Journal: J Cardiovasc Electrophysiol

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Abstract

Cryoballoon for heart failure: Time to consider earlier.

Yalin K, Ikitimur B
Atrial fibrillation (AF) is common in patients with heart failure and presence of AF increases the risk of acute decompensation and hospitalizations in those patients This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print
Yalin K, Ikitimur B
J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print | PMID: 36168870
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Abstract

Combined Atrial Fibrillation Ablation and Balloon Mitral Commissurotomy in Patients with Rheumatic Mitral Stenosis.

Díez-Delhoyo F, Sánchez De La Nava AM, Sanz-Ruiz R, Avila P, ... Atienza F, Fernández-Avilés F
Introduction
Ablation of atrial fibrillation (AF) is usually not considered in patients with rheumatic mitral stenosis (RMS). We analyzed the results of a combined procedure of AF ablation and percutaneous balloon mitral commissurotomy (PBMC).
Methods
We prospectively included 22 patients with severe RMS to undergo a combined PBMC+AF ablation procedure. Non-invasive mapping of the atria was also performed. A historical sample of propensity-scored matched patients who underwent PBMC alone was used as controls. The primary endpoint was freedom from AF/AT at 1-year. Multivariate analysis evaluated sinus rhythm (SR) predictors.
Results
Successful pulmonary vein isolation and ECGi-based drivers ablation was performed in 20 patients following PBMC. At 1-year, 75% of the patients in the combined group were in SR compared to 40% in the propensity-score matched group (p=0.004). The composite of AF recurrence, need for mitral surgery and all-cause mortality was also more frequent in the control group (65% vs. 30%; p=0.005). Catheter ablation (OR 1.58; 95% CI [1.17-17.37]; p=0.04) and AF type (OR 1.46; 95% CI [1.05-82.64]; p<0.001) were the only independent predictors of SR at 1-year. Non-invasive mapping in the combined group showed that the number of simultaneous rotors (OR 2.10; 95% CI [1.41-10.2]; p=0.04) was the only independent predictor of AF.
Conclusion
A combined procedure of AF ablation and PBMC significantly increased the proportion of patients in sinus rhythm at 1-year. Non-invasive mapping may help to improve AF characterization and guide personalized AF treatment. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print
Díez-Delhoyo F, Sánchez De La Nava AM, Sanz-Ruiz R, Avila P, ... Atienza F, Fernández-Avilés F
J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print | PMID: 36168873
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Abstract

Efficacy and feasibility of cryoballoon ablation for atrial fibrillation in patients with heart failure: A large-scale multicenter study.

Yanagisawa S, Suzuki H, Kanzaki Y, Ishikawa S, ... Inden Y, Murohara T
Introduction
Data are limited regarding outcomes of cryoballoon ablation for atrial fibrillation (AF) in patients with heart failure (HF). This large-scale multicenter study aimed to evaluate the prognosis of patients with HF after cryoballoon ablation for AF.
Methods
Among 3,655 patients undergoing cryoballoon ablation at 17 institutions, 549 patients (15%) (391 with paroxysmal AF and 158 with persistent AF) diagnosed with HF preoperatively were analyzed. Clinical endpoints were recurrence, mortality, and HF hospitalization after ablation.
Results
Most patients had a preserved left ventricular ejection fraction (LVEF) ≥50%. During a mean follow-up period of 25.7 months, recurrence, all-cause death, and HF hospitalization occurred in 29%, 4.0%, and 4.8%, respectively. Cardiac function on echocardiography and B-type natriuretic peptide (BNP) levels significantly improved postoperatively, and the effect was more pronounced in the non-recurrence group. Major complications occurred in 33 patients (6.0%), but most complications were phrenic nerve palsy (3.6%). Although death and HF hospitalization occurred more frequently in patients with LVEF ≤40% (n=73) and New York Heart Association (NYHA) class III-IV (n=19) than other subgroups, the BNP levels and LVEF significantly improved after ablation in all LVEF and NYHA class subgroups. High BNP levels, NHYA class, CHADS2 score, and structural heart disease, but not post-ablation recurrence, independently predicted death and HF hospitalization on multivariate analysis. The patients with tachycardia-induced cardiomyopathy had better recovery of BNP levels and LVEF after ablation than those with structural heart disease.
Conclusions
Cryoballoon ablation for AF in HF patients is feasible and leads to significantly improved cardiac function. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print
Yanagisawa S, Suzuki H, Kanzaki Y, Ishikawa S, ... Inden Y, Murohara T
J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print | PMID: 36168875
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Abstract

