Journal: J Cardiovasc Electrophysiol

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Abstract

Psychometric evaluation of the Implantable Cardioverter Defibrillator Body Image Concerns Questionnaire (ICD-BICQ).

Frydensberg VS, Johansen JB, Möller S, Strömberg A, Pedersen SS
Background
Patients receiving an implantable cardioverter defibrillator (ICD) generally adapt well to living with their device, but we know little about the prevalence of patients\' body image concerns (BICs) post implant.
Methods
The objectives were to evaluate the psychometric properties of the ICD-BICQ, find a cut-off indicating BICs and determine the prevalence of BICs. Construct validity was determined using the Kaiser-Meyer-Olkin test, Scree-plot and Explorative Factor Analysis. Internal consistency was examined via Cronbach\'s alpha. Correlations to other validated questionnaires, a weighted and simple scale and a cut-off indicating BICs was evaluated.
Results
In total, 331 patients completed the 39-item ICD-BICQ together with: Type D Scale (DS14), Generalized Anxiety Disorder scale (GAD-7), Patient Health Questionnaire (PHQ-9), and Florida Patient Acceptance Survey (FPAS). Five patients were excluded due to reoperations, leaving 326 patients in the analyses. Results revealed a one-factor structure with 32 items and Cronbach\'s alpha at 0.948. A cut-off at 36 points displayed the 20% patients with the highest score of BICs. The prevalence was 29.8 % in women and 18.4 % in men.
Conclusion
The psychometric evaluation of the 32-item ICD-BICQ showed acceptable construct validity and internal reliability. We recommend a cut-off score at 36 points to identify patients at risk of having BICs. The prevalence of BICs indicated that both men and women are at risk of having BICs. The ICD-BICQ can be used in clinical practice to help healthcare professionals to identify patients at risk of BICs and as to evaluate BICs when implementing new operation techniques. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Jun 2021; epub ahead of print
Frydensberg VS, Johansen JB, Möller S, Strömberg A, Pedersen SS
J Cardiovasc Electrophysiol: 05 Jun 2021; epub ahead of print | PMID: 34091980
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Abstract

Use of infrared thermography to delineate temperature gradients and critical isotherms during catheter ablation with normal and half normal saline: Implications for safety and efficacy.

Huang HD, Ravi V, Rhodes P, Du-Fay-de-Lavallaz JM, ... Sharma PS, Larsen TR
Background
Radiofrequency (RF) ablation with half-normal saline (HNS) has shown promise as a bail-out strategy following failed ventricular tachycardia ablation using standard approaches.
Objective
To use a novel infrared thermal imaging (ITI) model to evaluate biophysical and lesion characteristics during RF ablation using normal saline (NS) and HNS irrigation.
Methods
Left ventricular strips of myocardium were excised from fresh porcine hearts. RF ablation was performed using an open-irrigated ablation catheter (Thermocool ST/SF) with NS (n = 75) and HNS (n = 75) irrigation using different power settings (40/50 W), RF durations (30/60 s), contact force of 10-15 g, and flow rate of 15 ml/min. RF lesions were recorded using an infrared thermal camera and border zone, lethal, 100° isotherms were matched with necrotic borders after 2% triphenyltetrazolium chloride staining. Lesion dimensions and isotherms (mm2 ) were measured.
Results
In total, 150 lesions were delivered. HNS lesions were deeper (6.4 ± 1.1 vs. 5.7 ±0.8 mm; p = .03), and larger in volume (633 ± 153 vs. 468 ± 107 mm3 ; p = .007) than NS lesions. Steam pops (SPs) occurred during 19/75 lesions (25%) in the NS group and 32/75 lesions (43%) in the HNS group (p = .34). Lethal (57.8 ± 6.5 vs. 36.0 ± 3.9 mm2 ; p = .001) and 100°C isotherm areas (16.9 ± 6.9 vs. 3.8 ± 4.2 mm2 ; p = .003) areas were larger and were reached earlier in the HNS group.
Conclusions
RFA using HNS created larger lesions than NS irrigation but led to more frequent SPs. The presence of earlier lethal isotherms and temperature rises above 100°C on ITI suggest a potentially narrower therapeutic-safety window with HNS.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 31 May 2021; epub ahead of print
Huang HD, Ravi V, Rhodes P, Du-Fay-de-Lavallaz JM, ... Sharma PS, Larsen TR
J Cardiovasc Electrophysiol: 31 May 2021; epub ahead of print | PMID: 34061411
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Abstract

Delayed pericardial effusion after left atrial appendage closure with the LAmbre device: Importance of a fully open umbrella.

Xiao F, Chen Y, Chen Y, Zhou X, ... Su L, Huang W
Introduction
We aimed to investigate whether a modified implantation method facilitating a fully open umbrella can reduce the pericardial effusion/pericardial tamponade (PE/PT) rate after left atrial appendage closure (LAAC) with the LAmbre device compared with the conventional method (CM) in patients with non-valvular atrial fibrillation (NVAF).
Methods and results
Patients with NVAF who received either isolated LAAC or combined catheter ablation and LAAC using the LAmbre device at the First Affiliated Hospital of Wenzhou Medical University from January 2018 to December 2019 were enrolled. CM was used for device implantation in the initial 59 patients, while a modified method (MM) was used in the remaining 165 patients. Successful implantation was achieved in 98.3% of patients in the CM group and 98.8% in the MM group. A higher rate of a fully open umbrella (98.8% vs. 69%, p < .001), less requirement for recapture (46% vs. 62.1%, p = .036), and a lower incidence of delayed PE/PT (1.2% vs. 8.6%, p = .005) were found in the MM group compared with the CM group. All of the five delayed PT events occurred in patients with combined treatment. An umbrella that was not fully open was the only factor associated with delayed PE/PT events in a multivariable Cox model.
Conclusions
LAAC with the LAmbre device using an MM significantly increases the rate of a fully open umbrella and decreases the requirement for recapture and the incidence of delayed PE/PT. This method is more effective in patients with combined treatment.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1646-1654
Xiao F, Chen Y, Chen Y, Zhou X, ... Su L, Huang W
J Cardiovasc Electrophysiol: 30 May 2021; 32:1646-1654 | PMID: 33783902
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Abstract

Unipolar electrogram-based voltage mapping with far-field cancellation to improve detection of abnormal atrial substrate during atrial fibrillation.

Ragot D, Nayyar S, Massin SZ, Ha ACT, ... Dalvi R, Chauhan VS
Introduction
An important substrate for atrial fibrillation (AF) is fibrotic atrial myopathy. Identifying low voltage, myopathic regions during AF using traditional bipolar voltage mapping is limited by the directional dependency of wave propagation. Our objective was to evaluate directionally independent unipolar voltage mapping, but with far-field cancellation, to identify low-voltage regions during AF.
Methods
In 12 patients undergoing pulmonary vein isolation for AF, high-resolution voltage mapping was performed in the left atrium during sinus rhythm and AF using a roving 20-pole circular catheter. Bipolar electrograms (EGMs) (Bi) < 0.5 mV in sinus rhythm identified low-voltage regions. During AF, bipolar voltage and unipolar voltage maps were created, the latter with (uni-res) and without (uni-orig) far-field cancellation using a novel, validated least-squares algorithm.
Results
Uni-res voltage was ~25% lower than uni-orig for both low voltage and normal atrial regions. Far-field EGM had a dominant frequency (DF) of 4.5-6.0 Hz, and its removal resulted in a lower DF for uni-orig compared with uni-res (5.1 ± 1.5 vs. 4.8 ± 1.5 Hz; p < .001). Compared with Bi, uni-res had a significantly greater area under the receiver operator curve (0.80 vs. 0.77; p < .05), specificity (86% vs. 76%; p < .001), and positive predictive value (43% vs. 30%; p < .001) for detecting low-voltage during AF. Similar improvements in specificity and positive predictive value were evident for uni-res versus uni-orig.
Conclusion
Far-field EGM can be reliably removed from uni-orig using our novel, least-squares algorithm. Compared with Bi and uni-orig, uni-res is more accurate in detecting low-voltage regions during AF. This approach may improve substrate mapping and ablation during AF, and merits further study.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1572-1583
Ragot D, Nayyar S, Massin SZ, Ha ACT, ... Dalvi R, Chauhan VS
J Cardiovasc Electrophysiol: 30 May 2021; 32:1572-1583 | PMID: 33694221
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Abstract

Wall thickness-based adjustment of ablation index improves efficacy of pulmonary vein isolation in atrial fibrillation: Real-time assessment by intracardiac echocardiography.

Motoike Y, Harada M, Ito T, Nomura Y, ... Ozaki Y, Izawa H
Background
Ablation index (AI) linearly correlates with lesion depth and may yield better therapeutic performance in pulmonary vein isolation (PVI) when tailored to a patient\'s wall thickness (WT) in the left atrium (LA).
Methods and results
First study: In paroxysmal atrial fibrillation patients (PAF; n = 20), the average LA WT (mm) in each anatomical segment for PVI was measured by intracardiac echocardiography (ICE) placed in the LA; the optimal AI for creating 1-mm transmural lesion (AI/mm) was calculated. Second study: PAF (n = 80) patients were randomly assigned either to a force-time integral protocol (FTI; 400 g·s, n = 40) or a tailored-AI protocol (TAI; n = 40). In TAI, the LA WT in each segment was individually measured by ICE before starting ablation; a target AI was adjusted according to the individual WT in each segment (AI/mm × WT). The acute procedure outcomes and the 1-year AF-recurrence rate were compared between FTI and TAI. TAI had higher success rate of first-pass isolation (88% vs. 65%) and had lower incidence of residual PV-potentials/conduction-gaps after a circular ablation than FTI (15% vs. 45%). The procedure time to complete PVI decreased in TAI compared to FTI (52 vs. 83 min), being attributed to the increased radiofrequency power and the decreased radiofrequency application time in each point in TAI. TAI had a lower 1-year AF-recurrence rate than FTI.
Conclusion
TAI increased acute procedure success, decreased time for PVI, and reduced the 1-year AF-recurrence rate, compared to FTI. Understanding the precise ablation target and tailoring AI would improve the efficacy of PVI.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1620-1630
Motoike Y, Harada M, Ito T, Nomura Y, ... Ozaki Y, Izawa H
J Cardiovasc Electrophysiol: 30 May 2021; 32:1620-1630 | PMID: 33694206
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Abstract

Utility of fluoroscopy alone for monitoring of intrathoracic bleeding complications during transvenous lead extraction.

Issa ZF, Issa TZ
Background
Transvenous lead extraction (TLE) carries a significant risk of major complications, namely bleeding into the pericardial sac or thoracic cavity. While echocardiographic imaging has been recommended for intraprocedural monitoring for those complications, no studies had examined the potential benefits of fluoroscopy alone as an alternative to echocardiography. The aim of this study was to evaluate the utility of fluoroscopy for monitoring intrathoracic bleeding complications during TLE.
Methods
This is a single-center retrospective study of consecutive patients who underwent TLE of a pacemaker or ICD lead with fluoroscopy-only monitoring. At the beginning of each TLE procedure, baseline fluoroscopic images were obtained for both lung fields and the cardiac silhouette. Similar images were acquired again when hypotension develops during the procedure.
Results
Fluoroscopy alone (without echocardiographic imaging) was used in 783 consecutive patients (54% women; average age, 71.5 ± 12.9 years) who underwent TLE. There were 93 patients (11.9%) who experienced significant hypotension. Fluoroscopy showed no obvious cause for hypotension in 63 patients. Right ventricular inversion was implied by fluoroscopy in 27 patients. Fluoroscopy detected new pericardial effusion in two patients and new right pleural effusion in one patient, which prompted halting the extraction procedure and therapeutic intervention. Additionally, routine fluoroscopic images revealed the development of an unsuspected new small left pleural effusion in one patient and a pericardial effusion in another. In-hospital mortality rate was 0%.
Conclusions
In selected patients undergoing TLE, fluoroscopy can provide valuable information for identifying or excluding cardiovascular causes during periods of intraprocedural hemodynamic instability.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1724-1732
Issa ZF, Issa TZ
J Cardiovasc Electrophysiol: 30 May 2021; 32:1724-1732 | PMID: 33709412
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Abstract

Efficacy of catheter ablation for premature ventricular contractions in arrhythmogenic right ventricular cardiomyopathy.

Assis FR, Sharma A, Daimee UA, Murray B, ... Calkins H, Tandri H
Background
Premature ventricular contractions (PVCs) may be found in any stage of arrhythmogenic right ventricular cardiomyopathy (ARVC) and have been associated with the risk of sustained ventricular tachycardia (VT).
Objective
To investigate the role of PVC ablation in ARVC patients.
Methods
We studied consecutive ARVC patients who underwent PVC ablation due to symptomatic high PVC burden. Mean daily PVC burden and antiarrhythmic drug (AAD) use were assessed before and after the procedure. Complete long-term success was defined as more than 80% reduction in PVC burden off of membrane-active AADs.
Results
Eight patients (37 ± 15 years; 4 males) underwent PVC ablation. The mean daily PVC burden before ablation ranged from 5.4% to 24.8%. A total of 7 (87.5%) patients underwent epicardial ablation. Complete acute elimination of PVCs was achieved in 4 (50%) patients (no complications). The mean daily PVC burden variation ranged from an 87% reduction to a 26% increase after the procedure. Over a median follow-up of 345 days (range: 182-3004 days), only one (12.5%) patient presented complete long-term success, and 6 (75%) patients either maintained or increased the need for Class I or Class III AADs. A total of 2 (25%) patients experienced sustained VT for the first time following the ablation procedure, requiring repeat ablation. No death or heart transplantation occurred.
Conclusion
PVC ablation was not associated with a consistent reduction of the PVC burden in ARVC patients with symptomatic, frequent PVCs. PVC ablation may be reserved for highly symptomatic patients who failed AADs. Additional investigation is required to improve the efficacy of PVC ablation in ARVC patients.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1665-1674
Assis FR, Sharma A, Daimee UA, Murray B, ... Calkins H, Tandri H
J Cardiovasc Electrophysiol: 30 May 2021; 32:1665-1674 | PMID: 33783912
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Abstract

Experience and procedural efficacy of pulmonary vein isolation using the fourth and second generation cryoballoon: The shorter, the better?

Heeger CH, Bohnen JE, Popescu S, Meyer-Saraei R, ... Vogler J, Richard Tilz R
Background
The second-generation cryoballoon (CB2) provides effective and durable pulmonary vein isolation (PVI) associated with encouraging clinical outcome. The novel fourth-generation cryoballoon (CB4) incorporates a 40% shorter distal tip. This design change may translate into an increased rate of PVI real-time signal recording, facilitating an individualized ablation strategy using the time to effect (TTE).
Methods and results
Three hundred consecutive patients with paroxysmal or persistent atrial fibrillation were prospectively enrolled. The first 150 consecutive patients underwent CB2 based PVI (CB2 group) and the last 150 consecutive patients were treated with the CB4 (CB4 group). A total of 594/594 (100%, CB4) and 589/594 (99.2%, CB2) pulmonary veins (PVs) were successfully isolated utilizing the CB4 and CB2, respectively (p = .283). The real-time PVI visualization rate was 47% (CB4) and 39% (CB2; p = .005) and the mean freeze cycle duration 200 ± 90 s (CB4) and 228 ± 110 s (CB2; p < .001), respectively. The total procedure time did not differ between the groups (CB4: 64 ± 32 min) and (CB2: 62 ± 29 min, p = .370). No differences in periprocedural complications were detected.
Conclusions
A higher rate of real-time electrical PV recordings are seen using the CB4 as compared to CB2, which may facilitate an individualized ablation strategy using the TTE.

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

J Cardiovasc Electrophysiol: 30 May 2021; 32:1553-1560
Heeger CH, Bohnen JE, Popescu S, Meyer-Saraei R, ... Vogler J, Richard Tilz R
J Cardiovasc Electrophysiol: 30 May 2021; 32:1553-1560 | PMID: 33760304
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Abstract

Limited duration of antiarrhythmic drug use for newly diagnosed atrial fibrillation in a nationwide population under age 65.

D\'Angelo RN, Rahman M, Khanna R, Yeh RW, ... Tung P, Zimetbaum PJ
Introduction
Antiarrhythmic drugs (AADs) are commonly used for the treatment of newly diagnosed symptomatic atrial fibrillation (AF), however initial AAD choice, duration of therapy, rates of discontinuation, and factors associated with a durable response to therapy are poorly understood. This study assesses the initial choice and duration of antiarrhythmic drug therapy in the first 2 years after diagnosis of AF in a younger, commercially insured population.
Methods
A large nationally representative sample of patients age 20-64 was studied using the IBM MarketScan Database. Patients who started an AAD within 90 days of AF diagnosis with continuous enrollment for 1-year pre-index diagnosis and 2 years post-index were included. A Cox proportional hazards model was used to determine factors associated with AAD discontinuation.
Results
Flecainide was used most frequently (26.8%), followed by amiodarone (22.5%), dronedarone (18.3%), sotalol (15.8%), and propafenone (14.0%), with other AADs used less frequently. Twenty-two percent of patients who started on an AAD underwent ablation within 2 years, with 79% discontinuing the AAD after ablation. Ablation was the strongest predictor of AAD discontinuation (hazard ratio [HR], 1.70; 95% confidence interval [CI]: 1.61-1.80), followed by the male gender (HR, 1.10; CI: 1.02-1.19). Older patients (HR, 0.76; CI: 0.72-0.80; reference age 18-49) and those with comorbidities, including cardiomyopathy (HR, 075; CI: 0.61-0.91), diabetes (HR, 0.83; CI: 0.75-0.91), and hypertension (HR, 0.87; CI: 0.81-0.94) were less likely to discontinue AADs.
Conclusion
Only 31% of patients remained on the initial AAD at 2 years, with a mean duration of initial therapy 7.6 months before discontinuation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1529-1537
D'Angelo RN, Rahman M, Khanna R, Yeh RW, ... Tung P, Zimetbaum PJ
J Cardiovasc Electrophysiol: 30 May 2021; 32:1529-1537 | PMID: 33760297
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Abstract

Direct oral anticoagulants to treat left ventricular thrombus-A systematic review and meta-analysis: ELECTRAM investigators.

