force. The operators were blinded to the LI data. The characteristics of all ablation points with/without conduction gaps (Unsuccess or Success tags) after the first-attempt PVI were evaluated for the right/left PVs and anterior/posterior wall (RPV/LPV and AW/PW, respectively), and cutoff values of LI data were calculated for successful lesion formation.<br /><b>Results</b><br />A total of 5,257 ablation points in 102 patients (65 [58-72] years old, 65.7% male) were evaluated. The LI drop values were higher in the Success tags than Unsuccess tags on the LPV-AW and RPV-AW/PW (p<0.001), except for the LPV-PW (p=0.105). The %LI drop values (LI drop/initial LI) were higher for the Success tags in all areas (15.8 [12.2-19.6] vs. 11.6 [9.7-15.6]% in LPV-AW: p<0.001, 15.0 [11.5-19.3] vs. 11.4 [8.7-17.3]% in LPV-PW: p=0.035, 15.3 [11.5-19.4] vs. 9.9 [8.1-13.7]% in RPV-AW: p<0.001, and 13.3 [10.1-17.4] vs. 8.1 [6.3-9.5]% in RPV-PW, p<0.001). The LI drop and %LI drop cutoff values were 20.0 ohms and 11.6%, respectively.<br /><b>Conclusions</b><br />An insufficient LI drop with STABLEPOINT was associated with a gap formation during PVI, and the best cutoff values for the LI drop and %LI drop were 20.0 ohms and 11.6%, respectively. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Nov 2022; epub ahead of print</small></div>
Fukaya H, Mori H, Oikawa J, Kawano D, ... Kato R, Fukamizu S
J Cardiovasc Electrophysiol: 15 Nov 2022; epub ahead of print | PMID: 36378816
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<div><h4>Contact force catheter ablation for the treatment of Persistent Atrial Fibrillation: Results from the Persist-End Study.</h4><i>Lo M, Nair D, Mansour M, Calkins H, ... Li J, Natale A</i><br /><b>Introduction</b><br />Use of a novel magnetic sensor enabled optical contact force ablation catheter has been established to be safe and effective for treatment of symptomatic drug-refractory paroxysmal AF but has yet to be demonstrated in the persistent AF (PersAF) population.<br /><b>Methods</b><br />PERSIST-END was a multicenter, prospective, non-randomized, investigational study designed to demonstrate the safety and effectiveness of TactiCath™ Ablation Catheter, Sensor Enabled™(SE) (TactiCath SE) for use in the treatment of subjects with documented PersAF refractory or intolerant to at least one Class I/III AAD. The ablation strategy included pulmonary vein isolation and additional targets at physician discretion. Follow-up through 15-months, including a 3-month blanking period and 3-month therapy consolidation period, was performed with cardiac event and Holter monitoring. Primary safety, primary effectiveness, clinical success, and quality of life (QOL) endpoints were analyzed.<br /><b>Results</b><br />Of 224 subjects enrolled at 21 investigational sites in the US and Australia, 223 underwent ablation with the investigational catheter. The primary safety event rate was 3.1% (7 events in 7 subjects). The Kaplan-Meier estimate of freedom from AF/AFL/AT recurrence at 15-months was 61.6% and clinical success at 15 months was 89.8%. Subject QOL significantly improved following ablation as assessed via AFEQT (31.6 point increase, p<0.0001) and EQ-5D-5L (10.7 point increase, p<0.0001) and was met with a 53% reduction in all cause cardiovascular healthcare utilization.<br /><b>Conclusion</b><br />The sensor-enabled force-sensing catheter is safe and effective for the treatment of drug refractory recurrent symptomatic PersAF, reducing arrhythmia recurrence while improving QOL and healthcare utilization. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print</small></div>
Lo M, Nair D, Mansour M, Calkins H, ... Li J, Natale A
J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print | PMID: 36352771
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<div><h4>Long conduction time from the anterior left atrium to coronary sinus during entrainment pacing of a bi-atrial tachycardia: What is the mechanism?</h4><i>Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, ... Nishino M, Tanouchi J</i><br /><AbstractText>A 79-year-old man with ischemic heart disease underwent catheter ablation of persistent atrial tachycardia (AT). This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print</small></div>
Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, ... Nishino M, Tanouchi J
J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print | PMID: 36349703