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

Tondo C
I read with interest the Letter form Dillan and co-workers about the information they provided of an additional analysis comparing the safety and feasibility of two commonly used CT processing software package modalities, TeraRecon and TruPlan for pre-procedural planning of LAA occlusion using the Watchman Flex device. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print
Tondo C
J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print | PMID: 36168876
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Abstract

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

Dallan LAP, Rana MA, Arruda M, Yoon SH, Filby SJ
We have read with great interest the editorial entitled, \"Seize the day, …s(e)ize the device\" by Tondo, C This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print
Dallan LAP, Rana MA, Arruda M, Yoon SH, Filby SJ
J Cardiovasc Electrophysiol: 28 Sep 2022; epub ahead of print | PMID: 36168878
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Abstract

Intracardiac Echocardiography from Coronary Sinus.

Garg J, Kewcharoen J, Bhardwaj R, Contractor T, Jain S, Mandapati R
Intracardiac echocardiography (ICE) has become an essential tool and is an integral part of percutaneous interventional and electrophysiology (EP) procedures. Intracardiac echocardiography offers real-time, high-quality, near-field evaluation of cardiac anatomy. Standard ICE imaging includes placing the catheter in the right atrium (RA), right ventricle (RV), or left atrium (LA, via the transeptal approach). Coronary sinus echocardiography (CSE) is another alternative, where the ICE catheter is positioned in the coronary sinus (CS). This approach offers better catheter stability and allows operators to visualize cardiac structure with particularly excellent views of the LA, LAA, left ventricle (LV), and mitral annulus. Additionally, CSE is an attractive alternative in cases with unfavorable interatrial septum or fossa ovalis anatomical features that could lead to difficulty advancing ICE catheter in left atrium. In this article focusing on CSE, we provide illustration-based guidance to help operators identify critical cardiac structures from CSE. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 24 Sep 2022; epub ahead of print
Garg J, Kewcharoen J, Bhardwaj R, Contractor T, Jain S, Mandapati R
J Cardiovasc Electrophysiol: 24 Sep 2022; epub ahead of print | PMID: 36153661
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Abstract

Dynamic changes in atrial activation sequence during supraventricular tachycardia.

Gulcu O, Merovci I, Tuncez A, Kara M, ... Aras D, Topaloglu S
A 29-year-old woman presented with repeated paroxysms of palpitations resulting from a rapid narrow QRS complex tachycardia (NCT) This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Sep 2022; epub ahead of print
Gulcu O, Merovci I, Tuncez A, Kara M, ... Aras D, Topaloglu S
J Cardiovasc Electrophysiol: 23 Sep 2022; epub ahead of print | PMID: 36150136
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Abstract

Urgent Desensitization for Severe Amiodarone Intolerance with a 12-Step Protocol.

Purtell C, Mehta M, Steele R, Schoenfeld M
A 68-year-old man with severe nonischemic cardiomyopathy presented with cardiogenic shock and electrical storm. The patient had recently experienced a severe skin reaction to amiodarone and did not respond to alternative antiarrhythmic therapies. He underwent an emergent desensitization protocol and was able to tolerate amiodarone within 12 hours. This was effective at suppressing electrical storm and did not lead to any further allergic or hemodynamic issues. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Sep 2022; epub ahead of print
Purtell C, Mehta M, Steele R, Schoenfeld M
J Cardiovasc Electrophysiol: 23 Sep 2022; epub ahead of print | PMID: 36150137
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Abstract

A wide QRS tachycardia with the short and long ventriculoatrial interval in the presence of an atriofascicular pathway: What is the mechanism?

Cetin EHO, Kara M, Merovci I, Kulekci F, ... Aras D, Topaloglu S
Duality of conduction over atriofascicular (AF) fibers because of longitudinal dissociation reportedly explains cycle length alternans and/or VA changes during antidromic AF tachycardia. Spontaneous or ablation-heated AF automaticity is also kept in mind in the differential diagnosis of AF-related tachycardias. The change in the rate between the wide and the narrow QRS complex tachycardia, and the presence of fusion give us important clues in differential diagnosis for active or bystander participation of AF pathway or AF automaticity. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Sep 2022; epub ahead of print
Cetin EHO, Kara M, Merovci I, Kulekci F, ... Aras D, Topaloglu S
J Cardiovasc Electrophysiol: 23 Sep 2022; epub ahead of print | PMID: 36150138
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Abstract

Removal of an active fixation coronary sinus pacing lead five years post implant: a case report.