Shah S, Shah K, Turagam MK, Sharma A, ... Lakkireddy D, Garg J
Introduction
Though current guidelines currently recommend using warfarin, there is also a growing interest in the utilization of direct oral anticoagulants (DOACs) to treat left ventricular (LV) thrombus.
Methods
We performed a systematic search using PubMed, SCOPUS, EMBASE, Google Scholar, and ClinicalTrials.gov from inception to September 30, 2020, for studies that had reported outcomes in patients with left ventricular thrombus treated with DOACs (PROSPERO registration number CRD42020219761).
Results
Twelve studies (n = 867 patients) were included in the analysis. The pooled incidence of the systemic embolic events (SEE) with DOACs was 2.7%, whereas the thrombus resolution rate was 86.6%. The pooled incidence of overall bleeding (composite of major and minor bleeding) and major bleeding with DOACs were 5.6% and 1.1%, respectively. No significant difference was observed in terms of SEE (OR 0.81, 95% confidence interval [CI] 0.44-1.52, p = .54), major bleeding (OR 0.29, 95% CI 0.07-1.26, p = .24), and failure of LV thrombus resolution (OR 0.86, 95% CI 0.28-2.58, p = .68); whereas overall bleeding was significantly low in patients with LV thrombus treated with DOACs compared to vitamin K antagonists (VKAs) (OR 0.33, 95% CI 0.14-0.81, p = .02).
Conclusion
Our study demonstrates no significant difference in SEE, major bleeding, or failure of LV thrombus resolution between the two groups, thus demonstrating that DOACs are an efficacious and safe alternative for the treatment of LV thrombus compared to VKAs. However, further well-designed prospective trials are needed to answer important clinical questions-optimal dosing/duration of DOACs and its safety in the background of antiplatelet therapy.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1764-1771
Shah S, Shah K, Turagam MK, Sharma A, ... Lakkireddy D, Garg J
J Cardiovasc Electrophysiol: 30 May 2021; 32:1764-1771 | PMID: 33772939
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Abstract

Easily available ECG and echocardiographic parameters for prediction of left atrial remodeling and atrial fibrillation recurrence after pulmonary vein isolation: A multicenter study.

Moreno-Weidmann Z, Müller-Edenborn B, Jadidi AS, Bazan-Gelizo V, ... Arentz T, Viñolas X
Background
The assessment of noninvasive markers of left atrial (LA) low-voltage substrate (LVS) enables the identification of atrial fibrillation (AF) patients at risk for arrhythmia recurrence after pulmonary vein isolation (PVI).
Methods
In this prospective multicenter study, 292 consecutive AF patients (72% male, 62 ± 11 years, 65% persistent AF) underwent high-density LA voltage mapping in sinus rhythm. LA-LVS (<0.5 mV) was considered as significant at 2 cm2  or above. Preprocedural clinical electrocardiogram and echocardiographic data were assessed to identify predictors of LA-LVS. The role of the identified LA-LVS markers in predicting 1-year arrhythmia freedom after PVI was assessed in 245 patients.
Results
Significant LA-LVS was identified in 123 (42%) patients. The amplified sinus P-wave duration (APWD) best predicted LA-LVS, with a 148-ms value providing the best-balanced sensitivity (0.81) and specificity (0.88). An APWD over 160 ms was associated with LA-LVS in 96% of patients, whereas an APWD under 145 ms in 15%. Remaining gray zones improved their accuracy by introduction of systolic pulmonary artery pressure (sPAP) of 35 mmHg or above, age, and sex. According to COX regression, the risk of arrhythmia recurrence 12 months following PVI was twofold and threefold higher in patients with APWD 145-160 and over 160 ms, compared to APWD under 145 ms. Integration of pulmonary hypertension further improved the outcome prediction in the intermediate APWD group: Patients with APWD 145-160 ms and normal sPAP had similar outcome than patients with APWD under 145 ms (hazard ratio [HR] 1.62, p = .14), whereas high sPAP implied worse outcome (HR 2.56, p < .001).
Conclusions
The APWD identifies LA-LVS and risk for arrhythmia recurrence after PVI. Our prediction model becomes optimized by means of integration of the pulmonary artery pressure.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1584-1593
Moreno-Weidmann Z, Müller-Edenborn B, Jadidi AS, Bazan-Gelizo V, ... Arentz T, Viñolas X
J Cardiovasc Electrophysiol: 30 May 2021; 32:1584-1593 | PMID: 33772926
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Abstract

Three-dimensional visualization of bidirectional preferential pathway conduction of premature ventricular contractions originating from the outflow tract.

Yagyu S, Nagashima K, Wakamatsu Y, Otsuka N, ... Hirata S, Okumura Y
Introduction
Preferential pathway conduction is mostly detected as fractionated presystolic-potentials preceding the QRS during premature ventricular contractions (PVCs) and late-potentials during sinus rhythm (SR), but the electrophysiologic mechanisms and significance of these potentials have not been fully clarified. We describe a PVC case series in which the preferential pathway conduction was three-dimensionally visualized.
Methods
Five PVCs (two from the left coronary cusp, two from the commissure of the left and right coronary cusps, and one from the pulmonary artery) in four patients for which a fractionated presystolic-potential during the PVCs and late-potential during SR were recorded at the successful ablation site were reviewed, and three-dimensional coherent activation maps with the conduction velocity vector during the PVCs and SR were reconstructed.
Results
At the successful ablation site, an \"M\"-shaped discrete presystolic-potential and \"W\"-shaped discrete late-potential were recorded in all patients. The configuration of the inverted electrogram of the presystolic-potential was similar to that of the electrogram exhibiting the late-potential. We created coherent activation maps annotating the onset of the presystolic-potentials during the PVCs and offset of the late-potentials during SR, which suggested bidirectional conduction of the preferential pathway connecting the PVC origin to the myocardium.
Conclusion
Detailed activation mapping of these PVCs is consistent with the presence of fibers along the aortic or pulmonic valve ring that have preferential directions for conduction. PVCs produce a presystolic-potential. In SR, the fiber is activated late and from the opposite direction, producing an inverted potential inscribed on the end of the QRS.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1678-1686
Yagyu S, Nagashima K, Wakamatsu Y, Otsuka N, ... Hirata S, Okumura Y
J Cardiovasc Electrophysiol: 30 May 2021; 32:1678-1686 | PMID: 33772922
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Abstract

Optimal substrate modification strategies using catheter ablation in patients with persistent atrial fibrillation: 3-year follow-up outcomes.

Hsieh YC, Lin YJ, Lo MT, Chen YY, ... Lugtu IC, Chen SA
Objectives
This study aimed to assess the comparative efficacy of four ablation strategies on the incidence rates of freedom from atrial fibrillation (AF) or atrial tachycardia (AT) through a 3-year follow-up in patients with persistent AF.
Background
The optimal substrate modification strategies using catheter ablation for patients with persistent AF remain unclear.
Methods
Patients with persistent AF were enrolled consecutively to undergo each of four ablation strategies: (a) Group 1 (Gp 1, n = 69), pulmonary vein isolation (PVI) plus rotor ablation assisted by similarity index and phase mapping; (b) Gp 2 (n = 75), PVI plus linear ablations at the left atrium; (c) Gp 3 (n = 42), PVI plus the elimination of complex fractionated atrial electrograms; (d) Gp 4 (n = 67), PVI only. Potential confounders were adjusted via a multivariate survival parametric model.
Results
Baseline characteristics were similar across the four groups. At a follow-up period of 34.9 ± 38.6 months, patients in Gp 1 showed the highest rate of freedom from AF compared with the other three groups (p = .002), while patients in Gp 3 and 4 showed lower rates of freedom from AT than those of the other two groups (p = .006). Independent predictors of recurrence of AF were the ablation strategy (p = .002) and left atrial diameter (LAD) (p = .01).
Conclusion
In patients with persistent AF, a substrate modification strategy using rotor ablation assisted by similarity index and phase mapping provided a benefit for maintaining sinus rhythm compared with the other strategies. Both ablation strategy and baseline LAD predicted the 3-year outcomes of freedom from AT/AF.

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

J Cardiovasc Electrophysiol: 30 May 2021; 32:1561-1571
Hsieh YC, Lin YJ, Lo MT, Chen YY, ... Lugtu IC, Chen SA
J Cardiovasc Electrophysiol: 30 May 2021; 32:1561-1571 | PMID: 33825268
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Abstract

Totally peripheral approach for ICD lead vegetation removal in a GUCH patient.

Tarzia V, Tessari C, Bagozzi L, Migliore F, ... Fabozzo A, Gerosa G
AngioVac system (AngioDynamics) has already proved to be a useful tool in the treatment of thrombotic and endocarditic formations concerning the venous district. Herein, the AngioVac aspiration system combined with the bidirectional rotational Evolution mechanical sheath lead extraction was used for an effective and safety cardiac-device-related-infective-endocarditis removal in a grown-up congenital heart disease patient through a totally peripheral approach.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1778-1781
Tarzia V, Tessari C, Bagozzi L, Migliore F, ... Fabozzo A, Gerosa G
J Cardiovasc Electrophysiol: 30 May 2021; 32:1778-1781 | PMID: 33825266
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Abstract

Reassessment of clinical variables in cardiac resynchronization defibrillator patients at the time of first replacement: Death after replacement of CRT (DARC) score.

Theuns DAMJ, Niazi K, Schaer BA, Sticherling C, Yap SC, Caliskan K
Introduction
Cardiac resynchronization defibrillator (CRT-D) as primary prevention is known to reduce mortality. At the time of replacement, higher age and comorbidities may attenuate the benefit of implantable cardioverter-defibrillator (ICD) therapy. The purpose of this study was to evaluate the progression of comorbidities after implantation and their association with mortality following CRT-D generator replacement. In addition, a risk score was developed to identify patients at high risk for mortality after replacement.
Methods and results
We identified patients implanted with a primary prevention CRT-D (n = 648) who subsequently underwent elective generator replacement (n = 218) from two prospective ICD registries. The cohort consisted of 218 patients (median age: 70 years, male gender: 73%, mean left ventricular ejection fraction [LVEF]: 36 ± 11% at replacement). Median follow-up after the replacement was 4.2 years during which 64 patients (29%) died and 11 patients (5%) received appropriate ICD shocks. An increase in comorbidities was observed in 77 patients (35%). The 5-year mortality rate was 41% in patients with ≥2 comorbidities at the time of replacement. A risk score incorporating age, gender, LVEF, atrial fibrillation, anemia, chronic kidney disease, and history of appropriate ICD shocks at time of replacement accurately predicted 5-year mortality (C-statistic 0.829). Patients with a risk score of greater than 2.5 had excess mortality at 5-year postreplacement compared with patients with a risk score less than 1.5 (57% vs. 6%; p < .001).
Conclusion
A simple risk score accurately predicts 5-year mortality after replacement in CRT-D patients, as patients with a risk score of greater than 2.5 are at high risk of dying despite ICD protection.

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

J Cardiovasc Electrophysiol: 30 May 2021; 32:1687-1694
Theuns DAMJ, Niazi K, Schaer BA, Sticherling C, Yap SC, Caliskan K
J Cardiovasc Electrophysiol: 30 May 2021; 32:1687-1694 | PMID: 33825257
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Impact:
Abstract

The anatomical basis behind the neuromodulation effects associated with pulmonary vein isolation.

Aksu T, Yalin K, Bozyel S, Gopinathannair R, Gupta D
The anatomical basis underlying the neuromodulation effects seen with pulmonary vein (PV) isolation (PVI) is not fully understood. Left atrial (LA) electro-anatomical maps of 38 patients who underwent catheter cardioneuroablation for vagally mediated bradycarrhythmias were studied. During the procedure, LA ganglionic plexi (GPs) were systematically identified and ablated. Design PVI lines were created on these maps by a blinded observer, and the degree of overlap between four GPs and individual PVs was assessed. Here, 1.7 ± 7 (35.5 ± 17.0%) of the total 31.6 ± 10 GP ablation sites per patient were found to overlap with the design PVI lines. The overlap was higher for the right-sided GPs, p < .001. The degree of GP-PV overlap varied: 1 PV in 5 (13.2%) patients, 2 PVs in 15 (39.2%), 3 PVs in 16 (42.1%), and all 4 PVs in 2 (5.3%). No patient had zero GP-PV overlap. A vagal response was most commonly observed during ablation at the left superior GP (89.5%), while a sympathetic response was observed most often during the right superior GP ablation (97.4%). Some degree of GP-PV antral overlap is the norm, and this is more pronounced for the right-sided PVs. There is significant individual variability in the degree of overlap which may explain why neuromodulation effects are not seen universally following PVI.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1733-1736
Aksu T, Yalin K, Bozyel S, Gopinathannair R, Gupta D
J Cardiovasc Electrophysiol: 30 May 2021; 32:1733-1736 | PMID: 33844395
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Impact:
Abstract

Clinical predictors of heart block during atrioventricular nodal reentrant tachycardia ablation: A multicenter 18-year experience.

Makker P, Saleh M, Vaishnav AS, Coleman KM, ... John R, Mountantonakis SE
Background
Catheter ablation is considered the first-line treatment of symptomatic atrioventricular nodal reentrant tachycardia (AVNRT). It has been associated with a risk of heart block (HB) requiring a pacemaker. This study aims to determine potential clinical predictors of complete heart block as a result AVNRT ablation.
Methods
Consecutive patients undergoing catheter ablation for AVNRT from January 2001 to June 2019 at two tertiary hospitals were included. We defined ablation-related HB as the unscheduled implantation of pacemaker within a month of the index procedure. Use of electroanatomic mapping (EAM), operator experience, inpatient status, age, sex, fluoroscopy time, baseline PR interval, and baseline HV interval was included in univariate and multivariate models to predict HB post ablation.
Results
In 1708 patients (56.4 ± 17.0 years, 61% females), acute procedural success was 97.1%. The overall incidence of HB was 1.3%. Multivariate analysis showed that age more than 70 (odds ratio [OR] 7.907, p ≤ .001, confidence interval [CI] 2.759-22.666), baseline PR ≥ 190 ms (OR 2.867, p = .026, CI 1.135-7.239) and no use of EAM (OR 0.306, p = .037, CI 0.101-0.032) were independent predictors of HB.
Conclusion
Although the incidence of HB post AVNRT ablation is generally low, patients can be further stratified using three simple predictors.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1658-1664
Makker P, Saleh M, Vaishnav AS, Coleman KM, ... John R, Mountantonakis SE
J Cardiovasc Electrophysiol: 30 May 2021; 32:1658-1664 | PMID: 33844364
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Impact:
Abstract

Pulmonary vein isolation in atrial fibrillation patients guided by a novel local impedance algorithm: 1-year outcome from the CHARISMA study.

Solimene F, Giannotti Santoro M, De Simone A, Malacrida M, ... Narducci ML, Segreti L
Background
Highly localized impedance (LI) measurements during atrial fibrillation (AF) ablation have recently emerged as a viable real-time indicator of tissue characteristics and durability of the lesions created. We report the outcomes of acute and long-term clinical evaluation of the new DirectSense algorithm in AF ablation.
Methods
Consecutive patients undergoing AF ablation were included in the CHARISMA registry. RF delivery was guided by the DirectSense algorithm, which records the magnitude and time-course of the impedance drop. The ablation endpoint was pulmonary vein isolation (PVI), as assessed by the entrance and exit block.
Results
3556 point-by-point first-pass RF applications of >10 s duration were analyzed in 153 patients (mean age=59 ± 10 years, 70% men, 61% paroxysmal AF, 39% persistent AF). The mean baseline LI was 105 ± 15 Ω before ablation and 92 ± 12 Ω after ablation (p < .0001). Both absolute drops in LI and the time to LI drop (LI drop/τ) were greater at successful ablation sites (n = 3122, 88%) than at ineffective ablation sites (n = 434, 12%) (14 ± 8 Ω vs 6 ± 4 Ω, p < .0001 for LI; 0.73 [0.41-1.25] Ω/s vs. 0.35[0.22-0.59 Ω/s, p < .0001 for LI drop/τ). No major complications occurred during or after the procedures. All PVs had been successfully isolated. During a mean follow-up of 366 ± 130 days, 18 patients (11.8%) suffered an AF/atrial tachycardia recurrence after the 90-day blanking period.
Conclusion
The magnitude and time-course of the LI drop during RF delivery were associated with effective lesion formation. This ablation strategy for PVI guided by LI technology proved safe and effective and resulted in a very low rate of AF recurrence over 1-year follow-up.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1540-1548
Solimene F, Giannotti Santoro M, De Simone A, Malacrida M, ... Narducci ML, Segreti L
J Cardiovasc Electrophysiol: 30 May 2021; 32:1540-1548 | PMID: 33851484
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Impact:
Abstract

Cardioneuroablation for cardioinhibitory vasovagal syncope.

John LA, Mullis A, Payne J, Tung R, Aksu T, Winterfield JR
Background
Cardioneuroablation (CNA) is an emerging technique being used to treat patients with cardioinhibitory vasovagal syncope (VVS). We describe a case of CNA in targeting atrial ganglionated plexi (GP) based upon anatomical landmarks and fractionated electrogram (EGM) localization in a patient with cardioinhibitory syncope.
Case presentation
A 20-year-old healthy female presented with malignant VVS and symptomatic sinus pauses, with the longest detected at 10 s. She underwent acutely successful CNA with demonstration of vagal response (VR) noted after ablation of left sided GP, and tachycardia noted with right sided GP ablation. All GP sites were defined by anatomical landmarks and EGM analysis. By using the fractionation mapping software of Ensite Precision mapping system with high density mapping, fragmented EGMs were successfully detected in each GP site. One month after vagal denervation, there were no recurrent syncopal episodes or sinus pauses. Longer term follow-up with implantable loop recorder is planned.
Conclusion
We performed CNA in a patient with VVS by utilizing a novel approach of combined use of high density mapping and fractionation mapping software. With this approach, we were able to detect fractionation in all GP sites and demonstrate acute VR. This workflow may allow for a new, standardized technique suitable for widespread use.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1748-1753
John LA, Mullis A, Payne J, Tung R, Aksu T, Winterfield JR
J Cardiovasc Electrophysiol: 30 May 2021; 32:1748-1753 | PMID: 33855779
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Impact:
Abstract

Minimally decremental atriofascicular accessory pathway with bidirectional conduction.

Vijayaraman P
Atriofacicular pathways of Mahaim type are typically decrementally conducting accessory pathways without retrograde conduction properties, located on the right ventricular free wall at the tricuspid annulus. We report a patient with an atriofascicular pathway with minimal anterograde decremental conduction. Both long and short V-H antidromic atriofascicular reentrant tachycardias were induced and mechanism confirmed with electrophysiologic testing. Additionally, orthodromic atriofascicular reentrant tachycardia with narrow and right bundle branch block morphologies were inducible. Mahaim pathway was successfully ablated with elimination of both antidromic and orthodromic tachycardias.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1782-1786
Vijayaraman P
J Cardiovasc Electrophysiol: 30 May 2021; 32:1782-1786 | PMID: 33855768
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Impact:
Abstract

Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation.