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<div><h4>Effects of Radiofrequency Catheter Ablation for Premature Ventricular Complexes Originating from the Right Ventricular Outflow Tract on Right Ventricular Function.</h4><i>Uhm JS, Ko KY, Shim CY, Park JW, ... Pak HN, Lee MH</i><br /><b>Introduction</b><br />This study aimed to elucidate the relationship between premature ventricular complexes (PVCs) and right ventricular (RV) dysfunction, and the effects of radiofrequency catheter ablation (RFCA) on RV function.<br /><b>Methods</b><br />A total of 110 patients (age, 50.8 ± 14.4 years; 30 men) without structural heart disease who had undergone RFCA for RV outflow tract (RVOT) PVCs were retrospectively included. RV function was assessed using fractional area change (FAC) and global longitudinal strain (GLS) before and after RFCA. Clinical data were compared between the RV dysfunction (n = 63) and preserved RV function (n = 47) groups. The relationship between PVC burden and RV function was analyzed. Change in RV function before and after RFCA was compared between patients with successful and failed RFCA.<br /><b>Results</b><br />PVC burden was significantly higher in the RV dysfunction group than in the preserved RV function group (p < 0.001). FAC and GLS were significantly worse in proportion to PVC burden (p < 0.001 and p < 0.001, respectively). The risk factor associated with RV dysfunction was PVC burden [odds ratio (95% confidence interval), 1.092 (1.052-1.134); p < 0.001]. Improvement in FAC (13.0 ± 8.7% and -2.5 ± 5.6%, respectively; p < 0.001) and GLS (-6.8 ± 5.7% and 2.1 ± 4.2%, respectively; p < 0.001) was significant in the patients with successful RFCA, compared to the patients in whom RFCA failed.<br /><b>Conclusions</b><br />Frequent RVOT PVCs are associated with RV dysfunction. RV dysfunction is reversible by successful RFCA. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print</small></div>
Uhm JS, Ko KY, Shim CY, Park JW, ... Pak HN, Lee MH
J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print | PMID: 36349711
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<div><h4>Atrial fibrillation detection using insertable cardiac monitor after stroke: a real-word cohort study.</h4><i>Noubiap JJ, Thomas G, Middeldorp ME, Fitzgerald JL, Harper C, Sanders P</i><br /><b>Objective</b><br />This study aimed to report the real-word AF diagnostic yield of implantable cardiac monitor (ICM) in patients with stroke or transient ischemic attack (TIA), and compare it to patients with an ICM for unexplained syncope.<br /><b>Methods</b><br />We used patient data from device clinics across the USA with ICM remote monitoring via PaceMate™, implanted for stroke or TIA, and unexplained syncope. Patients with known AF or atrial flutter were excluded. The outcome was AF lasting ≥2 min, adjudicated by IBHRE certified cardiac device specialists.<br /><b>Results</b><br />We included a total of 2469 patients, 51.1% with stroke or TIA [mean age 69.7 (SD 12.2) years, 41.1% female] and 48.9% with syncope [mean age 67.0 (SD 17.1) years, 59.4% female. The cumulative AF detection rate in patients with stroke or TIA was 5.5%, 8.9%, and 14.0% at 12, 24, and 36 months, respectively. The median episode duration was 73 (IQR 10-456) min, ranging from 2 minutes to 40.9 days, with 52.3%, 28.6% and 4.4% of episodes lasting at least 1 hour, 6 hours and 24 hours, respectively. AF detection was increased by age (adjusted hazard ratio [for every 1-year increase] 1.024, 95% CI: 1.008-1.040; p=0.003), but was not influenced by sex (p=0.089). For comparison, the cumulative detection rate at 12, 24, and 36 months were respectively 2.4%, 5.2%, and 7.4% in patients with syncope.<br /><b>Conclusion</b><br />Patients with stroke or TIA have a higher rate of AF detection. However, this real-world study shows significantly lower AF detection rates to what has been previously reported. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print</small></div>
Noubiap JJ, Thomas G, Middeldorp ME, Fitzgerald JL, Harper C, Sanders P
J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print | PMID: 36349715
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<div><h4>Risk stratification of ventricular fibrillation in patients with symptomatic Brugada syndrome using pharmacological tests.</h4><i>Kawano K, Shinohara T, Kondo H, Ishii Y, ... Nakagawa M, Takahashi N</i><br /><b>Background</b><br />Brugada syndrome (BrS), which is characterized by J-point elevation in right precordial leads of 12-lead electrocardiogram, is associated with the occurrence of ventricular fibrillation (VF). However, risk stratification of VF in patients with BrS remains challenging.<br /><b>Objective</b><br />The aim of this study was to identify a risk predictor of VF in patients with BrS using pharmacological tests.<br /><b>Methods</b><br />Twenty-one consecutive patients with BrS and history of documented spontaneous VF (n = 16) or syncope presumed to be caused by lethal ventricular arrhythmia (n = 5) were enrolled. J-wave changes in response to intravenous verapamil, propranolol, and pilsicainide were separately assessed.