Carretta DM, Troccoli R, Carretta F, D\'Agostino C
Active fixation for a lead in the coronary sinus may be essential to select the optimal left ventricular pacing site, maximize the effectiveness of CRT and avoid dislodgement. The Medtronic Attain Stability lead allows fixation through a side helix concentric with the lead body. Although electrical performance of such a lead is well known, evidence of extractability remains poor especially in the long term. We describe the removal of an Attain Stability lead 63 months after implantation which, to the best of our knowledge, is the longest implant duration that has ever been reported, in an 81-year-old male patient. It was successfully achieved using simple traction and rotation maneuvers, demonstrating the long-term removal feasibility of such device. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2022; epub ahead of print
Carretta DM, Troccoli R, Carretta F, D'Agostino C
J Cardiovasc Electrophysiol: 22 Sep 2022; epub ahead of print | PMID: 36135599
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Abstract

Impedance-decline-guide power control long application time bipolar radiofrequency catheter ablation.

Saitoh O, Kasai T, Fuse K, Oikawa A, Furushima H, Chinushi M
Introduction
Bipolar (BIP) radiofrequency (RF) ablation creates deep myocardial lesions but ideal energy application modes to treat ventricular arrhythmias originating from deep inside the thick myocardium have not been well established. An experimental study was performed to clarify whether high power and long application time BIP ablation was performable by impedance-decline-guide power control (PC) and whether it could create transmural lesions in the thick ventricle with a minimum risk of steam-pop.
Methods and results
Perfused porcine ventricle (18.4 ± 2.3 mm) was placed in an experimental bath and BIP ablation (50 W) for 120 seconds was attempted with catheter contact of 30-g using two protocols; fixed power (FP) and impedance-decline-guide PC. In the latter protocol, BIP ablation was started from 50 W, while the energy was decreased to 40-20 W according to the impedance decline during RF ablation. FP ablation was attempted 30 applications and transmural lesion was created in all 30, although steam-pop occurred in 16/30 applications (53%). Low minimum impedance, large total impedance decline (TID) and %-TID were associated with the steam-pop occurrence. PC ablation was attempted in another 21 applications, and transmural lesion was created in all 21 without steam-pop. PC ablation was superior to FP ablation (21/21 vs. 14/30, P<0.001) in the creation of a transmural lesion without resulting in steam-pop.
Conclusions
High power and long application time BIP ablation seems to be feasible according to the impedance-decline-guide approach, which could create transmural lesions in thick porcine ventricle with a minimal risk of steam-pop. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 22 Sep 2022; epub ahead of print
Saitoh O, Kasai T, Fuse K, Oikawa A, Furushima H, Chinushi M
J Cardiovasc Electrophysiol: 22 Sep 2022; epub ahead of print | PMID: 36135613
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Abstract

Percutaneous Aspiration and Removal of Infected Leadless Pacemaker Vegetation.

Adamek KE, Haque N, Martinez-Parachini JR, Ayoub K, Richardson TD
Introduction
Leadless pacemakers represent an increasingly utilized alternative to traditional pacing methods in those with prior bacteremia or at high risk for infection. The acknowledged resistance to infection is illustrated by the exceedingly rare documentation of it.
Methods
We present a case of MSSA endocarditis with associated leadless pacemaker infection necessitating percutaneous aspiration of the device-associated vegetation followed by extraction of the leadless pacemaker.
Results
A large vegetation associated with a leadless pacemaker was percutaneously aspirated with a vacuum-assisted aspiration device, followed by successful extraction of the leadless pacemaker.
Conclusion
While leadless pacemakers are seldom involved in infective endocarditis, ultrasound evaluation in high-risk patients with an undetermined source is reasonable. Prior to extraction, it is practical to consider aspiration of large associated vegetations with a vacuum-assisted device. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 20 Sep 2022; epub ahead of print
Adamek KE, Haque N, Martinez-Parachini JR, Ayoub K, Richardson TD
J Cardiovasc Electrophysiol: 20 Sep 2022; epub ahead of print | PMID: 36125446
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Abstract

Safety of Left Atrial Appendage Closure in Heart Failure Patients.