Lam A, Küffer T, Hunziker L, Nozica N, ... Reichlin T, Roten L
Introduction
Chemical ablation by retrograde infusion of ethanol into the vein of Marshall (VOM-EI) can facilitate the achievement of mitral isthmus block. This study sought to describe the efficacy and safety of this technique.
Methods and results
Twenty-two consecutive patients (14 males, median age 71 years) with attempted VOM-EI for mitral isthmus ablation were included in the study. VOM-EI was successfully performed with a median of 4 ml of 96% ethanol in 19 patients (86%) and the mitral isthmus was successfully blocked in all (100%). Touch up endocardial and/or epicardial ablation after VOM-EI was necessary for 12 patients (63%). Perimitral flutter was present in 12 patients (63%) during VOM-EI and terminated or slowed by VOM-EI in 4 and 3 patients, respectively. The low-voltage area of the mitral isthmus region increased from 3.1 cm2 (interquartile range [IQR] 0-7.9) before to 13.2 cm2 (IQR: 8.2-15.0) after VOM-EI and correlated significantly with the volume of ethanol injected (p = .03). Median high-sensitive cardiac troponin-T increased significantly from 330 ng/L (IQR: 221-516) the evening of the procedure to 598 ng/L (IQR: 382-769; p = .02) the following morning. A small pericardial effusion occurred in three patients (16%), mild pericarditis in one (5%), and uneventful VOM dissection in two (11%). After a median follow-up of 3.5 months (IQR: 3.0-11.0), 10 of 18 patients (56%) with VOM-EI and available follow-up had arrhythmia recurrence. Repeat ablation was performed in five patients (50%) and peri-mitral flutter diagnosed in three (60%).
Conclusion
VOM-EI is feasible, safe, and effective to achieve acute mitral isthmus block.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1610-1619
Lam A, Küffer T, Hunziker L, Nozica N, ... Reichlin T, Roten L
J Cardiovasc Electrophysiol: 30 May 2021; 32:1610-1619 | PMID: 33928711
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Impact:
Abstract

Intrinsic cardiac autonomic nervous system: What do clinical electrophysiologists need to know about the \"heart brain\"?

Aksu T, Gopinathannair R, Gupta D, Pauza DH
It is increasingly recognized that the autonomic nervous system (ANS) is a major contributor in many cardiac arrhythmias. Cardiac ANS can be divided into extrinsic and intrinsic parts according to the course of nerve fibers and localization of ganglia and neuron bodies. Although the role of the extrinsic part has historically gained more attention, the intrinsic cardiac ANS may affect cardiac function independently as well as influence the effects of the extrinsic nerves. Catheter-based modulation of the intrinsic cardiac ANS is emerging as a novel therapy for the management of patients with brady and tachyarrhythmias resulting from hyperactive vagal activation. However, the distribution of intrinsic cardiac nerve plexus in the human heart and the functional properties of intrinsic cardiac neural elements remain insufficiently understood. The present review aims to bring the clinical and anatomical elements of the immune effector cell-associated neurotoxicity together, by reviewing neuroanatomical terminologies and physiological functions, to guide the clinical electrophysiologist in the catheter lab and to serve as a reference for further research.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1737-1747
Aksu T, Gopinathannair R, Gupta D, Pauza DH
J Cardiovasc Electrophysiol: 30 May 2021; 32:1737-1747 | PMID: 33928710
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Impact:
Abstract

Predictors of inappropriate shock in Brugada syndrome patients with a subcutaneous implantable cardiac defibrillator.

Casu G, Silva E, Bisbal F, Viola G, ... Bandino S, Berne P
Background
Subcutaneous implantable cardioverter defibrillators (S-ICDs) avoid complications secondary to transvenous leads, but inappropriate shocks (ISs) are frequent. Furthermore, IS data from patients with Brugada syndrome (BrS) with an S-ICD are scarce.
Objective
We aimed to establish the frequency and predictors of IS in this population.
Methods
We analyzed the clinical and electrocardiographic characteristics, automated screening test data, device programming, and IS occurrence in adult patients with BrS with an S-ICD.
Results
Thirty-nine patients were enrolled (69% male, mean age at diagnosis 46 ± 13 years, mean age at implantation 48 ± 13 years). During a mean follow-up of 26 ± 21 months, 18% patients experienced IS. Patients with IS were younger at the time of diagnosis (36 ± 8 vs. 48 ± 13 years, p = .018) and S-ICD implantation (38 ± 9 vs. 50 ± 23 years, p = .019) and presented with spontaneous type 1 Brugada electrocardiogram pattern more frequently at diagnosis or during follow-up (71% vs. 25%, p = .018). During automated screening tests, patients with IS showed lower QRS voltage in the primary vector in the supine position (0.58 ± 0.26 vs. 1.10 ± 0.35 mV, p = .011) and lower defibrillator automated screening score in the primary vector in the supine (123 ± 165 vs. 554 ± 390 mV, p = .005) and standing (162 ± 179 vs. 486 ± 388 mV, p = .038) positions. Age at diagnosis was the only independent predictor of IS (hazard ratio = 0.873, 95% confidence interval: 0.767-0.992, p = .037).
Conclusion
IS was a frequent complication in patients with BrS with an S-ICD. Younger age was independently associated with IS. A more thorough screening process might help prevent IS in this population.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1704-1711
Casu G, Silva E, Bisbal F, Viola G, ... Bandino S, Berne P
J Cardiovasc Electrophysiol: 30 May 2021; 32:1704-1711 | PMID: 33928706
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Impact:
Abstract

Ablation outcomes for atypical atrial flutter versus recurrent atrial fibrillation following index pulmonary vein isolation.

Akhtar T, Daimee UA, Sivasambhu B, Boyle TA, ... Calkins H, Spragg D
Background
Data related to electrophysiologic characteristics of atypical atrial flutter (AFL) following atrial fibrillation (AF) ablation and its prognostic value on repeat ablation success are limited.
Methods
We studied consecutive patients who underwent a repeat left atrial (LA) ablation procedure for either recurrent AF or atypical AFL, at least 3 months after index AF ablation, between January 2012 and July 2019. The demographics, clinical history, procedural data, complications, and 1-year arrhythmia-free survival rates were recorded for each subject after the first repeat ablation.
Results
A total of 336 patients were included in our study. Among these 336 patients, 102 underwent a repeat ablation procedure for atypical AFL and 234 underwent a repeat ablation procedure for recurrent AF. The mean age was 63.7 ± 10.7 years, and 72.6% of patients were men. The atypical AFL cohort had significantly higher LA diameters (4.6 vs. 4.4 cm, p = .04) and LA volume indices (LAVi; 85.1 vs. 75.4 ml/m2 , p = .03) compared to AF patients at repeat ablation. Atypical AFL patients were more likely to have had index radiofrequency (RF) ablation (as opposed to cryoballoon) than recurrent AF patients (98% vs. 81%, p = .01). Atypical AFLs were roof-dependent in 35.6% and peri-mitral in 23.8% of cases. Major complications at repeat ablation occurred in 0.9% of the total cohort. Arrhythmia-free survival at one year was significantly higher in the recurrent atypical AFL compared to the recurrent AF cohort (75.5 vs. 65.0%, p = .04).
Conclusion
In our series, roof-dependent flutter is the most common form of atypical atrial flutter post AF ablation. Patients developing atypical AFL after index AF ablation have greater LA dimensions than patients with recurrent AF. The success rate of first repeat ablation is significantly higher among patients with recurrent atypical AFL as compared to recurrent AF after index AF ablation.

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

J Cardiovasc Electrophysiol: 30 May 2021; 32:1631-1639
Akhtar T, Daimee UA, Sivasambhu B, Boyle TA, ... Calkins H, Spragg D
J Cardiovasc Electrophysiol: 30 May 2021; 32:1631-1639 | PMID: 33928697
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Impact:
Abstract

RF electrode-tissue coverage significantly influences steam pop incidence and lesion size.

Bourier F, Popa M, Kottmaier M, Maurer S, ... Hessling G, Deisenhofer I
Background
Steam pops are a rare complication associated with radiofrequency (RF) ablation and are hard to predict. The aim of this study was to assess the influence of coverage between the RF ablation electrode and cardiac tissue on steam pop incidence and lesion size.
Methods and results
An ex vivo model using porcine cardiac preparations and contact force sensing catheters was designed to perform RF ablations at different coverage levels between the RF electrode and cardiac tissue. During coverage level I, only the distal part of the ablation electrode was in contact with tissue. During coverage level II half of the ablation electrode, and during coverage level III the entire ablation electrode was embedded in tissue. RF applications (n = 60) at different coverage levels I-III were systematically performed using the same standardized ablation protocol. Ablations during coverage level III resulted in a significantly higher rate of steam pops (100%) when compared to ablations during coverage level II (10%) and coverage level I (0%), log rank p < .001. Coverage level I ablations resulted in significantly smaller lesion depths, diameters, and impedance drops when compared to higher coverage level ablations, p < .001. In the controlled ex vivo model, there was no difference in applied contact force or energy between different coverage levels.
Conclusions
The level of coverage between RF electrode, cardiac tissue, and the surrounding fluid significantly influenced the incidence of steam pops in an ex vivo setup. Larger coverage between RF electrode and tissue resulted in significantly larger lesion dimensions.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1594-1599
Bourier F, Popa M, Kottmaier M, Maurer S, ... Hessling G, Deisenhofer I
J Cardiovasc Electrophysiol: 30 May 2021; 32:1594-1599 | PMID: 33928696
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Impact:
Abstract

Caged-in: Successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus.

Briosa E Gala A, Pope MTB, Newton JD, Dawkins S, Betts TR
Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1655-1657
Briosa E Gala A, Pope MTB, Newton JD, Dawkins S, Betts TR
J Cardiovasc Electrophysiol: 30 May 2021; 32:1655-1657 | PMID: 33938078
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Impact:
Abstract

Superior vena cava isolation with 50 W high power, short duration ablation strategy.

Kusa S, Hachiya H, Sato Y, Hara S, ... Iesaka Y, Sasano T
Introduction
The optimal ablation strategy is unknown regarding a superior vena cava isolation (SVCI). This study aimed to examine the feasibility and safety and to analyze the lesion characteristics of the SVCI using high-power, short-duration (HPSD) ablation.
Methods and results
A total of 100 patients underwent an index SVCI using HPSD (n = 50, HPSD group) or conventional lower-power and longer-duration (n = 50, LPLD group) ablation, using the Thermocool Smarttouch SF. In the HPSD group, ablation was performed with a power of 50 W for 7 s, and was limited to 4 s at the lateral segment close to the right phrenic nerve. The ablation setting used in the LPLD group was 20-25 W for 20-30 s and was limited to 10-20 W for 15-30 s at the lateral segment when diaphragmatic capture was seen. An electrical SVCI was achieved in all patients. The HPSD group required a significantly shorter procedure time (10.8 ± 3.2 vs. 14.8 ± 6.4 min; p < .01), shorter radiofrequency duration (49 ± 16 vs. 282 ± 124 s; p < .01), fewer lesions (8.3 ± 2.5 vs. 10.4 ± 4.4; p < .01), and lower ablation index (316 ± 38 vs. 356 ± 62; p < .001) than the LPLD group. The incidence of a postprocedural asymptomatic mild diaphragmatic elevation was comparable (2% in the HPSD group vs. 6% in the LPLD group; p = .61).
Conclusion
The 50-W HPSD ablation strategy allowed for a successful, fast, and safe SVCI with the fewer ablation lesions and the lower ablation index.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1602-1609
Kusa S, Hachiya H, Sato Y, Hara S, ... Iesaka Y, Sasano T
J Cardiovasc Electrophysiol: 30 May 2021; 32:1602-1609 | PMID: 33949738
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Impact:
Abstract

Gender associated disparities in atrioventricular nodal reentrant tachycardia: A review article.

Etaee F, Elayi CS, Catanzarro J, Delisle B, ... Natale A, Darrat Y
Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common sustained supraventricular arrhythmias. An understanding of gender-related differences in AVNRT epidemiology, diagnosis, treatment, outcome, and complications can help guide a more effective diagnosis and treatment of the condition. The study aimed to perform a review of the available literature regarding all aspects of gender-related differences of AVNRT. We focused on all aspects of gender-related differences regarding AVNRT between men and women. A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct. Many investigations have demonstrated that the prevalence of AVNRT exhibited a twofold women-to-men predominance. The potential mechanism behind this difference due to sex hormones and autonomic tone. Despite being more common in women, there is a delay in offering and performing the first-line therapy (catheter ablation) compared to men. There were no significant gender-related discrepancies in patients who underwent ablation therapy for AVNRT, regarding the acute success rate of the procedure, long-term success rate, and recurrence of AVNRT. AVNRT is more common in women due to physiological factors such as sex hormones and autonomic tone. Catheter ablation is equally safe and efficacious in men and women; however, the time between the onset of symptoms and ablation is significantly prolonged in women. It is important for the medical community to be aware of this discrepancy and to strive to eliminate such disparities that are not related to patients\' choices.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1772-1777
Etaee F, Elayi CS, Catanzarro J, Delisle B, ... Natale A, Darrat Y
J Cardiovasc Electrophysiol: 30 May 2021; 32:1772-1777 | PMID: 33969588
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Impact:
Abstract

Acute shock efficacy of the subcutaneous implantable cardioverter-defibrillator according to the implantation technique.

Francia P, Adduci C, Angeletti A, Ottaviano L, ... Valsecchi S, Ziacchi M
Background
The traditional technique for subcutaneous implantable cardioverter defibrillator (S-ICD) implantation involves three incisions and a subcutaneous (SC) pocket. An intermuscular (IM) 2-incision technique has been recently adopted.
Aims
We assessed acute defibrillation efficacy (DE) of S-ICD (DE ≤65 J) according to the implantation technique.
Methods
We analyzed consecutive patients who underwent S-ICD implantation and DE testing at 53 Italian centers. Regression analysis was used to determine the association between DFT and implantation technique.
Results
A total of 805 patients were enrolled. Four groups were assessed: IM + 2 incisions (n = 546), SC + 2 incisions (n = 133), SC + 3 incisions (n = 111), and IM + 3 incisions (n = 15). DE was ≤65 J in 782 (97.1%) patients. Patients with DE ≤65 J showed a trend towards lower body mass index (25.1 vs. 26.5; p = .12), were less frequently on antiarrhythmic drugs (13% vs. 26%; p = .06) and more commonly underwent implantation with the 2-incision technique (85% vs. 70%; p = .04). The IM + 2-incision technique showed the lowest defibrillation failure rate (2.2%) and shock impedance (66 Ohm, interquartile range: 57-77). On multivariate analysis, the 2-incision technique was associated with a lower incidence of shock failure (hazard ratio: 0.305; 95% confidence interval: 0.102-0.907; p = .033). Shock impedance was lower with the IM than with the SC approach (66 vs. 70 Ohm p = .002) and with the 2-incision than the 3-incision technique (67 vs. 72 Ohm; p = .006).
Conclusions
In a large population of S-ICD patients, we observed a high defibrillation success rate. The IM + 2-incision technique provides lower shock impedance and a higher likelihood of successful defibrillation.

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

J Cardiovasc Electrophysiol: 30 May 2021; 32:1695-1703
Francia P, Adduci C, Angeletti A, Ottaviano L, ... Valsecchi S, Ziacchi M
J Cardiovasc Electrophysiol: 30 May 2021; 32:1695-1703 | PMID: 33969578
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Impact:
Abstract

Rate and impact on patient outcome and healthcare utilization of complications requiring surgical revision: Subcutaneous versus transvenous implantable defibrillator therapy.

Palmisano P, Ziacchi M, Ammendola E, D\'Onofrio A, ... Guerra F, Italian Association of Arrhythmology and Cardiac Pacing (AIAC)
Introduction
Comparison data on management of device-related complications and their impact on patient outcome and healthcare utilization between subcutaneous implantable cardioverter-defibrillator (S-ICD) and transvenous ICD (TV-ICD) are lacking. We designed this prospective, multicentre, observational registry to compare the rate, nature, and impact of long-term device-related complications requiring surgical revision on patient outcome and healthcare utilization between patients undergoing S-ICD or TV-ICD implantation.
Methods and results
A total of 1099 consecutive patients who underwent S-ICD or TV-ICD implantation were enrolled. Propensity matching for baseline characteristics yielded 169 matched pairs. Rate, nature, management, and impact on patient outcome of device-related complications were analyzed and compared between two groups. During a mean follow-up of 30 months, device-related complications requiring surgical revision were observed in 20 patients: 3 in S-ICD group (1.8%) and 17 in TV-ICD group (10.1%; p = .002). Compared with TV-ICD patients, S-ICD patients showed a significantly lower risk of lead-related complications (0% vs. 5.9%; p = .002) and a similar risk of pocket-related complications (0.6 vs. 2.4; p = .215) and device infection (0.6% vs. 1.2%; p = 1.000). Complications observed in S-ICD patients resulted in a significantly lower number of complications-related rehospitalizations (median 0 vs. 1; p = .013) and additional hospital treatment days (1.0 ± 1.0 vs. 6.5 ± 4.4 days; p = .048) compared with TV-ICD patients.
Conclusions
Compared with TV-ICD, S-ICD is associated with a lower risk of complications, mainly due to a lower risk of lead-related complications. The management of S-ICD complications requires fewer and shorter rehospitalizations.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1712-1723
Palmisano P, Ziacchi M, Ammendola E, D'Onofrio A, ... Guerra F, Italian Association of Arrhythmology and Cardiac Pacing (AIAC)
J Cardiovasc Electrophysiol: 30 May 2021; 32:1712-1723 | PMID: 33969569
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Impact:
Abstract

Measurement of patient confidence in self-management of atrial fibrillation: Initial validation of the Confidence in Atrial fibriLlation Management (CALM) Scale.

Tripp C, Gehi AK, Rosman L, Anthony S, Sears SF
Background
The patient experience of atrial fibrillation (AF) involves several daily self-care behaviors and ongoing confidence to manage their condition. Currently, no standardized self-report measure of AF patient confidence exists. The purpose of this study is to provide preliminary support for the reliability and validity of a newly developed confidence in AF management measure.
Methods
This study provides preliminary analysis of the Confidence in Atrial FibriLlation Management (CALM) scale, which was rationally developed to measure patient confidence related to self-management of AF. The scale was provided to a sample of AF patients N = 120, (59% male) electronically through a patient education platform. Principal component analysis (PCA) and Cronbach\'s α were employed to provide preliminary assessment of the validity and reliability of the measure.
Results
PCA identified a four-factor solution. Internal consistency of the CALM was considered excellent with Cronbach\'s α = .910. Additional PCA confirmed the value of a single factor solution to produce a total confidence score for improved utility and ease of clinical interpretation.
Conclusions
Initial assessment of a novel scale measuring patient confidence in managing AF provided promising reliability and validity. Patient confidence in self-management of AF may prove useful as a key marker and endpoint of the patient experience beyond QOL.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 30 May 2021; 32:1640-1645
Tripp C, Gehi AK, Rosman L, Anthony S, Sears SF
J Cardiovasc Electrophysiol: 30 May 2021; 32:1640-1645 | PMID: 33982364
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Impact:
Abstract

Recognition of the atrioventricular node anatomical structure: Connection between the retroaortic node and the compact node.