<br /><b>Results</b><br />uring the median follow-up period of 86.0 months, eight patients had VF recurrence (recurrence group) and 13 patients did not have VF recurrence (non-recurrence group). Intravenous propranolol injection induced significant J-wave augmentation (i.e., increase in amplitude >0.1 mV) in the inferior and/or lateral leads in the recurrence group compared to the non-recurrence group (P = 0.048 and P = 0.015, respectively). Kaplan-Meier analysis revealed that VF recurrence is significantly higher in patients with BrS and J-wave augmentation due to intravenous propranolol than in patients without J-wave augmentation (P = 0.014).<br /><b>Conclusion</b><br />The study results show that propranolol-induced J-wave augmentation is involved in the risk of VF in patients with BrS. The results suggest that early repolarization patterns in response to pharmacological tests may be useful for risk stratification of VF in patients with symptomatic BrS. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print</small></div>
Kawano K, Shinohara T, Kondo H, Ishii Y, ... Nakagawa M, Takahashi N
J Cardiovasc Electrophysiol: 09 Nov 2022; epub ahead of print | PMID: 36352766
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<div><h4>Clinical Outcomes of Radiofrequency Catheter Ablation of Ventricular Tachycardia in Patients with Hypertrophic Cardiomyopathy.</h4><i>Garg J, Kewcharoen J, Shah K, Turagam M, ... Mandapati R, Lakkireddy D</i><br /><b>Background</b><br />Monomorphic ventricular tachycardia (VT) is rare in patients with hypertrophic cardiomyopathy (HCM), management of which is challenging. Limited data exists on the utility of catheter ablation for the treatment of VT in this population.<br /><b>Objectives</b><br />We aimed to assess clinical outcomes of catheter ablation for VT in HCM patients <br /><b>Methods:</b><br/>A systematic search, without language restriction, using PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov was performed. The meta-analysis was performed using a meta-package for R version 4.0/RStudio version 1.2 and Freeman Tukey double arcsine method to establish the variance of raw proportions. Outcomes measured included 1) acute procedure success (defined as non-inducible for clinical VT), 2) freedom from VT at follow-up, 3) mortality.<br /><b>Results</b><br />This systematic review of six studies (three from US and three from Japan) incorporated a total of 68 drug-refractory HCM patients who underwent VT radiofrequency catheter ablation (mean age 57.6±13.3 years, mean LVEF 45.8±15.4%, 85% men, maximum septal wall thickness 17.4±4.6 mm, and 32.3% with an apical aneurysm). Acute procedural success was achieved in 84.5% patients (95% CI 70.6-95.2%) with 27.9% patients had recurrent VT requiring multiple ablations (median 1, IQR 1-3). During the follow-up period (18.3±11.7 months), the pooled incidence of freedom from recurrent VT after index procedure was 70.2% (95% CI 51.9-86.2%), while after the last ablation was 82.8% (95% 57-99.2%). There were two deaths during follow-up, one from heart failure and one from SCD 0.8% (95% CI 0-5.8%).<br /><b>Conclusion</b><br />The results of our pooled analysis demonstrated that catheter ablation for VT in HCM patients was associated with high acute procedural success, and reduced VT recurrence - findings comparable to previously published reports in other disease substrates. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print</small></div>
Garg J, Kewcharoen J, Shah K, Turagam M, ... Mandapati R, Lakkireddy D
J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print | PMID: 36335616
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<div><h4>Impact of different activation wavefronts on ischemic myocardial scar electrophysiological properties during high-density ventricular tachycardia mapping and ablation.</h4><i>Lima da Silva G, Cortez-Dias N, Nunes Ferreira A, Nakar E, ... Pinto FJ, de Sousa J</i><br /><b>Introduction:</b><br/>and objective</b><br />Scar-related ventricular tachycardia (VT) usually results from an underlying reentrant circuit facilitated by anatomical and functional barriers. The later are sensitive to the direction of ventricular activation wavefronts. We aim to evaluate the impact of different ventricular activation wavefronts on the functional electrophysiological properties of myocardial tissue.<br /><b>Methods</b><br />Patients with ischemic heart disease referred for VT ablation underwent high-density mapping using Carto®3 (Biosense Webster). Maps were generated during sinus rhythm, right and left ventricular pacing, and analyzed using a new late potential map software, which allows to assess local conduction velocities (LCV) and facilitates the delineation of intra-scar conduction corridors (ISCC); and for all stable VTs.<br /><b>Results</b><br />In 16 patients, 31 high-resolution substrate maps from different ventricular activation wavefronts and 7 VT activation maps were obtained. Local abnormal ventricular activities (LAVAs) were found in VT isthmus, but also in non-critical areas. The VT isthmus was localized in areas of LAVAs overlapping surface between the different activation wavefronts. The deceleration zone location differed depending on activation wavefronts. Sixty six percent of ISCCs were similarly identified in all activating wavefronts, but the one acting as VT isthmus was simultaneously identified in all activation wavefronts in all cases.<br /><b>Conclusion</b><br />Functional based substrate mapping may improve the specificity to localize the most arrhythmogenic regions within the scar, making the use of different activation wavefronts unnecessary in most cases. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print</small></div>