Das S, Lorente-Ros M, Wu L, Mehta D, Suri R
Introduction
Left atrial appendage closure (LAAC) is an intervention aimed at stroke prevention in non-valvular atrial fibrillation (NVAF). There is a 3-fold increased risk of stroke in patients with concomitant presence of atrial fibrillation (AF) and heart failure (HF). While anticoagulation is effective, only 60% receive it. We aimed at studying the safety of LAAC in heart failure (HF) patients using a national all-payer database.
Methods
We queried the National Inpatient Sample (NIS) for the year 2016-18 for WATCHMAN device insertion using ICD 10 procedure codes. We divided the study population into HF and non- HF groups. Outcomes were compared using appropriate statistical tests, p value <0.05 was considered significant.
Results
34,385 LAAC procedures were identified of which 8,530 (24.8%) were done in patients with HF. The mean (SD) age of the study population was 76 (7.9) years and 42% were female. There was no difference in mean age between HF and non-HF groups. Our findings indicate that there is no difference in inpatient mortality and cardiac complications between the HF and non-HF groups. However, non-cardiac complications including acute kidney injury and respiratory failure were higher in the HF group.
Conclusion
LAAC appears to be a safe procedure in patients with HF. The study is limited by a short follow up period and long-term follow up is required before definitive conclusions can be made. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 20 Sep 2022; epub ahead of print
Das S, Lorente-Ros M, Wu L, Mehta D, Suri R
J Cardiovasc Electrophysiol: 20 Sep 2022; epub ahead of print | PMID: 36125496
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Abstract

Impact of intracardiac echocardiography on readmission morbidity and mortality following atrial fibrillation ablation.

Deshpande S, Sawatari H, Ahmed R, Nair RG, ... Chahal CAA, Padmanabhan D
Background
The use of intracardiac echocardiography (ICE) is beneficial during ablation of atrial fibrillation (AF). Evidence is conflicting regarding the clinical impact of using ICE on arrhythmia recurrence and mortality.
Objective
To identify whether ICE use during AF ablation leads to reduced morbidity and mortality using a large national all-payer claims database.
Methods
Patients undergoing catheter ablation of AF during 2010-2017 were identified using International Classification of Diseases-9th and 10th Revision-Clinical Modification (ICD-9-CM and ICD-10-CM) from the Nationwide Readmissions Database (NRD). Propensity matching was used to generate a control group without ICD. Patient demographics, Charlson Comorbidity indexes, time from discharge to readmission and the reason of readmission were extracted.
Results
From 2010 to 2017, 51,129 patients were included in the analysis out of which ICE was used in 8,005 (15.7%) patients. The in-hospital mortality at readmission was significantly higher in the patients without ICE use (2.9% vs 1.7%, p=0.02). The length of stay (LOS) at readmission was significantly higher in non-ICE arm (median [IQR]: 3 [2-6] vs 2 [3-5] days, p<0.0001) with similar healthcare associated cost (HAC) in both the groups (median [IQR]: US$7,507.3 [4,057.8 - 15,474.2] vs 7,339.4 [4,024.8 - 15,191.6], p=0.43). Freedom from readmission was 12% higher (HR[95%CI]: 0.88 [0.83-0.94], p<0.0001) with the use of ICE at 90-day follow-up, which was driven by 24% reduction in heart failure at follow-up (HR[95%CI]: 0.76 [0.60-0.96], p=0.02).
Conclusions
ICE use during AF ablation procedure reduces readmissions at 90-days by 12%, driven by a 24% decrease in HF-related admissions. The non-ICE arm showed a significantly higher LOS which offsets marginally higher HAC in the ICE arm. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 20 Sep 2022; epub ahead of print
Deshpande S, Sawatari H, Ahmed R, Nair RG, ... Chahal CAA, Padmanabhan D
J Cardiovasc Electrophysiol: 20 Sep 2022; epub ahead of print | PMID: 36128625
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Abstract

Clinical Outcomes with Very High Power Very Short Duration Ablation for Atrial Fibrillation: The Jury is Still Out.

Calvert P, Gupta D
While the landscape of atrial fibrillation (AF) ablation is changing rapidly, radiofrequency (RF) remains the current gold standard This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print
Calvert P, Gupta D
J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print | PMID: 36124386
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Abstract

Impact on right ventricular performance in patients undergoing permanent pacemaker implantation: left bundle branch pacing versus right ventricular septum pacing.