Wang F, Zhang LL, Meng W, Bin Z, ... Wu QW, Zhang S
Introduction
The complex electrophysiological phenomena related to the atrioventricular node (AVN) are due to its complex anatomical structures. Aside from the inferior nodal extension (INE), other node-like tissues, such as the retroaortic node (RN), have been described less extensively and may also share the mechanism of normal conduction and abnormal conduction in AVN re-entrant tachycardia.
Methods
High-density sections of the entire AVN were obtained from rats and rabbits. Fibrosis was analyzed by Masson\'s trichrome staining. Connexin (Cx43, Cx40, and Cx45) and ion channel (Nav 1.5, Cav 3.1, and HCN4) proteins were immunohistochemically labeled for the analysis of tissue features. Three-dimensional (3D) reconstruction of the AV junction was performed to clarify the relationships among different structures.
Results
The RN expressed the same connexin isoforms as the compact node (CN) and INE. Nav 1.5 labeling was observed at low levels in the CN, RN, and INE, where Cav 3.1 and HCN4 were expressed. The CN connected with the RN in a narrow strip pattern at the start of the CN. The RN presented as a shuttle shape and was the only tissue directly connected with the atrium in the anterior septum.
Conclusion
The RN connects with the AVN anatomically, suggesting that direct electrical conduction occurs between them. The entrance of the atria into the AVN is distal to the RN, which may form the fast AVN pathway.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 May 2021; epub ahead of print
Wang F, Zhang LL, Meng W, Bin Z, ... Wu QW, Zhang S
J Cardiovasc Electrophysiol: 29 May 2021; epub ahead of print | PMID: 34053145
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Abstract

Recent Advances in Gene Therapy for Atrial Fibrillation.

Yoo S, Geist GE, Pfenniger A, Rottmann M, Arora R
Atrial fibrillation (AF) is the most common heart rhythm disorder in adults and a major cause of stroke. Unfortunately, current treatments for AF are suboptimal as they are not targeting the molecular mechanisms underlying AF. In this regard, gene therapy is emerging as a promising approach for mechanism-based treatment of AF. In this review, we summarize recent advances and challenges in gene therapy for this important cardiovascular disease. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 29 May 2021; epub ahead of print
Yoo S, Geist GE, Pfenniger A, Rottmann M, Arora R
J Cardiovasc Electrophysiol: 29 May 2021; epub ahead of print | PMID: 34053133
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Impact:
Abstract

Flecainide-induced AV Dyssynchrony and Atrial Latency Progression in a Patient with a Dual Chamber Pacemaker.

Alston M, Chang D, Mitra R
Flecainide is a class 1C antiarrhythmic primarily used for the management of supraventricular arrhythmias. We report a case of a patient with paroxysmal atrial fibrillation and recently implanted dual chamber pacemaker with resultant atrial latency who underwent flecainide treatment resulting in worsening atrial latency, progressive dyspnea, and pacemaker syndrome physiology. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 29 May 2021; epub ahead of print
Alston M, Chang D, Mitra R
J Cardiovasc Electrophysiol: 29 May 2021; epub ahead of print | PMID: 34053127
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Abstract

Functional electrographic flow patterns in patients with persistent atrial fibrillation predict outcome of catheter ablation.

Szili-Torok T, Kis Z, Bhagwandien R, Wijchers S, ... Kong MH, Ruppersberg P
Aims
Electrographic flow (EGF) mapping is a method to detect action potential sources within the atria. In a double-blinded retrospective study we evaluated whether sources detected by EGF are related to procedural outcome.
Methods
EGF maps were retrospectively generated using the Ablamap® software from unipolar data recorded with a 64-pole basket catheter from patients who previously underwent focal impulse and rotor modulation-guided ablation. We analyzed patient outcomes based on source activity (SAC) and variability. Freedom from atrial fibrillation (AF) was defined as no recurrence of AF, atypical flutter or atrial tachycardia at the follow-up visits.
Results
EGF maps were from 123 atria in 64 patients with persistent or long-standing persistent AF. Procedural outcome correlation with SAC peaked at >26%. S-type EGF signature (source-dependent AF) is characterized by stable sources with SAC > 26% and C-type (source-independent AF) is characterized by sources with SAC ≤ 26%. Cases with AF recurrence at 3-, 6-, or 12-month follow-up showed a median final SAC 34%; while AF-free patients had sources with significantly lower median final SAC 21% (p = .0006). Patients with final SAC and Variability above both thresholds had 94% recurrence, while recurrence was only 36% for patients with leading source SAC and variability below threshold (p = .0001). S-type EGF signature post-ablation was associated with an AF recurrence rate 88.5% versus 38.1% with C-type EGF signature.
Conclusions
EGF mapping enables the visualization of active AF sources. Sources with SAC > 26% appear relevant and their presence post-ablation correlates with high rates of AF recurrence.

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

J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print
Szili-Torok T, Kis Z, Bhagwandien R, Wijchers S, ... Kong MH, Ruppersberg P
J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print | PMID: 34041824
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Impact:
Abstract

Predictors of long-term success after catheter ablation of premature ventricular complexes.

Im SI, Voskoboinik A, Lee A, Higuchi S, ... Park KM, Gerstenfeld EP
Introduction
Some patients have late recurrence after acutely successful radiofrequency catheter ablation (RFCA) of premature ventricular complexes (PVCs). The aim of this study was to evaluate predictors of long-term success following acutely successful PVC RFCA.
Methods
We identified consecutive patients at our institution with frequent PVCs undergoing RFCA and reviewed procedural data and medical records. Acute success was defined as elimination of targeted PVCs for at least 30-min after RFCA. Long-term success was defined as absence of targeted PVCs during all follow-up visits and PVC-burden <5% on follow-up monitoring.
Results
Among 241 patients (mean age 57 ± 15 years, 58% male), 161 (66.8%) had long-term success with median follow-up of 17.7 (IQR, 12.2-29.8) months. Unadjusted predictors of late PVC recurrence were increasing age, diabetes mellitus and alcohol use, while female-sex, shorter ablation-time, right ventricular PVC-origin, single PVC morphology, and earliest bipolar activation ≥24 ms pre-QRS were predictors of long-term success. In multivariate-analysis, female-sex, single-PVC morphology and earliest-onset of PVC ≥ 24 ms pre-QRS were independent predictors for long-term success. The positive-predictive value of earliest-bipolar onset of PVC ≥ 24 ms pre-QRS for long-term success was 0.77 (p < .001). Negative-predictive value of PVC < 15 ms pre-QRS for long-term success was 0.86 (p = .003), suggesting that RFCA when the bipolar electrogram preceded QRS by <15 ms was unlikely to result in long-term success.
Conclusions
Female-sex, single-PVC morphology, and earliest-onset of bipolar electrogram ≥24 ms pre-QRS were multivariable predictors of long-term success in patients with PVCs undergoing RFCA. RFCA at sites with local onset <15 ms pre-QRS are unlikely to be successful.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print
Im SI, Voskoboinik A, Lee A, Higuchi S, ... Park KM, Gerstenfeld EP
J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print | PMID: 34041816
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Abstract

Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with Longstanding Persistent Atrial Fibrillation.

McGilvray MMO, Bakir NH, Kelly MO, Perez SC, ... Melby SJ, Damiano RJ
Introduction
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat.
Methods & results
Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range [IQR] 4.0-12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence.
Conclusion
Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print
McGilvray MMO, Bakir NH, Kelly MO, Perez SC, ... Melby SJ, Damiano RJ
J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print | PMID: 34041815
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Impact:
Abstract

Comparison of clockwise and counterclockwise right atrial flutter using high-resolution mapping and automated velocity measurements.

Yvorel C, Da Costa A, Lerebours C, Guichard JB, ... Benali K, Isaaz K
Background
Only few studies have been performed that explore the electrophysiological differences between clockwise (CW) and counterclockwise (CCW) right atrial (RA) cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) using the high-resolution Rhythmia mapping system.
Objectives
We sought to compare CW and CCW CTI-dependent AFL in pure right AFL patients (pts) using the ultra-high-definition (ultra-HD) Rhythmia mapping system and we mathematically developed a cartography model based on automatic velocity RA measurements to identify electrophysiological AFL specificities.
Methods and results
Thirty-three pts were recruited. The mean age was 71 ± 13 years old. The sinus venosus (SV) block line was present in 32/33 of cases (97%) and no significant difference was found between CCW and CW CTI AFL (100% vs. 91%; p = .7). No line was localized in the region of the crista terminalis (CT). A superior gap was present in the posterior line in 14/31 (45.2%) but this was similarly present in CCW AFL, when compared to CW AFL (10/22 [45.5%] vs. 4/10 [40%]; p = .9). When present, the extension of the posterior line of block was observed in 18/31 pts (58%) without significant differences between CCW and CW CI AFL (12/22 [54.5%] vs. 6/10 [60%]; p = .9) The Eustachian ridge line of block was similarly present in both groups (82% [18/22] vs. 45.5% [5/11]; p = .2). The absence of the Eustachian ridge line of block led to significantly slowed velocity in this area (28 ± 10 cm/s; n = 8), and the velocities were similarly altered between both groups (26 ± 10 [4/22] vs. 29.8 ± 11 cm/s [4/11]; p = .6). We created mathematical, three-dimensional RA reconstruction-velocity model measurements. In each block localization, when the block line was absent, velocity was significantly slowed (≤20 cm/s). A systematic slowdown in conduction velocity was observed at the entrance and exit of the CTI in 100% of cases. This alteration to the conduction entrance was localized at the lateral side of the CTI for the CCW AFL and at the septal side of the CTI for CW AFL. The exit-conduction alteration was localized at the CTI septal side for the CCW AFL and at the CTI lateral side for the CW AFL.
Conclusion
The ultra-HD Rhythmia mapping system confirmed the absence of significant electrophysiological differences between CCW and CW AFL. The mechanistic posterior SV and Eustachian ridge block lines were confirmed in each arrhythmia. A systematic slowing down at the entrance and exit of the CTI was demonstrated in both CCW and CW AFL, but in reverse positions.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print
Yvorel C, Da Costa A, Lerebours C, Guichard JB, ... Benali K, Isaaz K
J Cardiovasc Electrophysiol: 25 May 2021; epub ahead of print | PMID: 34041809
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Impact:
Abstract

Pulmonary vein isolation guided by moderate ablation index targets combined with strict procedural endpoints for patients with paroxysmal atrial fibrillation.

Wang YJ, Tian Y, Shi L, Zeng LJ, ... Yang XC, Liu XP
Introduction
Ablation index (AI)-guided radiofrequency ablation has been increasingly used for the treatment of drug-resistant paroxysmal atrial fibrillation (AF),but the optimal AI targets remain to be determined. We aimed to examine the efficacy and safety of catheter ablation guided by moderate AI values but more strict procedural endpoints in patients with paroxysmal AF.
Methods
We conducted a retrospective review of a consecutive series of patients who received their first AI-guided ablation for paroxysmal AF from 2017 to 2018. The standard procedural protocol recommends AI targets as follows: anterior: 400-450; posterior: 280-330; and roof/inferior wall: 380-430. After circumferential pulmonary vein isolation (PVI), we performed bipolar pacing along the ablation line, adenosine triphosphate (ATP)-provocation, and waited for 30 min to verify PVI. The primary clinical outcome was the rate of freedom from AF recurrence at 12 months.
Results
A total of 140 consecutive patients were included. The mean procedure and ablation times were 132.2 ± 30.2 min and 24.2 ± 7.9 min, respectively. The first-pass isolation and final isolation rates were documented in 49.3% and in 100% of the patients, respectively. At 12 months, single-procedure freedom from atrial tachyarrhythmias was observed in 92.1% of patients. No major procedure-related complications were encountered.
Conclusions
Moderate AI-guided catheter ablation is highly effective for the treatment of drug-refractory paroxysmal AF in real-world settings. Over 90% of patients achieved single-procedure arrhythmia-free survival at 1 year. The outcome was obtained without major complications and the procedure involved relatively short procedure and ablation times.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print
Wang YJ, Tian Y, Shi L, Zeng LJ, ... Yang XC, Liu XP
J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print | PMID: 34028119
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Impact:
Abstract

Durability of mitral isthmus ablation with and without ethanol infusion in the vein of Marshall.

Ishimura M, Yamamoto M, Himi T, Kobayashi Y
Introduction
Ethanol infusion in the vein of Marshall (EIVOM) effectively creates a linear ablation lesion in the mitral isthmus (MI). However, data on the long-term success rates of MI ablation is limited.
Methods and results
Our cohort consisted of 560 patients with nonparoxysmal atrial fibrillation (AF) who underwent an initial MI ablation. Ablations were performed by only radiofrequency (RF) in 384 (RF group) or by RF and EIVOM in 176 (EIVOM/RF group) patients; 5 ml anhydrous ethanol was used to perform EIVOM in advance of RF. Following EIVOM, RF pulses were delivered to the lateral MI line. Bidirectional MI block was fully achieved in 353/384 (92%) (First 318, Re-do 35) patinents in the RF group and 171/176 (97%) (First 128, Re-do 43) patients in the EIVOM/RF group (p = .09 in the first, p = .10 in the re-do ablation cases). In cases with complete MI line block, recurrent AF or atrial tachycardia was observed in 130/353 (37%) patients in the RF group and in 64/171 (37%) patients in the EIVOM/RF group (log-rank p = .12 in the first, and p = .30 in the re-do ablation cases). Of the total 560 patients, 123 proceeded to the subsequent ablation session. Reconduction across MI line block was observed in 39/80 (49%) patients in the RF group and 25/43 (58%) patients in the EIVOM/RF group (p = .32).
Conclusion
EIVOM effectively ensures MI line block; however, the reconduction rate was similar between the two groups.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print
Ishimura M, Yamamoto M, Himi T, Kobayashi Y
J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print | PMID: 34028116
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Impact:
Abstract

Effectiveness of ethanol infusion into the vein of Marshall combined with a fixed anatomical ablation strategy (the \"upgraded 2C3L\" approach) for catheter ablation of persistent atrial fibrillation.

Lai Y, Liu X, Sang C, Long D, ... Dong J, Ma C
Introduction
Linear ablation in addition to pulmonary vein antrum isolation (PVAI) has failed to improve the success rate for persistent atrial fibrillation (PeAF), due to incomplete block of ablation lines, especially in the mitral isthmus (MI).
Methods and results
The study enrolled 191 patients (66 in group 1 and 125 in group 2). In group 1, ethanol infusion into the vein of Marshall was first performed, followed by radiofrequency (RF) applications targeting bilateral PVAI and bidirectional block in the roofline, cavotricuspid isthmus, and MI. In group 2, PVAI and the three linear ablations were completed using only RF energy. MI block was achieved in 63 (95.5%) and 101 (80.8%) patients in groups 1 and 2, respectively (p = .006). Patients in group 1 had shorter ablation time for left pulmonary vein antrum (8.15 vs. 12.59 min, p < .001) and MI (7.0 vs. 11.8 min, p < .001) and required less cardioversion (50 [78.5%] vs. 113 [90.4%], p = .007). During the 12-month follow-up, 58 (87.9%) patients were free from atrial fibrillation/atrial tachycardia in group 1 compared with 81 (64.8%) in group 2 (p < .001). In multivariate cox regression, the \"upgraded 2C3L\" procedure is associated with a lower recurrence rate (hazard ratio = 0.27, 95% confidence interval = 0.12-0.59).
Conclusion
Compared with the conventional \"2C3L\" approach, the \"upgraded 2C3L\" approach has higher effectiveness for ablation of PeAF.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print
Lai Y, Liu X, Sang C, Long D, ... Dong J, Ma C
J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print | PMID: 34028114
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Impact:
Abstract

Outcomes of transvenous lead extraction using the TightRail™ mechanical rotating dilator sheath and excimer laser sheath.

Misra S, Swayampakala K, Coons P, Cerbie C, ... Love C, Mehta R
Background
Transvenous lead extraction (TLE) is an important part of comprehensive lead management. The selection of tools available has expanded in recent years but data on their efficacy is limited.
Objective
To evaluate outcomes using the TightRail™ mechanical rotating mechanical dilator sheath in comparison to excimer laser sheaths and describe factors predictive of successful extraction.
Methods
Patients undergoing TLE at a single tertiary center (2013-2019) were included in a prospective registry. Leads targeted for extraction with either an SLS II/Glidelight™ or TightRail™ sheath were included. Outcomes were analyzed on a per-lead basis. Generalized estimating equation (GEE) models were used to assess differences in lead extraction success by extraction tool used while adjusting for nonindependence of multiple leads extracted from the same patient. Covariates included patient comorbidities, lead characteristics, and sheath size.
Results
A total of 575 leads extracted from 372 patients were included. Overall success rate was 97%. TightRail™ was the first tool used in 180 (31.3%) leads with success rate of 61.7%; laser sheaths were the first tool in 395 leads (68.7%) with success rate of 67.8%. Predictors of successful extraction included lead age, lead type, and sheath sizing. Extraction success did not differ based on whether a laser or TightRail™ sheath was used (adjusted odds ratio = 0.94; 95% confidence interval = 0.59-1.50).
Conclusion
The TightRail™ sheath is an effective tool for TLE. Lead age, lead type, and sheath sizing were predictive of successful extraction but sheath type was not. These findings are hypothesis generating and warrant further investigation in a prospective, randomized study.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print
Misra S, Swayampakala K, Coons P, Cerbie C, ... Love C, Mehta R
J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print | PMID: 34028112
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Impact:
Abstract

Prevalence and Incidence of Patients with Paroxysmal Supraventricular Tachycardia in the United States.