Lima da Silva G, Cortez-Dias N, Nunes Ferreira A, Nakar E, ... Pinto FJ, de Sousa J
J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print | PMID: 36335623
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<div><h4>Recurrences of tachycardia after repeated slow pathway ablation: What is the diagnosis?</h4><i>Vijay S, Shah H, Lokhandwala Y</i><br /><AbstractText>A 30-year-old man with a structurally normal heart was referred to us with a 2-year history of recurrent episodes of rapid paroxysmal palpitations This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print</small></div>
Vijay S, Shah H, Lokhandwala Y
J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print | PMID: 36335625
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<div><h4>Long QT begets long QT.</h4><i>Viskin S</i><br /><AbstractText>Although the congenital and the drug-induced long QT syndromes (LQTS) were first recognized This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print</small></div>
Viskin S
J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print | PMID: 36335630
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<div><h4>Multiple Wavefront Substrate Mapping Using a Novel Late Potential Mapping Algorithm: Can One Wavefront Rule Them All?</h4><i>Hawson J, Lee G</i><br /><AbstractText>Catheter ablation is now part of standard care for patients with structural heart disease and ventricular tachycardia (VT) This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print</small></div>
Hawson J, Lee G
J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print | PMID: 36335631
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<div><h4>Outcomes of Catheter Ablation for Ventricular Tachycardia in Patients with Sarcoidosis: Insights from the National Inpatient Sample Database (2002-2018).</h4><i>Tan JL, Jin C, Lee JZ, Gaughan J, Iwai S, Russo AM</i><br /><b>Background</b><br />Data on utilization, major complications, and in-hospital mortality of catheter ablation (CA) for sarcoidosis-related ventricular tachycardia (VT) are limited. We sought to determine the outcomes of sarcoidosis-related VT, and incidence and predictors of complications associated with the CA procedure.<br /><b>Methods</b><br />We queried the 2002-2018 National Inpatient Sample database to identify patients aged ≥18 years with sarcoidosis admitted with VT. 1:3 propensity score-matched (PSM) analysis was used to compare patient outcomes between CA and medically managed groups. Multivariable regression was performed to determine independent predictors of in-hospital mortality and procedural complications associated with the CA procedure.<br /><b>Results</b><br />Of 3220 sarcoidosis patients with VT, 132 (4.1%) underwent CA. Patients who underwent CA were younger, male predominant, more likely Caucasian, had differences in baseline comorbidities including more likely to have heart failure, less likely to have prior MI, COPD, or severe renal disease, had a higher mean household income, and more likely admitted to a larger/urban teaching hospital. After PSM, we examined 106 CA cases and 318 medically managed cases. There was a trend toward a lower in-hospital mortality rate in the CA group when compared to the medically managed group (1.9% vs 6.6%, P = 0.08). The most common complications were pericardial drainage (5.3%), postoperative hemorrhage (3.8%), accidental puncture peri-procedure (3.0%), and cardiac tamponade (2.3%). Independent predictors of in-hospital mortality and procedural complications among the CA group included congestive heart failure (OR, 13.2; 95% CI, 1.7-104.2) and mild to moderate renal disease (OR, 3.9; 95% CI, 1.1-13.3).<br /><b>Conclusions</b><br />Compared to patients with sarcoidosis-related VT who received medical therapy alone, those who underwent CA have a trend for lower mortality rate despite procedure-related complications occurring as high as 9.1%. Additional studies are recommended to better evaluate the benefits and risks of VT ablation in this group. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print</small></div>
Tan JL, Jin C, Lee JZ, Gaughan J, Iwai S, Russo AM
J Cardiovasc Electrophysiol: 06 Nov 2022; epub ahead of print | PMID: 36335632
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