Huang X, Lin M, Huang S, Guo J, ... MaolongSu , Binni Cai
Background
The novel method of left bundle branch pacing (LBBP) has been reported to achieve better electrical and mechanical synchrony in the left ventricle than conventional right ventricular pacing (RVP). However, its effects on right ventricle (RV) performance are still unknown.
Methods
Consecutive patients undergoing dual-chamber pacemaker (PM) implantation for sick sinus syndrome (SSS) with normal cardiac function and a narrow QRS complex were recruited for the study. The pacing characteristics and echocardiogram parameters were measured to evaluate RV function, interventricular and RV synchrony, and were compared between ventricular pacing-on and native-conduction modes.
Results
A total of 84 patients diagnosed with SSS and an indication for pacing therapy were enrolled. Forty-two patients (50%; mean age 65.50 ± 9.30 years; 35% male) underwent successful LBBP and 42 patients (50%; mean age 69.26 ± 10.08 years; 33% male) RVSP, respectively. Baseline characteristics were similar between the two groups. We found no significant differences in RV function [RV-FAC (Fractional Area Change)%, 47.13±5.69 vs. 48.60±5.83, p=.069; Endo-GLS (Global Longitudinal Strain)%, -28.88±4.94 vs. -29.82±5.35, p=.114; Myo-GLS%, -25.72±4.75 vs. -25.72±5.21, p=.559; Free Wall St%, 27.40±8.03 vs. -28.71±7.34, p=.304] between the native-conduction and LBBP capture modes, while the RVSP capture mode was associated with a significant reduction in the above parameters compared with the native-conduction mode (P < .0001). The interventricular synchrony in the LBBP group was also superior to the RVSP group significantly.
Conclusion
LBBP is a pacing technique that seems to associate with a positive and protective impact on RV performance. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print
Huang X, Lin M, Huang S, Guo J, ... MaolongSu , Binni Cai
J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print | PMID: 36124394
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Abstract

Radiofrequency ablation of atrial fibrillation - 50W or 90W?

Mueller J, Nentwich K, Ene E, Berkovitz A, ... Halbfass P, Deneke T
Background
This study sought to evaluate the short and mid-term efficacy and safety of the novel very high power very short duration (vHPvSD) 90W approach compared to HPSD 50W for AF ablation as well as reconnection patterns of 90W ablations.
Methods and results
Consecutive patients undergoing first AF ablation with vHPvSD (90W; predefined ablation time of 3 seconds for posterior wall ablation and 4 seconds for anterior wall ablation) were compared to patients using HPSD (50W; ablation index-guided; AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) retrospectively. A total of 84 patients (67.1 ± 9.8 years; 58% male; 47% paroxysmal AF) were included (42 with 90W, 42 with 50W) out of a propensity score matched cohort. 90W ablations revealed shorter ablation times (10.5 ± 6.7 min vs. 17.4 ± 9.9 min; p=0.001). No major complication occurred. 90W ablations revealed lower first pass PVI rates (40% vs. 62%; p=0.049) and higher AF recurrences during blanking period (38% vs. 12%; p=0.007). After 12 months, both ablation approaches revealed comparable mid-term outcomes (62% vs. 70%; log rank p=0.452). In a multivariable Cox regression model persistent AF (HR 1.442, CI 1.035 - 2.010, p=0.031) and increased procedural duration (HR 1.011, CI 1.005 - 1.017, p=0.001) were identified as independent predictors of AF recurrence during follow-up.
Conclusions
AF ablation using 90W vHPvSD reveals a similar safety profile compared to 50W ablation with shorter ablation times. However, vHPvSD ablation was associated with lower rates of first-pass isolations and increased AF recurrences during the blanking period. After 12 months 90W revealed comparable efficacy results to 50W ablations in a non-randomized, propensity matched comparison. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print
Mueller J, Nentwich K, Ene E, Berkovitz A, ... Halbfass P, Deneke T
J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print | PMID: 36124396
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Abstract

Late pacemaker implantation after atrioventricular nodal reentrant tachycardia ablation: A systematic review and meta-analysis.