Rehorn M, Sacks NC, Emden MR, Healey B, ... Cyr PL, Pokorney SD
Background
Paroxysmal supraventricular tachycardia (PSVT) encompasses a range of heart rhythm disorders leading to rapid heart rates. By virtue of its episodic nature, diagnosing PSVT is difficult, and estimating incidence and prevalence on a population level is challenging. The objective of this study was to estimate the incidence and prevalence of PSVT in the United States (US) in contemporary practice.
Methods and results
Observational retrospective longitudinal study using claims, enrollment, and demographic data from the IBM MarketScan® Commercial Research database (age < 65) and the Medicare Limited Dataset (age ≥ 65) from 2008-2016. Patients with a PSVT diagnosis code (ICD-9: 427.0; ICD-10: I47.1) on ≥2 outpatient, ≥1 emergency room, or ≥1 inpatient visit were considered as having PSVT. Patients with AF/AFL were excluded from the initial analysis given the potential for misclassification. Incidence was estimated by assessing diagnoses made during year five of continuous enrollment. Lastly, a sensitivity analysis was performed by including patients with both PSVT and AF/AFL diagnoses. Period prevalence and incidence rate were estimated to be 332.9 (323.2-342.9) and 57.8 (52.8-63.3) per 100,000 individuals respectively when excluding patients with AF/AFL. Projected to the 2018 US census, prevalence and incidence are 1.26 million (1.21-1.30 million) and 188,981 (172,891-206,943) respectively. Including patients with AF/AFL, the prevalence may increase to 479.7 (467.9-491.8) with an incidence of 93.4 (86.9-100.5) per 100,000 individuals or a prevalence of 2.06 million (2.01-2.12 million).
Conclusions
Approximately 1 in 300 people in the US had PSVT with the highest rates in older and female patients. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print
Rehorn M, Sacks NC, Emden MR, Healey B, ... Cyr PL, Pokorney SD
J Cardiovasc Electrophysiol: 23 May 2021; epub ahead of print | PMID: 34028109
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Impact:
Abstract

Atrial Fibrillation and Atrial Cardiomyopathies.

Baman JR, Cox JL, McCarthy PM, Kim D, ... Passman RS, Wilcox JE
Atrial fibrillation (AF) is the most common arrhythmia among adults. While there have been incredible advances in the management of AF and its clinical sequelae, investigation of atrial cardiomyopathies (ACM) is becoming increasingly more prominent. ACM refers to the electromechanical changes-appreciated sub-clinically and/or clinically-that underlie atrial dysfunction and create an environment ripe for the development of clinically apparent AF. There are several subtypes of ACM, distinguished by histologic features. Recent progress in cardiovascular imaging, including echocardiography with speckle-tracking (e.g. strain analysis), cardiovascular magnetic resonance imaging (CMR), and atrial 4-D flow CMR, has enabled increased recognition of ACM. Identification of ACM and its features carry clinical implications, including elevating a patient\'s risk for development of AF, as well as associations with outcomes related to catheter-based and surgical AF ablation. In this review, we explore the definition and classifications of ACM, its complex relationship with clinical AF, imaging modalities, and clinical implications. We propose next steps for a more unified approach to ACM recognition that can direct further research into this complex field. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print
Baman JR, Cox JL, McCarthy PM, Kim D, ... Passman RS, Wilcox JE
J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print | PMID: 33993617
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Impact:
Abstract

The effect of catheter ablation for ventricular arrhythmias originating from the left ventricular papillary muscles on mitral valve function.

Sink J, Turin A, Cytron J, Green A, ... Vasaiwala S, Vasaiwala S
Background
Ablation of ventricular arrhythmias (VA) originating from the left ventricular (LV) papillary muscles (PM) has the potential to damage the mitral valve apparatus resulting in mitral regurgitation (MR). This study sought to evaluate the effect of radiofrequency (RF) ablation of a PM on MR severity.
Methods
Patients with pre- and postablation transthoracic echocardiograms who underwent PM ablation for treatment of VA were retrospectively identified and compared to similar patients who underwent VA ablation at non-PM sites. MR severity was evaluated pre- and postablation in both groups and graded as none/trace (Grade 0); mild/mild-to-moderate (Grade 1); moderate (Grade 2); moderate-to-severe/severe (Grade 3).
Results
A total of 45 and 49 patients were included in the PM and non-PM groups, respectively. There were no significant baseline demographic differences. The PM group had longer RF ablation times (22.3 vs. 13.3 min, p < .01) compared to the non-PM group. Most patients had low-grade MR in both groups at baseline. Change in pre- versus postablation MR within the PM group was not statistically significant by Wilcoxon rank-sum test (Figure 2, p = .46). MR severity following ablation was also evaluated using logistic regression models. The odds ratio for worsening MR in the PM group compared to non-PM was 0.19 (95% confidence interval: 0.008-4.18, p = .29) after adjusting for comorbidities, LV ejection fraction, and LV internal end-diastolic diameter.
Conclusion
RF ablation of VA originating from PM under intracardiac echocardiography guidance did not result in clinically or statistically significant worsening of MR.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print
Sink J, Turin A, Cytron J, Green A, ... Vasaiwala S, Vasaiwala S
J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print | PMID: 33993577
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Impact:
Abstract

Epicardial access complications during electrophysiology procedures.

Romero J, Patel K, Lakkireddy D, Alviz I, ... Natale A, Di Biase L
Introduction
Percutaneous epicardial access (EA) was first described more than two decades ago. Since its initial introduction, indications for its utilization in the field of electrophysiology have expanded dramatically.
Discussion
Epicardial mapping and ablation in patients with ventricular tachycardia is routinely performed in tertiary electrophysiology centers around the world. Although limited by lack of randomized controlled trials, epicardial ablation for atrial fibrillation has been suggested as a conjunctive strategy in patients who have failed an initial endocardial catheter ablation attempt, and it is necessary for placement of some left atrial appendage occlusion devices as well. An accurate understanding of the cardiac anatomy is crucial to avoid complications such as inadvertent right ventricular puncture, injury to the coronary arteries, abdominal viscera, phrenic nerves, and esophagus during both EA and catheter ablation.
Conclusion
The aim of this review is to provide a comprehensive overview of the cardiac anatomy, technical aspects to optimize the safety of epicardial puncture, recognize and avoid potential complications.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print
Romero J, Patel K, Lakkireddy D, Alviz I, ... Natale A, Di Biase L
J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print | PMID: 33993576
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Impact:
Abstract

Esophageal luminal temperature rise during atrial fibrillation ablation is associated with lower radiofrequency electrode distance and baseline impedance.

Khoshknab M, Kuo L, Zghaib T, Arkles J, ... Desjardins B, Nazarian S
Introduction
Esophageal injury during atrial fibrillation (AF) ablation is a life-threatening complication. We sought to measure the association of esophageal temperature attenuation with radiofrequency (RF) electrode impedance, contact force, and distance from the esophagus.
Methods
The retrospective study cohort included 35 patients with mean age 64 ± 10 years, of whom 74.3% were male, and 40% had persistent AF. All patients had undergone preprocedural cardiac magnetic resonance (CMR) followed by AF ablation with luminal esophageal temperature monitoring. Lesion locations were co-registered with CMR image segmentations of left atrial and esophageal anatomy. Luminal esophageal temperature, time matched RF lesion data, and ablation distance from the nearest esophageal location were collected as panel data.
Results
Luminal esophageal temperature changes corresponding to 3667 distinct lesions, delivered with mean power 27.9 ± 5.5 W over a mean duration of 22.2 ± 10.5 s were analyzed. In multivariable analyses, clustered per patient, examining posterior wall lesions only, and adjusted for lesion power and duration as set by the operator, lesion distance from the esophagus (-0.003°C/mm, p < .001), and baseline impedance (-0.015°C/Ω, p < .001) were associated with changes in luminal esophageal temperature.
Conclusion
Esophageal luminal temperature rises are associated with shorter lesion distance from esophagus and lower baseline impedance during RF lesion delivery. When procedural strategy requires RF delivery near the esophagus, selection of sites with higher baseline impedance may improve safety.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print
Khoshknab M, Kuo L, Zghaib T, Arkles J, ... Desjardins B, Nazarian S
J Cardiovasc Electrophysiol: 15 May 2021; epub ahead of print | PMID: 33993572
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Impact:
Abstract

Robotic assisted cryothermic biatrial Cox-Maze.

Roberts HG, Wei LM, Dhamija A, Cook CC, Badhwar V
Introduction
Robotic cryothermic Cox-Maze (CM) IV is a minimally invasive procedure that reliably replicates the biatrial lesion set of the CM III by utilizing cryothermia as a single power source.
Methods
Herein we describe a step by step creation of the biatrial CM III lesion sets utilizing the minimally invasive robotic platform.
Results
Technical details are reviewed for this single incision, single stage, highly effective option for stand-alone or concomitant surgical ablation of atrial fibrillation (AF).
Conclusion
Robotic cryothermic CM IV can be safely performed as a stand-alone or concomitant procedure, and offers a comprehensive surgical ablation solution for patients with AF.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print
Roberts HG, Wei LM, Dhamija A, Cook CC, Badhwar V
J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print | PMID: 33969577
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Impact:
Abstract

\"Second line medications\" for supraventricular arrhythmias in children: In-hospital efficacy and adverse events during treatment initiation of sotalol and flecainide.

Kahr PC, Moffett BS, Miyake CY, Kim JJ, Valdes SO
Introduction
Sotalol and flecainide are used as second line agents in children for the treatment of supraventricular arrhythmias (SA) refractory to anti-beta adrenergic antiarrhythmics or digoxin. Efficacy and adverse events in this cohort have not been well described. Here, we report our institutional experience of second line treatment initiation for SA in children.
Methods and results
Utilizing an institutional database, 247 patients initiated on sotalol and 81 patients initiated on flecainide were identified. Congenital heart disease (CHD) was present in 40% of patients. Arrhythmia-free discharge on single or dual agent therapy (in combination with other antiarrhythmics) was 87% for sotalol and 91% for flecainide. Neither age, sex, dosing, presence of CHD nor arrhythmia subtype were associated with alterations in in-hospital efficacy. Compared to baseline, QTc intervals in sotalol patients (436 [416-452 ms] vs. 415 [400-431 ms], p < .01) and QRS intervals in flecainide patients (75 [68-88 ms] vs. 62 [56-71 ms], p < .01) were prolonged. Dose reduction or discontinuation due to QRS prolongation occurred in 9% of patients on flecainide. QTc prolongation resulting in dose reduction/discontinuation of sotalol was encountered in 9 patients (4%) and death with documented torsade de pointes in 2 patients (1%), with 9 of 11 patients having underlying CHD.
Conclusion
In children requiring second line agents for treatment of SA, both sotalol and flecainide appear to be highly efficacious. Although predominantly safe in otherwise healthy patients, electrocardiogram changes can occur and children with underlying cardiac disease may have an increased risk of adverse events and rhythm-related side effects during initiation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print
Kahr PC, Moffett BS, Miyake CY, Kim JJ, Valdes SO
J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print | PMID: 33969576
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Impact:
Abstract

Atrial thrombus detection on transoesophageal echocardiography in patients with atrial fibrillation undergoing cardioversion or catheter ablation: A pooled analysis of rates and predictors.

Noubiap JJ, Agbaedeng TA, Ndoadoumgue AL, Nyaga UF, Kengne AP
Objective
To summarize data on the rates and predictors of left atrial thrombus/left atrial appendage thrombus (LAT/LAAT) detection by transoesophageal echocardiography (TEE) before electrical cardioversion (ECV) or catheter ablation (CA) for atrial fibrillation (AF).
Methods
EMBASE, MEDLINE, and Web of Science Core Collection were searched to identify all studies providing relevant data and published by October 7, 2020. A random-effects meta-analysis method was used to pool effect size estimates.
Results
A total of 85 studies were included, reporting data from 56 660 patients with AF. In patients undergoing CA and ECV, the pooled prevalence of LAT/LAAT was 1.8% and 7.5% in those not on oral anticoagulation (OAC), 1.8% and 5.5% in those taking OAC, and 1.3% and 4.9% in case of adequate OAC, respectively. According to the type of OAC, the prevalence was 2.0% and 7.6% for vitamin K antagonist, 1.3% and 3.5% for direct oral anticoagulant. Predictors of LAT/LAAT detection were nonparoxysmal AF (odds ratio [OR]: 3.6, 95% confidence interval: 2.4-5.2), hypertension (OR: 2.9, 1.2-7.0), previous stroke (OR: 3.0, 1.6-5.63), heart failure (OR: 4.3, 2.7-6.8), and CHADS2 score ≥2 (OR: 3.3, 1.9-5.8) for patients undergoing CA; and heart failure (OR: 2.8, 1.3-6.2) and the CHA2 DS2 -VASc score (OR: 2.55, 1.5-4.5) for those undergoing ECV.
Conclusion
The prevalence of LAT/LAAT in AF patients undergoing ECV or CA varies widely, mainly due to differences in patient risk profiles and OAC types. Further research should determine whether the predictors of LAT/LAAT detection identified by this study could be used to select patients who require preprocedural TEE.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print
Noubiap JJ, Agbaedeng TA, Ndoadoumgue AL, Nyaga UF, Kengne AP
J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print | PMID: 33969568
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Impact:
Abstract

Prone-position computed tomography in the late phase for detecting intracardiac thrombi in the left atrial appendage before catheter ablation for atrial fibrillation.

Nakamura R, Oda A, Tachibana S, Sudo K, ... Sasano T, Yamauchi Y
Background
Contrast computed tomography (CT) is a useful tool for the detection of intracardiac thrombi. We aimed to assess the accuracy of the late-phase prone-position contrast CT (late-pCT) for thrombus detection in patients with persistent or long-standing persistent atrial fibrillation (AF).
Methods
Early and late-phase pCT were performed in 300 patients with persistent or long-standing AF. If late-pCT did not show an intracardiac contrast defect (CD), catheter ablation (CA) was performed. Immediately before CA, intracardiac echocardiography (ICE) from the left atrium was performed to confirm thrombus absence and the estimation of the blood velocity of the left atrial appendage (LAA). For patients with CDs on late-pCT, CA performance was delayed, and late-pCT was performed again after several months following oral anticoagulant alterations or dosage increases.
Results
Of the 40 patients who exhibited CDs in the early phase of pCT, six showed persistent CDs on late-pCT. In the remaining 294 patients without CDs on late-pCT, the absence of a thrombus was confirmed by ICE during CA. In all six patients with CD-positivity on late-pCT, the CDs vanished under the same CT conditions after subsequent anticoagulation therapy, and CA was successfully performed. Furthermore, the presence of residual contrast medium in the LAA on late-pCT suggested a decreased blood velocity in the LAA ( ≤ 15 cm/s) (sensitivity = 0.900 and specificity = 0.621).
Conclusions
Late-pCT is a valuable tool for the assessment of intracardiac thrombi and LAA dysfunction in patients with persistent or long-standing persistent AF before CA.

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

J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print
Nakamura R, Oda A, Tachibana S, Sudo K, ... Sasano T, Yamauchi Y
J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print | PMID: 33969567
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Impact:
Abstract

Formation of low-voltage zones on the anterior left atrial wall due to mechanical compression by the ascending aorta.

Hayashida S, Nagashima K, Kurokawa S, Arai M, ... Iso K, Okumura Y
Background
Although low-voltage zones (LVZs) in the left atrium (LA) are considered arrhythmogenic substrates in some patients with atrial fibrillation (AF), the pathophysiologic factors responsible for LVZ formations remain unclear.
Objective
To elucidate the anatomical relationship between the LA and ascending aorta responsible for anterior LA wall remodeling.
Methods
We assessed the relationship between existence of LVZs on the anterior LA wall and the three-dimensional computed tomography image measurements in 102 patients who underwent AF ablation.
Results
Twenty-nine patients (28%) had LVZs grearer than 1.0 cm2 on the LA wall in the LA-ascending aorta contact area (LVZ group); no LVZs were seen in the other 73 patients (no-LVZ group). The LVZ group (vs. no-LVZ group) had a smaller aorta-LA angle (21.0 ± 7.7° vs. 24.9 ± 7.1°, p = .015), greater aorta-left-ventricle (LV) angle (131.3 ± 8.8° vs. 126.0 ± 7.9°; p = .005), greater diameter of the noncoronary cusp (NCC; 20.4 ± 2.2 vs. 19.3 ± 2.5 mm; p = .036), thinner LA wall-thickness adjacent to the NCC (2.3 ± 0.7 vs. 2.8 ± 0.8 mm; p = .006), and greater cardiothoracic ratio (percentage of the area in the thoracic area, 40.1 ± 7.1% vs. 35.4 ± 5.7%, p < .001). The aorta-LA angle correlated positively with the patients\' body mass index (BMI), and the aorta-LV angle correlated negatively with the body weight and BMI.
Conclusion
Deviation of the ascending aorta\'s course and distention of the NCC appear to be related to the development of LA anterior wall LVZs in the LA-ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with the limited thoracic space may contribute to the development of LVZs associated with AF.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print
Hayashida S, Nagashima K, Kurokawa S, Arai M, ... Iso K, Okumura Y
J Cardiovasc Electrophysiol: 08 May 2021; epub ahead of print | PMID: 33969564
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Impact:
Abstract

The utility of a novel mapping algorithm utilizing vectors and global pattern of propagation for scar-related atrial tachycardias.

Kuroda S, Wazni OM, Saliba WI, Hilow H, ... Anter E, Hussein AA
Background
Activation maps of scar-related atrial tachycardias (AT) can be challenging to interpret due to difficulty in inaccurate annotation of electrograms, and an arbitrarily predefined mapping window. A novel mapping software integrating vector data and applying an algorithmic solution taking into consideration global activation pattern has been recently described (Coherent™, Biosense Webster \"Investigational\").
Objective
We aimed to assess the investigational algorithm to determine the mechanism of AT compared with the standard algorithm.
Methods
This study included patients who underwent ablation of scar-related AT using the Carto 3 and the standard activation algorithm. The mapping data were analyzed retrospectively using the investigational algorithm, and the mechanisms were evaluated by two independent electrophysiologists.
Results
A total of 77 scar-related AT activation maps were analyzed (89.6% left atrium, median tachycardia cycle length of 273 ms). Of those, 67 cases with a confirmed mechanism of arrhythmia were used to compare the activation software. The actual mechanism of the arrhythmia was more likely to be identified with the investigational algorithm (67.2% vs. 44.8%, p = .009). In five patients with dual-loop circuits, 3/5 (60%) were correctly identified by the investigational algorithm compared to 0/5 (0%) with the standard software. The reduced atrial voltage was prone to lead to less capable identification of mechanism (p for trend: .05). The investigational algorithm showed higher inter-reviewer agreement (Cohen\'s kappa .62 vs. .47).
Conclusions
In patients with scar-related ATs, activation mapping algorithms integrating vector data and \"best-fit\" propagation solution may help in identifying the mechanism and the successful site of termination.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 May 2021; epub ahead of print
Kuroda S, Wazni OM, Saliba WI, Hilow H, ... Anter E, Hussein AA
J Cardiovasc Electrophysiol: 04 May 2021; epub ahead of print | PMID: 33955116
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Impact:
Abstract

The impact of basic atrial rhythm during catheter ablation of atrial fibrillation on clinical outcomes: Lessons from the German Ablation Registry.