Sim MG, Chan SP, Kojodjojo P, Tan ES
Introduction
Catheter ablation (CA) of atrioventricular nodal reentrant tachycardia (AVNRT) is associated with late pacemakers for AV block (AVB). We performed a systematic review and meta-analysis of the pooled incidence of late pacemakers for AVB after CA of AVNRT.
Methods and results
Relevant studies were identified from 4 electronic databases (PubMed, EMBASE, Scopus, Cochrane Trial Register) from inception to 2022. A random effects model was used to calculate the odds of late pacemakers in CA of AVNRT compared to atrioventricular reentrant tachycardia (AVRT). Of 533 articles screened, 13 were included in systematic review. CA for AVNRT was performed in 16,471 patients (mean age 54±17 years, 63% females), of which 68 (0.4%) underwent pacemaker implantation for late AVB. Meta-analysis was performed in 5 of the 13 studies (mean follow-up duration 7±4 years). Patients who underwent CA of AVNRT were older (58±17 vs 52±20 years, p<0.001), and more likely female (60% vs 41%, p<0.001) than AVRT. Pooled estimates of late pacemakers for AVB were higher in CA of AVNRT than AVRT (0.5% vs 0.2%, p=0.006), with CA in AVNRT associated with almost 2-fold increased odds of late pacemakers indicated for AVB (OR 1.94, 95%CI 1.08-3.47, p=0.027) compared to AVRT.
Conclusion
AVNRT ablation is safe but associated with a low but definitely increased risk of requiring pacing in the later years due to AVB. This association is confirmed by pooling over 16,000 AVNRT patients receiving clinically indicated ablation and is helpful in providing informed consent for prospective patients undergoing ablation for AVNRT. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print
Sim MG, Chan SP, Kojodjojo P, Tan ES
J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print | PMID: 36124400
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Abstract

Atrioventricular Nodal Reentrant Tachycardia: Are there unknown long-term consequences of ablating the (incompletely) known?

Ip JE
Although atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common form of paroxysmal supraventricular tachycardia This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print
Ip JE
J Cardiovasc Electrophysiol: 19 Sep 2022; epub ahead of print | PMID: 36124404
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Abstract

Characterization of high-power and very-high-power short-duration radiofrequency lesions performed with a new-generation catheter and a temperature-control ablation mode.

Granero CL, Díez EF, Francés RM, Madrid AH, ... Gómez JLZ, Planas JM
Introduction
High-power short-duration (HPSD) has been proposed to shorten procedure times while maintaining efficacy and safety. We evaluated the differences in size and geometry between radiofrequency lesions obtained with this method and conventional ones.
Methods and results
Twenty-eight sets of ten perpendicular radiofrequency applications were performed with two commercially available catheters: a temperature-controlled HPSD catheter (QDot Micro) and a conventional power-controlled catheter (Thermocool SmartTouch) on porcine left ventricle. Different power settings (35, 40, 50 and 90W), contact force (CF, 10 and 20g), Ablation Index (AI, 400 and 550) and application times were combined to create conventional (35-40W), HPSD (50W) and very high-power short-duration (VHPSD, 90W) lesions, that were cross-sectioned and measured. 4-seconds VHPSD lesions were smaller, shallower and thinner than HPSD performed with the QDot Micro catheter in any scenario of CF or AI (61±7.8mm3 , 6.1±0.3mm wide and 2.9±0.1mm deep with 10g; 72.2±0.5mm3 , 6.8±0.3mm wide and 2.9±0.2mm deep with 20g). Conventional and HPSD lesions performed with the temperature-controlled catheter were generally bigger, deeper and wider than the ones obtained with the power-controlled catheter, as well as more consistent in size. This was especially true with the lower CF and AI scenario, while differences were less notable with other setting combinations.
Conclusion
VHPSD lesions performed with QDot Micro catheter were smaller than any other lesions, which is especially attractive for posterior left atrial wall ablation. On the contrary, conventional-powered and HPSD lesions performed with this catheter were equally sized (or even bigger with lower CF and AI objective), as well as more consistent in size, which would guarantee transmurality in other locations. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 18 Sep 2022; epub ahead of print
Granero CL, Díez EF, Francés RM, Madrid AH, ... Gómez JLZ, Planas JM
J Cardiovasc Electrophysiol: 18 Sep 2022; epub ahead of print | PMID: 36116038
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Abstract

Direct comparison of two 50 Watts high power short duration approaches - temperature- versus Ablation Index-guided Radiofrequency Ablation for Atrial Fibrillation.

Guckel D, Bergau L, Braun M, El Hamriti M, ... Sommer P, Sohns C
Introduction
Approaches applying higher energy levels for shorter periods (high power short duration, HPSD) to improve lesion formation for atrial fibrillation (AF) ablation have been introduced. This single center study aimed to compare the efficacy, safety and lesion formation using the novel DiamondTemp (DT) catheter or an ablation index (AI)-guided HPSD ablation protocol using a force-sensing catheter with surround-flow irrigation.
Methods
113 consecutive patients undergoing radiofrequency-guided catheter ablation (RFCA) for AF were included. 45 patients treated with the DT catheter (50 W, 9 sec), were compared to 68 consecutive patients undergoing AI-guided ablation (AI anterior 550; AI posterior 400) adherent to a 50W HPSD protocol. Procedural data and AF recurrence were evaluated.
Results
Acute procedural success was achieved in all patients (n=113, 100%). DT-guided AF ablation was associated with a longer mean procedure duration (99.10±28.30 min vs. 78.24±25.55, p<0.001) and more RF applications (75.24±30.76 min vs. 61.27±14.06, p=0.019). RF duration (792.13±311.23 sec vs. 1035.54±287.24 sec, p<0.001) and fluoroscopy dose (183.81±178.13 yGym2 vs. 295.80±247.54 yGym2 , p=0.013) were lower in the DT group. AI-guided HPSD was associated with a higher AF-free survival rate without reaching statistical significance (p=0.088). Especially patients with PERS AF (p=0.009) as well as patients with additional atrial arrhythmia substrate (p=0.002) benefited from an AI-guided ablation strategy.
Conclusion
Temperature- and AI- controlled HPSD RFCA using 50W was safe and effective. AI-guided HPSD ablation seems to be associated with shorter procedure durations and fewer RF applications. Particularly in advanced AF, freedom from AF-recurrence may be improved using an AI-guided HPSD approach. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Sep 2022; epub ahead of print
Guckel D, Bergau L, Braun M, El Hamriti M, ... Sommer P, Sohns C
J Cardiovasc Electrophysiol: 14 Sep 2022; epub ahead of print | PMID: 36104929
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Abstract

Subclinical sinus node dysfunction in patients with atrial fibrillation ~Insight from ultra-high-resolution mapping of human sinoatrial exits~.

Eguchi T, Miyazaki S, Tsuji T, Nagao M, ... Uzui H, Tada H
Background
Even a short duration of paroxysmal episodes of atrial fibrillation (AF) is associated with sinus node (SN) remodeling and a reduced SN reserve or dysfunction. The number of earliest atrial activation sites (EASs) during sinus rhythm decreases according to the decrease in the SN reserve.
Objective
We sought to evaluate the EASs during sinus rhythm using an ultra-high-density mapping system.
Methods
This study included 35 patients (supraventricular tachycardia [SVT]/paroxysmal AF [PAF]/persistent AF [PsAF] =5/21/9) who underwent ultra-high-resolution endocardial mapping of the SN area at rest and during β-stimulation. The number of EASs was determined by the LUMIPOINT™ algorithm.
Results
The number of EASs was greatest in SVT patients both at rest (SVT/PAF/PsAF = 1.4±0.8/1.0±0/1.0±0, p=0.04) and during β-stimulation (SVT/PAF/PsAF = 2.6±1.0/1.3±0.6/1.0±0, p <0.01). The number significantly increased with β-stimulation as compared to baseline in the PAF patients (p=0.02), but not in the PsAF patients. The brain natriuretic peptide (BNP) level was significantly higher in AF than SVT patients (SVT/PAF/PsAF = 12.3[10.1-14.5]/25.7[14.8-36.0] /73.4[57.6-140] pg/ml, p<0.01). In the PAF patients, the BNP level was significantly higher in those with unicentric EASs than multicentric EASs during β-stimulation (28.1[19.1-46.5] vs. 13.1[9.4-26.9] pg/ml, p=0.03), and the optimal cutoff point for the BNP level predicting unicentric EASs was 21.8 pg/ml (sensitivity 82.6%; specificity 85.7%).
Conclusions
AF patients have a smaller number of EASs and poorer response to β-stimulation than non-AF patients. An elevated BNP level might predict subclinical SN dysfunction in patients with PAF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Sep 2022; epub ahead of print
Eguchi T, Miyazaki S, Tsuji T, Nagao M, ... Uzui H, Tada H
J Cardiovasc Electrophysiol: 14 Sep 2022; epub ahead of print | PMID: 36104930
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Abstract

Pericarditis following left atrial ablation.