Rottner L, Brachmann J, Lewalter T, Kuck KH, ... Rillig A, Metzner A
Background
The impact of basic atrial rhythm (sinus rhythm [SR] vs. atrial fibrillation [AF]) during AF ablation on efficacy and safety is unknown.
Methods
About 3375 patients from the German Ablation Registry undergoing first-time AF ablation were divided according to the type of AF and the basic atrial rhythm during the ablation procedure: paroxysmal AF (PAF) and SR [group Ia], PAF and AF [group Ib]), persistent AF and SR (IIa), and persistent AF and AF (IIb).
Results
Patients in SR (n = 2312 [67%]) underwent cryoballoon ablation more often (Ia vs. Ib p = .002 and IIa vs. IIb p = .010, whereas in patients in AF (n = 1063 [33%]) radiofrequency (RF)-based ablation (Ia vs. Ib p = .006 and IIa vs. IIb p = .014) including left and/or right atrial substrate modification was more frequently performed. Depending on the basic rhythm there was no difference regarding arrhythmia recurrence during long-term follow-up. For patients suffering from persistent AF acute procedure-related complications were more often documented when ablated in AF (9.1% vs. 4.6%, p = .012). which was mainly driven by the higher occurrence of pericardial effusion/tamponade. For patients suffering from persistent AF, favorable results were found regarding 366-day Kaplan-Meier estimates of the incidence of MACCE (death, myocardial infarction, and stroke; p = .011) and the composite endpoint of death, myocardial infarction, stroke, and major bleeding (p = .006), when ablated in SR.
Conclusion
Basic atrial rhythm at the time of AF ablation did not affect long-term rhythm outcome. For patients suffering from persistent AF a more favorable acute and long-term safety profile was observed when ablated in SR.

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

J Cardiovasc Electrophysiol: 04 May 2021; epub ahead of print
Rottner L, Brachmann J, Lewalter T, Kuck KH, ... Rillig A, Metzner A
J Cardiovasc Electrophysiol: 04 May 2021; epub ahead of print | PMID: 33955108
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Impact:
Abstract

Ultrahigh density atrio-ventricular dual-chamber mapping as a next generation tool for ablation of accessory pathways.

Mori H, Kawano D, Sumitomo N, Muraji S, ... Kato R, Matsumoto K
Introduction
Detailed three-dimensional (3D) mapping has been useful for effective radiofrequency catheter ablation. The Rhythmia system can create atrio-ventricular dual-chamber mapping, which reveals the atrial and ventricular potentials all at once in the same map. The aim of this study was to investigate the utility of mapping the atrium and ventricle simultaneously with a high-density 3D mapping system for the ablation of accessory pathways (AP).
Methods
From July 2015 to August 2020, 111 patients underwent ablation of APs. Dual-chamber maps were created in 50 patients (median age 15 [10-54], 32 male [64.0%]), while 61 patients underwent radiofrequency (RF) ablation with conventional single-chamber 3D maps. The background characteristics and procedural details were compared between the dual-chamber mapping group and the conventional single-chamber mapping group.
Results
The number of RF applications (median [IQR]; 1.0 [1.0-3.0] vs. 3.0 [1.0-6.0], p = .0023), RF time (median [IQR], s; 9.2 [2.0-95.7] vs. 95.6 [4.1-248.7], p = .0107), and RF energy (median [IQR], J; 248.4 [58.7-3328.2] vs. 2867.6 [134.2-7728.4], p = .0115) were significantly lower in the dual-chamber group. The fluoroscopy time (median [IQR], min; 19.9 [14.2-26.1] vs. 26.5 [17.7-43.4], p = .0025) and fluoroscopy dose (median [IQR], mGy; 52.5 [31.3-146.0] vs. 119.0 [43.7-213.5], p = .0249) were also significantly lower in the dual-chamber than single-chamber mapping group.
Conclusion
The dual-chamber mapping was useful for ablating accessory pathways and reducing the number of RF applications, total RF energy, and radiation exposure as compared with traditional mapping techniques.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 04 May 2021; epub ahead of print
Mori H, Kawano D, Sumitomo N, Muraji S, ... Kato R, Matsumoto K
J Cardiovasc Electrophysiol: 04 May 2021; epub ahead of print | PMID: 33955099
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Impact:
Abstract

Role of immunosuppressive therapy in the management refractory postprocedural pericarditis.

Narasimhan B, Turagam MK, Garg J, Della Rocca DG, ... Natale A, Lakkireddy D
Objective
To assess the safety and efficacy of a novel immunosuppressive regimen-combination Methotrexate/Prednisone (cMtx/P)-in the management of severe refractory rPPP.
Methods
In this multicenter, nonrandomized, retrospective, observational study, 408 consecutive patients diagnosed with persistent rPPP between 2017 and 19 were included. Patients with refractory symptoms despite 3 months of conventional therapy were initiated on a 4-week regimen of oral steroids. Persistence of symptoms at this point, that is, rPPP (n = 25; catheter based = 18, open surgical = 7) prompted therapy with Methotrexate (7.5-15 mg weekly) with folate supplementation along with low dose prednisone (5 mg PO) for a further 3 months. Patients were followed for a total of 11.3 ± 1.8 months.
Results
Treatment refractory rPPP occurred in 6.1% of the study population prompting immunosuppressive therapy with cMtx/P. All patients demonstrated complete symptom resolution following 3 months of treatment with an 85% decline in clinically significant pericardial effusions. One patient developed recurrent pericarditis during the 11-month follow-up. Therapy was well tolerated with no significant drug related adverse effects.
Conclusion
cMtx/P therapy is a safe and effective adjunct in the management of rPPP refractory to standard therapy.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 02 May 2021; epub ahead of print
Narasimhan B, Turagam MK, Garg J, Della Rocca DG, ... Natale A, Lakkireddy D
J Cardiovasc Electrophysiol: 02 May 2021; epub ahead of print | PMID: 33942420
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Impact:
Abstract

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

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

© 2020 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1346-1354
Ip JE, Xu L, Lerman BB
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1346-1354 | PMID: 33010088
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Impact:
Abstract

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

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

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1268-1280
Ravikumar V, Annoni E, Parthiban P, Zlochiver S, ... Mulpuru SK, Tolkacheva EG
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1268-1280 | PMID: 33570241
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Impact:
Abstract

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

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

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1240-1250
Miyauchi S, Tokuyama T, Shintani T, Nishi H, ... Komatsuzawa H, Nakano Y
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1240-1250 | PMID: 33590642
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Impact:
Abstract

An anatomical approach to determine the location of the sinoatrial node during catheter ablation.

Shimamoto K, Yamagata K, Nakajima K, Kamakura T, ... Nagase S, Kusano KF
Introduction
The sinoatrial node (SAN) should be identified before superior vena cava (SVC) isolation to avoid SAN injury. However, its location cannot be identified without restoring sinus rhythm. This study evaluated the usefulness of the anatomically defined SAN by comparing it with the electrically confirmed SAN (e-SAN) to predict the top-most position of e-SAN and thus establish a safe and more efficient anatomical reference for SVC isolation than the previously reported reference of the right superior pulmonary vein (RSPV) roof.
Methods and results
The e-SAN was identified as the earliest activation site in the electroanatomical map obtained during sinus rhythm. The anatomically defined SAN, the cranial edge of the crista terminalis (CT) visualized with intracardiac echocardiography (CT top), and the RSPV roof, which was obtained from the overlaid electroanatomical image of SVC and RSPV, were tagged on one map. The distance from the e-SAN to each reference was measured. Among 77 patients, the height of the e-SAN from the CT top was a median (interquartile range) of -2.0 (-8.0 to 4.0) mm. The e-SAN existed from 10 mm above the CT top or lower in 74 (96%) patients and from the RSPV roof or below in 73 (95%) patients. The reference of 10 mm above the CT top is more proximal to the right atrium than the RSPV roof and can provide longer isolatable SVC sleeves (30.0 [20.0-35.0] vs. 24.0 [18.0-30.0] mm, p < .001). The e-SAN tended to be found above the CT top when the heart rate during mapping was faster (adjusted odds ratio [95% confidence interval] per 10-bpm increase: 1.71 [1.20-2.43], p < .01).
Conclusion
The CT top is useful for predicting the upper limit of the e-SAN and can provide a better reference for SVC isolation than the RSPV roof.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1320-1327
Shimamoto K, Yamagata K, Nakajima K, Kamakura T, ... Nagase S, Kusano KF
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1320-1327 | PMID: 33600020
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Impact:
Abstract

Effect of metformin on outcomes of catheter ablation for atrial fibrillation.

Deshmukh A, Ghannam M, Liang J, Saeed M, ... Oral E, Oral H
Background
Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF). The effect of antidiabetic medications on AF or the outcomes of catheter ablation (CA) has not been well described. We sought to determine whether metformin treatment is associated with a lower risk of atrial arrhythmias after CA in patients with DM and AF.
Methods and results
A first CA was performed in 271 consecutive patients with DM and AF (age: 65 ± 9 years, women: 34%; and paroxysmal AF: 51%). At a median of 13 months after CA (interquartile range: 6-30), 100/182 patients (55%) treated with metformin remained in sinus rhythm without antiarrhythmic drug therapy, compared with 36/89 patients (40%) not receiving metformin (p = .03). There was a significant association between metformin therapy and freedom from recurrent atrial arrhythmias after CA in multivariable Cox hazards models (hazard ratio [HR]: 0.66; ±95% confidence interval [CI]: 0.44-0.98; p = .04) that adjusted for age, sex, body mass index, AF type (paroxysmal vs. nonparoxysmal), antiarrhythmic medication, obstructive sleep apnea, chronic kidney disease, coronary artery disease, left ventricular ejection fraction, and left atrial diameter. A Cox model that also incorporated other antidiabetic agents and fasting blood glucose demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with metformin treatment (HR: 0.63; ±95% CI: 0.42-0.96; p = .03).
Conclusions
In patients with DM, treatment with metformin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after CA for AF. Whether this effect is due to glycemic control or pleiotropic effects on electroanatomical mechanisms of AF remains to be determined.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1232-1239
Deshmukh A, Ghannam M, Liang J, Saeed M, ... Oral E, Oral H
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1232-1239 | PMID: 33600005
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Impact:
Abstract

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

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

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1376-1384
Irles D, Salerno F, Cassagneau R, Eschalier R, ... Frey P, Other members of the STIMulation cardiaque post-TAVI (STIM-TAVI) study
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1376-1384 | PMID: 33625762
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Impact:
Abstract

Use of the inverse solution guidance algorithm method for RF ablation catheter guidance.

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

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1281-1289
Lv W, Barrett CD, Arai T, Bapat A, ... Cohen RJ, Lee K
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1281-1289 | PMID: 33625757
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Abstract

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

Paixão GMM, Lima EM, Batista LM, Santos LF, ... Gomes PR, Ribeiro AL
Background
Ventricular pre-excitation is characterized by the presence of atrioventricular accessory pathways, predisposing to arrhythmias. Although it is well established that risk stratification in symptomatic patients should be invasive, there is a lack of evidence of the benefit in asymptomatic.
Objective
Evaluate ventricular pre-excitation in the electrocardiogram (ECG) as a risk factor for overall mortality in patients of Telehealth Network of Minas Gerais (TNMG), Brazil.
Methods
This observational study was developed with the database of digital ECGs (2010-2017) from TNMG. The electronic cohort was obtained by linking data from ECG exams and those from the national mortality information system. Only the first ECG was considered. Clinical data were self-reported, and ECGs were interpreted manually by cardiologists and automatically by the Glasgow University Interpreter software. Hazard ratio (HR) for mortality was estimated using weighted Cox regression.
Results
Nearly 1 665 667 patients were included (median age: 50 [Q1: 34; Q3: 63] years; 41.4% were male). In a mean follow-up of 3.7 years, the overall mortality rate was 3.1%. The prevalence of ventricular pre-excitation was 0.07%. In multivariate analysis, adjusting for sex and age, ventricular pre-excitation was not associated with an increased risk of mortality (HR: 1.41; 95% confidence interval [CI]: 0.56-3.57; p = .47) when compared to the whole sample or to patients with normal ECG (HR: 1.41; 95% CI: 0.53-4.36; p = .43). In a subanalysis on accessory pathway location, there was no evidence of a higher risk of death related to any location.
Conclusion
Ventricular pre-excitation was not associated with an increased risk of mortality in a primary care cohort.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1290-1295
Paixão GMM, Lima EM, Batista LM, Santos LF, ... Gomes PR, Ribeiro AL
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1290-1295 | PMID: 33650721
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Impact:
Abstract

Ventricular activation pattern assessment during right ventricular pacing: Ultra-high-frequency ECG study.

Curila K, Jurak P, Halamek J, Prinzen F, ... Leinveber P, Osmancik P
Background
Right ventricular (RV) pacing causes delayed activation of remote ventricular segments. We used the ultra-high-frequency ECG (UHF-ECG) to describe ventricular depolarization when pacing different RV locations.
Methods
In 51 patients, temporary pacing was performed at the RV septum (mSp); further subclassified as right ventricular inflow tract (RVIT) and right ventricular outflow tract (RVOT) for septal inflow and outflow positions (below or above the plane of His bundle in right anterior oblique), apex, anterior lateral wall, and at the basal RV septum with nonselective His bundle or RBB capture (nsHBorRBBp). The timings of UHF-ECG electrical activations were quantified as left ventricular lateral wall delay (LVLWd; V8 activation delay) and RV lateral wall delay (RVLWd; V1 activation delay).
Results
The LVLWd was shortest for nsHBorRBBp (11 ms [95% confidence interval = 5-17]), followed by the RVIT (19 ms [11-26]) and the RVOT (33 ms [27-40]; p < .01 between all of them), although the QRSd for the latter two were the same (153 ms (148-158) vs. 153 ms (148-158); p = .99). RV apical capture not only had a longer LVLWd (34 ms (26-43) compared to mSp (27 ms (20-34), p < .05), but its RVLWd (17 ms (9-25) was also the longest compared to other RV pacing sites (mean values for nsHBorRBBp, mSp, anterior and lateral wall captures being below 6 ms), p < .001 compared to each of them.
Conclusion
RVIT pacing produces better ventricular synchrony compared to other RV pacing locations with myocardial capture. However, UHF-ECG ventricular dysynchrony seen during RVIT pacing is increased compared to concomitant capture of basal septal myocytes and His bundle or proximal right bundle branch.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1385-1394
Curila K, Jurak P, Halamek J, Prinzen F, ... Leinveber P, Osmancik P
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1385-1394 | PMID: 33682277
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Abstract

Etiology is a predictor of recurrence after catheter ablation of ventricular arrhythmias in pediatric patients.

Gulletta S, Vergara P, Vitulano G, Foppoli L, ... Agricola E, Della Bella P
Background
Ventricular arrhythmias (VAs) are rare in pediatric patients, especially in absence of structural heart disease (SHD). Few data are available regarding the invasive VAs treatment with catheter ablation (CA) in pediatric patients and predictors of outcomes have not been fully investigated.
Objective
To describe the clinical presentation, procedural characteristics, and outcomes in pediatric patients undergoing CA for VAs.
Methods
Eighty-one consecutive pediatric patients (58 male [72%], 15.5 ± 2.2 years) treated by CA for ventricular tachycardia (VT) or premature ventricular beats (PVBs) were retrospectively evaluated. Study endpoints were VAs recurrence and mortality for any cause.
Results
Ninety-five procedures were performed in 81 patients, 52 (55%) PVBs and 43 (45%) VT ablations. During a follow-up of 35.0 months (interquartile range = 13.0-71.0), 14 patients (14.7%) had a VA recurrence: 11 (33.3%) patients treated with CA for VT and 3 (6.2%) patients treated for PVBs (p < .001). One patient (1%) died 26 months after the procedure during an electrical storm. Patients with SHD had higher VAs recurrence rate, as compared with idiopathic VAs (pairwise log-rank p < .001). Patients treated with CA for VT had higher VA recurrence rate, as compared with PVB patients (pairwise log-rank p = .002). At Cox multivariate analysis only SHD was an independent predictor of VAs recurrence (hazard ratio = 5.56, 95% confidence interval = 2.68-11.54, p < .001).
Conclusion
CA of VAs is effective and safe in a pediatric population. CA of idiopathic and fascicular VAs are associated with lower recurrence rate, than VAs in the setting of SHD.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1337-1345
Gulletta S, Vergara P, Vitulano G, Foppoli L, ... Agricola E, Della Bella P
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1337-1345 | PMID: 33682256
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Impact:
Abstract

The mechanisms of left septal and anterior wall reentrant atrial tachycardias analyzed with ultrahigh resolution mapping: The role of functional block in the circuit.

Miyazaki S, Hasegawa K, Ishikawa E, Mukai M, ... Uzui H, Tada H
Background
Low voltage areas (LVAs) are most commonly observed on the left atrial (LA) septal/anterior wall.
Objective
We explored the mechanisms of LA septal/anterior wall reentrant tachycardias (LASARTs) using ultrahigh resolution mapping.
Methods
This study included seven consecutive LASARTs in six patients (75 [62.2-82.8] years, 4 women) who underwent atrial tachycardia (AT) mapping and ablation using Rhythmia systems.
Results
The AT cycle length was 266 (239-321) ms. During ATs, 11.0 (9.0-12.9) cm2 of LVAs were identified in all, and 0.8 (0.7-1.7) cm2 of dense scar was identified in four patients. Five ATs rotated around dense scar, while two rotated around functional linear block, which was confirmed during atrial pacing after AT termination. The AT circuit length was 8.7 ± 2.1 cm with a conduction velocity of 30.4 ± 3.7 cm/s. A median of 3.0 (2.0-4.0) slow conduction areas per circuit were identified, and 17/23 (73.9%) areas were present in LVAs, while they were at the border of the LVA and normal voltage areas in the remaining 6/23 (26.1%). Global activation histograms facilitated the identification of the critical isthmus in all. Tailor-made ablation at critical isthmuses successfully eliminated all ATs. However, one patient with AT related to functional linear block experienced recurrent AT related to dense scar, which progressed after the procedure. During a mean 14 ± 13 month follow-up after the last procedure, no patients experienced recurrent ATs without any complications.
Conclusion
LASARTs consist of not only fixed conduction blocks but also functional conduction blocks. Ultrahigh resolution mapping is highly useful to decide the optimal tailor-made ablation strategy based on the mechanisms.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1305-1319
Miyazaki S, Hasegawa K, Ishikawa E, Mukai M, ... Uzui H, Tada H
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1305-1319 | PMID: 33682247
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Abstract

Quantification of artifacts during cardiac magnetic resonance in patients with leadless Micra pacemakers.

Hála P, Neužil P, Keller J, Moučka P, ... Vymazal J, Reddy V
Introduction
When cardiac magnetic resonance (MR) is performed after previous leadless transcatheter pacemaker implantation, an image distortion has to be expected in the heart region and evaluation of myocardial tissue can be affected. In this clinical prospective study, we aim to assess the extent and impact of this artifact on individual ventricular segments and compare it to conventional pacing devices.
Methods
Total of 20 patients with leadless pacemaker placed in the right ventricle underwent cardiac MR imaging in a 1.5 Tesla scanner. A multiplanar segmentation was used to demarcate the left and right ventricular myocardium as well as the pacemaker-caused image artifact in systolic and diastolic time frames. Artifact size and its relative influence on myocardial segments were quantitatively assessed and expressed in AHA-17 model.
Results
Implanted leadless pacemaker caused an image artifact with a volume of 48 ± 5 ml. Most distorted were the apical septal (53 ± 23%), apical inferior (30 ± 18%), and midventricular inferoseptal (30 ± 20%) segments. The artifact intersection with basal and lateral segments was none or negligible (up to 2%). The portion of left ventricular (LV) myocardium affected by the artifact was significantly higher in systole (8 ± 4%) compared to diastole (10 ± 3%; p < .001).
Conclusion
Implantation of leadless pacemaker represents no obstacle for cardiac MR imaging but causes an image artifact located mostly in septal, inferoseptal, and anteroseptal segments of apical and midventricular LV myocardium. With the exception of the apex, diastolic timing reduces the image distortion of all segments and improves global ventricular assessment.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1367-1375
Hála P, Neužil P, Keller J, Moučka P, ... Vymazal J, Reddy V
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1367-1375 | PMID: 33682228
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Impact:
Abstract

Predictors of permanent pacemaker insertion after TAVR: A systematic review and updated meta-analysis.

Mahajan S, Gupta R, Malik AH, Mahajan P, ... Mehta SS, Lakkireddy DR
Objectives
The aim of this analysis was to evaluate the predictors associated with increased risk of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR).
Background
While TAVR has evolved as the standard of care for patients with severe aortic stenosis, conduction abnormalities leading to the need for PPMI is one of the most common postprocedural complications.
Methods
A systematic literature search was performed to identify relevant trials from inception to May 2020. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.
Results
Thirty-seven observational studies with 71 455 patients were identified. The incidence of PPMI following TAVR was 22%. Risk was greater in men and increased with age. Patients with diabetes mellitus, presence of right bundle branch block, baseline atrioventricular conduction block, and left anterior fascicular block were noted to be at higher risk. Other significant predictors include the presence of high calcium volume in the area below the left coronary cusp and noncoronary cusp, use of self-expandable valve over balloon-expandable valve, depth of implant, valve size/annulus size, predilatation balloon valvuloplasty, and postimplant balloon dilation.
Conclusion
Fourteen factors were found to be associated with increased risk of PPMI after TAVR, suggesting early identification of high-risk populations and targeting modifiable risk factors may aid in reducing the need for this post TAVR PPMI.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1411-1420
Mahajan S, Gupta R, Malik AH, Mahajan P, ... Mehta SS, Lakkireddy DR
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1411-1420 | PMID: 33682218
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Impact:
Abstract

Subcutaneous implantable cardioverter-defibrillator electrode fracture: Follow-up, troubleshooting, and evaluation.

Kella DK, Stambler BS
The subcutaneous-implantable cardioverter-defibrillator (S-ICD) and its electrode were developed to avoid long-term complications of transvenous leads in the vasculature. We report a case of unexpected, inappropriate S-ICD shocks due to oversensing of high-amplitude, nonphysiologic, electrical noise artifacts that were not preceded by high-impedance alerts or sensing electrogram noise detections. Following explant, high-magnification X-ray imaging of the S-ICD electrode demonstrated partial fracture of the distal sensing conductor located near a short radius bend in the electrode at the electrode-header interface. Clinicians should be aware of a potential for fatigue failure fracture of the S-ICD electrode. Recommendations for systematic S-ICD follow-up and troubleshooting are discussed.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1452-1457
Kella DK, Stambler BS
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1452-1457 | PMID: 33694226
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Impact:
Abstract

Alterations in atrial electrogram amplitude as steady sinus rhythm transitions to paroxysmal atrial fibrillation during continuous monitoring in patients with implantable cardiac devices: Insights from the IMPACT study.

Kantharia BK, Lip GYH, Martin DT
Objectives
We aimed to evaluate whether device measured amplitudes of atrial electrogram (AEGM) would change when measured in sinus rhythm (SR) transitioning to paroxysmal atrial fibrillation (AF) from previous steady SR, and significance of such change.
Methods
From the IMPACT trial\'s database we selected two groups; (A) those who developed AF (n = 164), and (B) propensity-matched control (n = 459) who stayed in SR during continuous Home Monitoring (HM) to compare AEGMs amplitudes at baseline SR and transition phase.
Results
During 420.0 ± 349.2 days (mean ± SD) from first postenrollment HM transmission to AF event transmission in Group A, and corresponding 515.3 ± 407.0 days in Group B, baseline and transition AEGM amplitude were 2.88 ± 1.146 and 2.74 ± 1.186 mV, respectively, for Group A (p = .1), and 2.88 ± 1.155 and 2.79 ± 1.145, respectively, for Group B (p < .005). Comparison of differences of AEGM amplitude, 0.14 ± 1.072 mV in Group A and 0.09 ± 0.893 mV in Group B were insignificant (p = .3). Age, sex, and hypertension identified as confounders had no association to AEGM changes (p = NS).
Conclusions
Independent of age, sex, and hypertension, AEGMs amplitudes decline over a long period of time in patients with defibrillators and substrate for AF. The significance of such change remains unclear as it occurs whether patients develop AF or not, but raises a possibility of progressive atrial myopathy that patients with substrate for AF may be predisposed to.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1357-1363
Kantharia BK, Lip GYH, Martin DT
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1357-1363 | PMID: 33709486
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Impact:
Abstract

Impact of diagnosis-to-ablation time on non-pulmonary vein triggers and ablation outcomes in persistent atrial fibrillation.

Takamiya T, Nitta J, Inaba O, Sato A, ... Goya M, Sasano T
Introduction
Non-pulmonary vein (PV) triggers are a major cause of atrial tachyarrhythmia (ATA) recurrence after catheter ablation. However, the effect of the diagnosis-to-ablation time (DAT) on non-PV triggers in persistent atrial fibrillation is unknown.
Methods and results
This observational study evaluated 502 consecutive persistent AF patients who underwent initial ablation. We compared 408 patients whose DAT was <3 years with 94 patients whose DAT was ≥3 years. Following PV and posterior wall isolation, 193 non-PV triggers, including 50 AFs, 30 atrial tachycardias (ATs), and 113 repetitive atrial premature beats, were elicited and ablated in 137 (27%) patients. Specifically, 80 non-PV AF/AT triggers were provoked in 64 (13%) patients, being identified more frequently in the DAT ≥ 3 years group than in the DAT < 3 years group (20% vs. 11%, p = .025) especially with a higher prevalence of coronary sinus/inferior left atrial triggers. During a median follow-up of 770 days, the ATA recurrence-free rate was higher in the DAT < 3 years group than the DAT ≥ 3 years group (79% vs. 53% at 2 years, p < .001). In a multivariate analysis, female sex (odds ratio: 2.70, p = .002) and a longer DAT (odds ratio: 1.13/year, p = .008) were predictors of non-PV AF/AT triggers, and a longer DAT (hazard ratio: 1.12/year, p < .001) and non-PV AT/AF triggers (hazard ratio: 1.79, p = .009) were associated with ATA recurrence.
Conclusion
Early ablation after the first diagnosis of persistent AF may reduce emerging non-PV AF/AT triggers and ATA recurrence.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1251-1258
Takamiya T, Nitta J, Inaba O, Sato A, ... Goya M, Sasano T
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1251-1258 | PMID: 33713521
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Impact:
Abstract

Comparison of acute and long-term outcomes of Evolution and TightRail™ mechanical dilator sheaths during transvenous lead extraction.

Bahadır N, Canpolat U, Kaya EB, Sahiner ML, ... Yorgun H, Aytemir K
Background
Powered transvenous lead extraction (TLE) tools are commonly required to remove the leads with long implant duration due to fibrotic adhesions. However, comparative data are lacking among different types of TLE tools.
Aim
To compare the efficacy and safety of two different rotational mechanical dilator sheaths in retrospectively analyzed patients who underwent TLE.
Methods and results
A total of 566 lead extractions from 302 patients using TightRail™ (333 lead extractions from 169 patients) and Evolution® (233 lead extractions from 133 patients) mechanical dilator sheaths were performed between July 2009 and June 2018. Acute and long-term outcomes of study groups were compared. There is no statistically significant difference between Evolution® and TightRail™ groups in procedural success (93.9% vs. 94%), clinical success (99.2% vs. 98%), and major complications (3.8% vs. 1.2%), respectively (p > .05). In multivariate regression analysis, lead dwell time, the number of extracted leads, and baseline leukocyte count were found as independent predictors of procedural success (p < .05). During the median follow-up of 36.6 (0.2-118) months, all-cause mortality was observed in 73 patients (25.6% in the Evolution® vs. 23.1 in the TightRail™ group, p > .05). Chronic renal disease, heart failure, and coagulopathy were shown as independent predictors of all-cause mortality in multivariate regression analysis (p < .05).
Conclusion
TLE using TightRail™ or Evoluation® mechanical dilator sheaths was a safe and effective therapeutic option. Both mechanical dilator sheaths showed similar efficacy, safety, and all-cause mortality at acute and long-term follow-up of patients who underwent TLE.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1395-1404
Bahadır N, Canpolat U, Kaya EB, Sahiner ML, ... Yorgun H, Aytemir K
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1395-1404 | PMID: 33724617
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Impact:
Abstract

Combined management of esophagopericardial fistula sustained after catheter ablation for atrial fibrillation.

Dhaliwal KK, Pawa R, Lata AL
Introduction
Radiofrequency ablation (RFA) is an effective treatment modality for atrial fibrillation (AF); however, serious complications can occur. We present the case of a highly morbid consequence, the esophagopericardial fistula (EPF).
Case
A hemodynamically unstable patient with a history of AF and recent RFA presented with chest pain and was found to have pneumopericardium and pericardial effusion. The patient went to the operating room emergently for combined management with surgical pericardial window and endoscopic stent placement.
Conclusion
EPF must be on the differential diagnosis while evaluating patients who develop constitutional symptoms or sudden onset chest pain days or weeks after catheter ablation for AF. Early detection followed by aggressive management with a combined surgical and endoscopic approach may be considered for successful treatment of this type of postablation esophageal perforation if an atrioesophageal fistula is effectively ruled out.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1449-1451
Dhaliwal KK, Pawa R, Lata AL
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1449-1451 | PMID: 33724615
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Impact:
Abstract

Renal denervation for the treatment of ventricular arrhythmias: A systematic review and meta-analysis.

Prado GM, Mahfoud F, Lopes RD, Moreira DAR, ... Ukena C, Armaganijan LV
Introduction
Ventricular arrhythmias (VAs) are a major cause of morbidity and mortality in patients with heart disease. Recent studies evaluated the effect of renal denervation (RDN) on the occurrence of VAs. We conducted a systematic review and meta-analysis to determine the efficacy and safety of this procedure.
Methods and results
A systematic search of the literature was performed to identify studies that evaluated the use of RDN for the management of VAs. Primary outcomes were reduction in the number of VAs and implantable cardioverter-defibrillator (ICD) therapies. Secondary outcomes were changes in blood pressure and renal function. Ten studies (152 patients) were included in the meta-analysis. RDN was associated with a reduction in the number of VAs, antitachycardia pacing, ICD shocks, and overall ICD therapies of 3.53 events/patient/month (95% confidence interval [CI] = -5.48 to -1.57), 2.86 events/patient/month (95% CI = -4.09 to -1.63), 2.04 events/patient/month (95% CI = -2.12 to -1.97), and 2.68 events/patient/month (95% CI = -3.58 to -1.78), respectively. Periprocedural adverse events occurred in 1.23% of patients and no significant changes were seen in blood pressure or renal function.
Conclusions
In patients with refractory VAs, RDN was associated with a reduction in the number of VAs and ICD therapies, and was shown to be a safe procedure.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1430-1439
Prado GM, Mahfoud F, Lopes RD, Moreira DAR, ... Ukena C, Armaganijan LV
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1430-1439 | PMID: 33724602
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Impact:
Abstract

High-power, short-duration atrial fibrillation ablation compared with a conventional approach: Outcomes and reconnection patterns.

Hansom SP, Alqarawi W, Birnie DH, Golian M, ... Nair GM, Sadek MM
Background
The effectiveness, safety, and pulmonary vein (PV) reconnection patterns of point-by-point high-power, short-duration (HPSD) ablation relative to conventional force-time integral (FTI)-guided strategies for atrial fibrillation (AF) ablation are unknown.
Objectives
To compare 1-year freedom from atrial arrhythmia (AA), complication rates, procedural times, and PV reconnection patterns with HPSD AF AF ablation versus an FTI-guided low-power, long-duration (LPLD) strategy.
Methods
We compared consecutive patients undergoing a first ablation procedure for paroxysmal or persistent AF. The HPSD protocol utilized a power of 50 W and durations of 6-8 s posteriorly and 8-10 s anteriorly. The LPLD protocol was FTI-guided with a power of ≤25 W posteriorly (FTI ≥ 300g·s) and ≤35 W anteriorly (FTI ≥ 400g·s).
Results
In total, 214 patients were prospectively included (107 HPSD, 107 LPLD). Freedom from AA at 1 year was achieved in 79% in the HPSD group versus 73% in the LPLD group (p = .339; adjusted hazard ratio with HPSD, 0.67; 95% confidence interval, 0.36-1.23; p < .004 for non-inferiority). Procedure duration was shorter in the HPSD group (229 ± 60 vs. 309 ± 77 min; p < .005). Patients undergoing repeat ablation had a higher propensity for reconnection at the right PV carina in the HPSD group compared with the LPLD group (14/30 = 46.7% vs. 7/34 = 20.6%; p = .035). There were no differences in complication rates.
Conclusion
HPSD AF ablation resulted in similar freedom from AAs at 1 year, shorter procedure times, and a similar safety profile when compared with an LPLD ablation strategy. Patients undergoing HPSD ablation required more applications at the right carina to achieve isolation, and had a significantly higher rate of right carinal reconnections at redo procedures.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1219-1228
Hansom SP, Alqarawi W, Birnie DH, Golian M, ... Nair GM, Sadek MM
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1219-1228 | PMID: 33751694
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Impact:
Abstract

Left atrial thickness and acute thermal injury in patients undergoing ablation for atrial fibrillation: Laser versus radiofrequency energies.

Gao X, Chang D, Bilchick KC, Hussain SK, ... Neuzil P, Mangrum JM
Introduction
Thermally induced cardiac lesions result in necrosis, edema, and inflammation. This tissue change may be seen with ultrasound. In this study, we sought to use intracardiac echocardiography (ICE) to evaluate pulmonary vein tissue morphology and assess the acute tissue changes that occur following radiofrequency (RF) or laser ablation for atrial fibrillation (AF).
Methods and results
Patients with AF underwent pulmonary vein isolation (PVI) using irrigated RF or laser balloon. Pre- and post-ablation ICE imaging was performed from within each pulmonary vein (PV). At least 10 transverse imaging planes per PV were evaluated and each plane was divided into eight segments. The PV/atrial wall thickness and the luminal area were measured at each segment. Twenty-seven patients underwent PVI (15 with laser, 12 with RF). Ninety-eight pulmonary veins were analyzed (58 PVs laser; 40 PVs RF). At baseline, there were no regional differences in PV wall thickness in the right-sided veins. The anterior regions of left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) were significantly thicker compared with the posterior and inferior regions (p < .01). Post-ablation, PV wall thickness in RF group increased 24.1% interquartile range (IQR) (17.2%-36.7%) compared with 1.2% IQR (0.4%-8.9%) in laser group, p = .004. In all PVs, RF ablation resulted in significantly greater percent increase in wall thickness compared with laser. Additionally, RF resulted in more variable changes in regional PV wall thickness; with more increases in wall thickness in anterior versus posterior LSPV (75.4 ± 58.5% vs. 46.8 ± 55.6%, p < .01), anterior versus posterior right superior pulmonary vein (RSPV) (62.9 ± 63.9% vs. 44.6 ± 51.7%, p < .05), and superior versus inferior RSPV (69.1 ± 45.4% vs. 35.9 ± 45%, p < .05). There were no significant regional differences in PV wall thickness changes for the laser group.
Conclusions
Rotational ICE can be used to measure acute tissue changes with ablation. Regional variability in baseline wall thickness was nonuniformly present in PVs. Acute tissue changes occurred immediately post-ablation. Compared with laser balloon, RF shows markedly more thickening post-ablation with significant regional variations.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1259-1267
Gao X, Chang D, Bilchick KC, Hussain SK, ... Neuzil P, Mangrum JM
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1259-1267 | PMID: 33760290
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Abstract

Navigating inferior vena cava filters in invasive cardiology procedures: A systematic review.

Shah K, Patel S, Hanson I, Williamson B, ... Haines DE, Mehta NK
Background
Transfemoral venous access (TFV) is the cornerstone of minimally invasive cardiac procedures. Although the presence of inferior vena cava filters (IVCFs) was considered a relative contraindication to TFV procedures, small experiences have suggested safety. We conducted a systematic review of the available literature on cardiac procedural success of TFV with IVCF in-situ.
Methods
Two independent reviewers searched PubMed, EMBASE, SCOPUS, and Google Scholar from inception to October 2020 for studies that reported outcomes in patients with IVCFs undergoing TFV for invasive cardiac procedures. We investigated a primary outcome of acute procedural success and reviewed the pooled data for patient demographics, procedural complications, types of IVCF, IVCF dwell time, and procedural specifics.
Results
Out of the 120 studies initially screened, 8 studies were used in the final analysis with a total of 100 patients who underwent 110 procedures. The most common IVCF was the Greenfield Filter (36%), 60% of patients were males and the mean age was 67.8 years. The overall pooled incidence of acute procedural success was 95.45% (95% confidence interval = 89.54-98.1) with no heterogeneity (I2  = 0%, p = 1) and there were no reported filter-related complications.
Conclusion
This systematic review is the largest study of its kind to demonstrate the safety and feasibility of TFV access in a variety of cardiac procedures in the presence of IVCF.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1440-1448
Shah K, Patel S, Hanson I, Williamson B, ... Haines DE, Mehta NK
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1440-1448 | PMID: 33772931
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Abstract

Chronic rate dependent exit block after pulmonary vein isolation.

Makker P, Dulmovits E, Beldner S
Rate dependent exit block across the pulmonary veins has been previously described immediately following catheter ablation. We report a case of rate dependent pulmonary vein exit block seen at repeat ablation 7 years after the index procedure. To our knowledge, this is the first report of chronic rate dependent exit block discovered years after circumferential pulmonary vein antral isolation.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1458-1460
Makker P, Dulmovits E, Beldner S
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1458-1460 | PMID: 33772918
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Abstract

Cardiac perforation due to a fracture of a recalled Accufix bipolar active fixation pacing lead 29 years after implantation: A case report.

Kimura T, Kitamura T, Tokioka S, Takahashi M, Hojo R, Fukamizu S
The Accufix bipolar active fixation atrial pacing lead (Model 330-801; Telectronics) can have mechanical complications due to a fracture of its J retention wire. An 80-year-old man had the Accufix atrial pacing lead implanted 29 years prior, and surgical removal was required because a part of the lead was perforating the apex of the right ventricle. Regular follow-up examinations are recommended to eliminate the possibility of protrusion and detachment of the J retention wire, even if the clinical course after implantation is stable for a prolonged period.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1461-1463
Kimura T, Kitamura T, Tokioka S, Takahashi M, Hojo R, Fukamizu S
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1461-1463 | PMID: 33783898
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Abstract

Transvenous lead extraction in patients with persistent left superior vena cava.

Curnis A, Aboelhassan M, Cerini M, Salghetti F, ... Fouad DA, Bontempi L
Purpose
Predictors of difficulty and complications of transvenous lead extraction (TLE) have been investigated in several studies; however, little is known about the venous anatomical characteristics that can have an impact on procedural outcomes. Among them, the persistent left superior vena cava (PLSVC) is a common anomaly often discovered incidentally during cardiac device implantation and could raise concerns if TLE is indicated. We report technical considerations and outcomes of TLE for two patients with leads implanted via PLSVC.
Methods and results
Two cardiac implantable electronic device recipients with isolated PLSVC required TLE due to infective endocarditis in one case and lead failure in the other. In the first case, TLE procedure was performed in a hybrid operating room with minimally invasive video-assisted thoracoscopic monitoring due to the high procedural risk. Two active fixation 20-year-old pacing leads were removed with a relatively short fluoroscopy time. In the second case, we successfully extracted a single-coil active fixation lead without the need of a locking stylet or advanced extraction tools. There were no procedural complications or adverse events at 1-year follow-up.
Conclusion
TLE procedures for two patients with isolated PLSVC were successfully completed with less difficulty and tools than expected based on the characteristics of the targeted leads. If indicated, TLE in the presence of a PLSVC should be considered in experienced centers.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1407-1410
Curnis A, Aboelhassan M, Cerini M, Salghetti F, ... Fouad DA, Bontempi L
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1407-1410 | PMID: 33783892
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Abstract

Minimal fluoroscopy approach for right-sided supraventricular tachycardia ablation with a novel ablation technology: Insights from the multicenter CHARISMA clinical registry.

Cauti FM, Rossi P, La Greca C, Piro A, ... Bianchi S, Anselmino M
Background
No data exist on the ability of the novel Rhythmia 3-D mapping system to minimize fluoroscopy exposure during transcatheter ablation of arrhythmias. We report data on the feasibility and safety of a minimal fluoroscopic approach using this system in supraventricular tachycardia (SVT) procedures.
Methods
Consecutive patients were enrolled in the CHARISMA registry at 12 centers. All right-sided procedures performed with the Rhythmia mapping system were analyzed. The acquired electroanatomic information was used to reconstruct 3-D cardiac geometry; fluoroscopic confirmation was used whenever deemed necessary.
Results
Three hundred twenty-five patients (mean age = 56 ± 17 years, 57% male) were included: 152 atrioventricular nodal reentrant tachycardia, 116 atrial flutter, 41 and 16 right-sided accessory pathway and atrial tachycardia, respectively. Overall, 27 481 s of fluoroscopy were used (84.6 ± 224 s per procedure, equivalent effective dose = 1.1 ± 3.7 mSv per patient). One hundred ninety-two procedures (59.1%) were completed without the use of fluoroscopy (zero fluoroscopy, ZF). In multivariate analysis, the presence of a fellow in training (OR = 0.15, 95% CI: 0.05-0.46; p = .0008), radiofrequency application (0.99, 0.99-1.00; p = .0002), and mapping times (0.99, 0.99-1.00; p = .042) were all inversely associated with ZF approach. Acute procedural success was achieved in 97.8% of the cases (98.4 vs. 97% in the ZF vs. non-ZF group; p = .4503). During a mean of 290.7 ± 169.6 days follow-up, no major adverse events were reported, and recurrence of the primary arrhythmia was 2.5% (2.1 vs. 3% in the ZF vs. non-ZF group; p = .7206).
Conclusions
The Rhythmia mapping system permits transcatheter ablation of right-sided SVT with minimal fluoroscopy exposure. Even more, in most cases, the system enables a ZF approach, without affecting safety and efficacy.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1296-1304
Cauti FM, Rossi P, La Greca C, Piro A, ... Bianchi S, Anselmino M
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1296-1304 | PMID: 33783875
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Abstract

Electrophysiologic and electroanatomic characterization of ventricular arrhythmias in non-compaction cardiomyopathy: A systematic review.

Bhaskaran A, Campbell T, Virk S, Bennett RG, Kizana E, Kumar S
Background
Non-compaction cardiomyopathy (NCCM) is a form of structural heart disease prone to ventricular arrhythmias (VAs) and sudden cardiac death. Non-compacted myocardium may harbor VA substrate, though some reports suggest otherwise.
Objective
This study aimed to characterize the electrophysiologic (EP) features of VA in NCCM.
Methods
We performed a systematic review of case reports, case series, and observational studies.
Results
One hundred and thirty-five cases of NCCM from studies between 2000 and 2020 were included. Mean age was 34 ± 20 years, mean left ventricular (LV) ejection fraction was 42 ± 15% with two cases having late gadolinium enhancement on magnetic resonance imaging. The LV apex was the most common non-compacted segment (86%); 10% involved the right ventricle (RV). Antiarrhythmic failure was documented in 16 cases, of which 50% failed more than one agent. Only 23% of monomorphic VAs localized to regions of non-compaction on electrocardiogram. Most frequently, VAs localized to the RV outflow tract (n = 21), posterior fascicle (n = 19), and anterolateral LV apex (n = 9). All cases with apical exits arose from the non-compacted myocardium. On EPS, 83% of sustained VTs were due to re-entry, 17% due to focal mechanism. Catheter ablation was performed in 39 cases, with 7 requiring more than 1 procedure. Acute VA non-inducibility was achieved in 82% and VA-free survival was reported in 85% over a mean follow-up of 24 months.
Conclusion
The majority of VAs in NCCM arise remotely from non-compacted myocardium, and non-re-entrant mechanism seen in ~1/5th of sustained VTs. Catheter ablation outcomes appear favorable. Further study is needed to understand the pathophysiology of VA in NCCM.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1421-1429
Bhaskaran A, Campbell T, Virk S, Bennett RG, Kizana E, Kumar S
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1421-1429 | PMID: 33792994
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Abstract

Influence of baseline inducibility and activation mapping on ablation outcomes in patients with structural heart disease and ventricular tachycardia.

Cano Ó, Pérez-Roselló V, Ayala HD, Izquierdo M, ... Sancho-Tello MJ, Martínez-Dolz L
Introduction
Stand-alone substrate ablation has become a standard ventricular tachycardia (VT) ablation strategy. We sought to evaluate the influence of baseline VT inducibility and activation mapping on ablation outcomes in patients with structural heart disease (SHD) undergoing VT ablation.
Methods
Single center, observational and retrospective study including consecutive patients with SHD and documented VT undergoing ablation. Baseline VT induction was attempted before ablation in all patients and VT activation mapping performed when possible. Ablation was guided by activation mapping for mappable VTs plus substrate ablation for all patients. Ablation outcomes and complications were evaluated.
Results
One hundred and sixty patients were included and were classified in three groups according to baseline VT inducibility:group 1 (non inducible, n = 18), group 2 (1 VT morphology induced, n = 53), and group 3 (>1 VT morphology induced, n = 89). VT activation mapping was possible in 35%. After a median follow-up of 38.5 months, baseline inducibility of greater than 1 VT morphology was associated with a significant incidence of VT recurrence (42% for group 3 vs. 15.1% for group 2% and 5.6% for group 1, Log-rank p < .0001) and activation mapping with a lower rate of VT recurrence (24% vs. 36.3%, Log-rank p = .035). Baseline inducibility of greater than 1 VT morphology (hazards ratio [HR]: 12.05, 95% confidence interval [CI]: 1.60-90.79, p = .016) was an independent predictor of VT recurrence while left ventricular ejection fraction less than 30% (HR: 1.93, 95% CI: 1.13-3.25, p = .014) and advanced heart failure (HR: 4.69, 95% CI: 2.75-8.01, p < .0001) were predictors of mortality or heart transplantation. Complications occurred in 11.2% (5.6% hemodynamic decompensation).
Conclusion
Baseline VT inducibility and activation mapping may add significant prognostic information during VT ablation procedures.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1328-1336
Cano Ó, Pérez-Roselló V, Ayala HD, Izquierdo M, ... Sancho-Tello MJ, Martínez-Dolz L
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1328-1336 | PMID: 33834564
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Abstract

Repositioning and extraction of stylet-driven pacing leads with extendable helix used for left bundle branch area pacing.

le Polain de Waroux JB, Wielandts JY, Gillis K, Hilfiker G, ... Duytschaever M, Tavernier R
Conventional stylet-driven leads with extendable helix can be implanted successfully for left bundle branch area pacing (LBBAP) with a low acute complication rate. We report two cases in which lead repositioning after a first unsuccessful attempt to LBBAP was associated with fracture of the helix rotating mechanism and failure to fully extract the pacing lead.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1464-1466
le Polain de Waroux JB, Wielandts JY, Gillis K, Hilfiker G, ... Duytschaever M, Tavernier R
J Cardiovasc Electrophysiol: 29 Apr 2021; 32:1464-1466 | PMID: 33825263
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Abstract

Comparison of the lesion formation and safety in ex vivo porcine heart study: Using ThermoCool SmartTouch and ThermoCool SmartTouch-SF catheters.

Guo M, Qu L, Zhang N, Yan R, ... Sun M, Wang R
Background
The study was performed to compare the efficacy and safety during radiofrequency ablation (RFA) using ThermoCool SmartTouch (ST) and ThermoCool SmartTouch-SF (STSF) catheters in the porcine heart.
Methods and results
RFA was performed on the porcine myocardium by using two irrigated ablation catheters. Three groups were divided based on the different contact forces (CFs): low contact force (LCF) (1-3 g), medium contact force (MCF) (5-10 g), and high contact force (HCF) (15-20 g). In each group, RFA was delivered at four power settings of 30, 40, 50, 60 W. At each power, RFA was applied to reach the target ablation index (AI) of 350, 450, and 500. Altogether, 360 RF lesions were created by using 72 ablation conditions. AI value was positively correlated with lesion size using ST and STSF catheters. At a fixed power, lesion dimensions significantly smaller in the LCF group, whereas did not differ between MCF and HCF groups. Furthermore, at a fixed CF, lesion dimensions increased with power set at 40 W compared with 30 W but decreased with high-power RF energy (50 and 60 W). Although the average lesion surface diameter and the maximum diameter was increased using the STSF catheter, there were no significant differences in LV between the two catheters. The steam pop provoked more frequently using ST catheter and showed a negative correlation with CF and positive correlation with high-power energy.
Conclusion
The STSF catheter is safer and equally effective in lesion formation compared with the ST catheter. LV was increased along with the early increase of CF and power, whereas a further increase of CF and power significantly reduces the lesion size.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print
Guo M, Qu L, Zhang N, Yan R, ... Sun M, Wang R
J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print | PMID: 33928716
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Abstract

Behavior of AV synchrony pacing mode in a leadless pacemaker during variable AV conduction and arrhythmias.

Garweg C, Khelae SK, Chan JYS, Chinitz L, ... Kristiansen N, Steinwender C
Introduction
MARVEL 2 assessed the efficacy of mechanical atrial sensing by a ventricular leadless pacemaker, enabling a VDD pacing mode. The behavior of the enhanced MARVEL 2 algorithm during variable atrio-ventricular conduction (AVC) and/or arrhythmias has not been characterized and is the focus of this study.
Methods
Of the 75 patients enrolled in the MARVEL 2 study, 73 had a rhythm assessment and were included in the analysis. The enhanced MARVEL 2 algorithm included a mode-switching algorithm that automatically switches between VDD and ventricular only antibradycardia pacing (VVI)-40 depending upon AVC status.
Results
Forty-two patients (58%) had persistent third degree AV block (AVB), 18 (25%) had 1:1 AVC, 5 (7%) had variable AVC status, and 8 (11%) had atrial arrhythmias. Among the 42 patients with persistent third degree AVB, the median ventricular pacing (VP) percentage was 99.9% compared to 0.2% among those with 1:1 AVC. As AVC status changed, the algorithm switched to VDD when the ventricular rate dropped less than 40 bpm. During atrial fibrillation (AF) with ventricular response greater than 40 bpm, VVI-40 mode was maintained. No pauses longer than 1500 ms were observed. Frequent ventricular premature beats reduced the percentage of AV synchrony. During AF, the atrial signal was of low amplitude and there was infrequent sensing.
Conclusion
The mode switching algorithm reduced VP in patients with 1:1 AVC and appropriately switched to VDD during AV block. No pacing safety issues were observed during arrhythmias.

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

J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print
Garweg C, Khelae SK, Chan JYS, Chinitz L, ... Kristiansen N, Steinwender C
J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print | PMID: 33928713
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Abstract

Progressive increase in activation delay during premature stimulation is related to ventricular fibrillation in Brugada syndrome.

Hasegawa Y, Izumi D, Ikami Y, Otsuki S, ... Chinushi M, Minamino T
Introduction
The local conduction delay has been deemed to play an important role in the perpetuation of ventricular fibrillation (VF) in Brugada syndrome (BrS). We evaluated the relationship between the activation delay during programmed stimulation and cardiac events in BrS patients.
Methods
This study included 47 consecutive BrS patients who underwent an electrophysiological study and received implantable cardiac defibrillator therapy. We divided the patients into two groups based on whether they had developed VF (11 patients) or not (36 patients) during the follow-up period of 89 ± 53 months. The activation delay was assessed using the interval between the stimulus and the QRS onset during programmed stimulation. The mean increase in delay (MID) was used to characterize the conduction curves.
Results
The MID at the right ventricular outflow tract (RVOT) was significantly greater in patients with VF (4.5 ± 1.2 ms) than in those without VF (2.2 ± 0.9 ms) (p < .001). A receiver operating characteristics curve analysis indicated that the optimal cut-off point for discriminating VF occurrence was 3.3 with 88.9% sensitivity and 91.3% specificity. Furthermore, patients with an MID at the RVOT ≥ 3.3 ms showed significantly higher rates of VF recurrence than those with an MID at the RVOT < 3.3 ms (p < .001). The clinical characteristics, including the signal-averaged electrocardiogram measurement and VF inducibility were similar between the two groups.
Conclusion
A prolonged MID at the RVOT was associated with VF and maybe an additional electrophysiological risk factor for VF in BrS patients.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print
Hasegawa Y, Izumi D, Ikami Y, Otsuki S, ... Chinushi M, Minamino T
J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print | PMID: 33928698
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Abstract

Mapping and Ablation of Post-AF Atrial Tachycardias.

Chugh A
Atrial tachycardias (AT) are commonly encountered in patients undergoing catheter ablation of persistent atrial fibrillation (AF). Unlike typical atrial flutter that can be readily recognized and ablated, these post-AF tachycardias can arise from a wide variety of locations and involve a multiplicity of mechanisms. Apart from diagnostic challenges, radiofrequency ablation to eliminate the tachycardias may require multiple approaches. In addition, specialized techniques such as epicardial and chemical ablation may be required for definitive treatment. This review describes the various mechanisms and approaches to mapping and ablation of these challenging tachycardias This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print
Chugh A
J Cardiovasc Electrophysiol: 28 Apr 2021; epub ahead of print | PMID: 33928695
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Abstract

Uninterrupted versus interrupted direct oral anticoagulation for catheter ablation of atrial fibrillation: A systematic review and meta-analysis.

Asad ZUA, Akhtar KH, Jafry AH, Khan MH, ... Lakkireddy DR, Gopinathannair R
Introduction
To evaluate the safety of uninterrupted versus interrupted direct oral anticoagulation (DOAC) for patients undergoing catheter ablation (CA) of atrial fibrillation (AF).
Methods
We conducted a systematic search of MEDLINE and EMBASE for randomized controlled trials (RCT) and observational studies comparing uninterrupted versus interrupted DOAC for patients undergoing CA of AF. Primary outcome was major bleeding. Secondary outcomes included minor bleeding, stroke or transient ischemic attack (TIA) or thromboembolism (TE), silent cerebral ischemic events, and cardiac tamponade. Meta-analysis was stratified by study design. Risk ratios (RR) with 95% confidence intervals were calculated using random effects model and Mantel-Haenszel method was used to pool RR.
Results
A total of 13 studies (7 randomized, 6 observational) comprising 3595 patients were included. The RCT restricted analysis did not show any difference in terms of major bleeding (risk ratio [RR] = 0.79; [0.35-1.79]), minor bleeding (RR = 0.99 [0.68-1.43]), stroke or TIA or TE (RR = 0.80 [0.19-3.32]), silent cerebral ischemic events (RR = 0.64 [0.32-1.28]), and cardiac tamponade (RR = 0.61 [0.20-1.92]). Observational study restricted analysis showed a protective effect of uninterrupted DOAC on silent cerebral ischemic events (RR = 0.45 [0.31-0.67]) and no difference in other outcomes.
Conclusions
There is no difference in bleeding and thromboembolic outcomes with uninterrupted versus interrupted DOAC for CA of AF and observational data suggests that uninterrupted DOACs are protective against silent cerebral ischemic lesions.

© 2021 Wiley Periodicals LLC.

J Cardiovasc Electrophysiol: 15 Apr 2021; epub ahead of print
Asad ZUA, Akhtar KH, Jafry AH, Khan MH, ... Lakkireddy DR, Gopinathannair R
J Cardiovasc Electrophysiol: 15 Apr 2021; epub ahead of print | PMID: 33861494
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