Aksu T, Mutluer FO, Tanboga HI, Gupta D
We aimed to evaluate the incidence of acute pericarditis following cardioneuroablation (CNA) and to compare this with patients undergoing left atrial (LA) radiofrequency ablation for atrial fibrillation (AF). This is a single-center prospective study. During the study period, CNA for vasovagal syncope was performed in 42 patients, pulmonary vein isolation (PVI) for paroxysmal AF in 46 patients, and posterior wall isolation (PWI) in addition to PVI for persistent AF in 22 patients. Pericarditis was reported by 18 (16.4%) patients overall: 1 (2.4%) patient in CNA group, 8 (17.4%) patients in PVI group, and 9 (40.9%) patients in PWI (p<0.001). On univariable logistic regression analysis, CNA was associated with a lower risk of pericarditis (odds ratio 0.11, 95% CI 0.01-0.97), while ablation of PWI plus PVI was associated with a higher risk of pericarditis compared with PVI (odds ratio 3.29, 95% CI 1.05-10.3). This study shows that pericarditis is extremely uncommon following CNA and is significantly less frequent than following AF ablation. This difference is likely related to the much lower amount of LA ablation necessary in this group. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Sep 2022; epub ahead of print
Aksu T, Mutluer FO, Tanboga HI, Gupta D
J Cardiovasc Electrophysiol: 08 Sep 2022; epub ahead of print | PMID: 36073138
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Abstract

The hemodynamic effect of simulated atrial fibrillation on left ventricular function.

Stojadinović P, Deshraju A, Wichterle D, Fukunaga M, ... Kautzner J, Šramko M
Background
Atrial fibrillation (AF) is the most common sustained arrhythmia in humans. The onset of the arrhythmia can significantly impair cardiac function. This hemodynamic deterioration has been explained by several mechanisms such as the loss of atrial contraction, shortening of ventricular filling, or heart rhythm irregularity. This study sought to evaluate the relative hemodynamic contribution of each of these components during in-vivo simulated human AF.
Methods
Twelve patients undergoing catheter ablation for paroxysmal AF were paced simultaneously from the proximal coronary sinus and the His bundle region according to prescribed sequences of irregular R-R intervals with the average rate of 90 bpm and 130 bpm, which were extracted from the database of digital ECG recordings of AF from other patients. The simulated AF was compared to regular atrial pacing with spontaneous atrioventricular conduction and regular simultaneous atrioventricular pacing at the same heart rate. Beat-by-beat left atrial and left ventricular pressures including LV dP/dT and Tau index were assessed by direct invasive measurement; beat-by-beat stroke volume and cardiac output (index) were assessed by simultaneous pulse-wave doppler intracardiac echocardiography.
Results
Simulated AF led to significant impairment of left ventricular systolic and diastolic function. Both loss of atrial contraction and heart rate irregularity significantly contributed to hemodynamic impairment. This effect was pronounced with increasing heart rate.
Conclusion
Our findings strengthen the rationale for therapeutic strategies aiming at rhythm control and heart rate regularization in patients with AF. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Sep 2022; epub ahead of print
Stojadinović P, Deshraju A, Wichterle D, Fukunaga M, ... Kautzner J, Šramko M
J Cardiovasc Electrophysiol: 07 Sep 2022; epub ahead of print | PMID: 36069129
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Abstract

Sacubitril/Valsartan: An Antiarrhythmic Drug?

Huang E, Bernard ML, Elise Hiltbold A, Khatib S, ... Dominic P, Morin DP
Heart failure (HF) is a major cause of morbidity and mortality, with nearly half of all HF-related deaths resulting from sudden cardiac death (SCD), most often from an arrhythmic event. The pathophysiologic changes that occur in response to the hemodynamic stress of HF may lead to increased arrhythmogenesis. Theoretically, medications that block these arrhythmogenic substrates would decrease the risk of SCD. Sacubitril/valsartan, the combined angiotensin receptor and neprilysin inhibitor (ARNi; tradename Entresto), has been shown to decrease cardiovascular mortality and hospitalization in patients with HF with reduced ejection fraction (HFrEF). Emerging evidence suggests that ARNi also may play a role in reducing arrhythmogenesis and thereby SCD. This review summarizes the current data regarding this ARNi and its potential antiarrhythmic effects. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Sep 2022; epub ahead of print
Huang E, Bernard ML, Elise Hiltbold A, Khatib S, ... Dominic P, Morin DP
J Cardiovasc Electrophysiol: 07 Sep 2022; epub ahead of print | PMID: 36069136
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Abstract

Mechanism and Management of Leaks Arising after Left Atrial Appendage Closure (LAAC).

Charate R, Ahmed A, Aedma SK, Singh V, ... Natale A, Lakkireddy D
This article reviews the latest available data in regard to the diagnosis, management, and intervention of both central and peri-device leaks that arise after Left Atrial Appendage Closure (LAAC). The aim of this article is to have better understanding in both addressing leaks arising after LAAC, and which interventions and closure methods are best served for each type of residual leak based on etiology, size, and operator experience. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 07 Sep 2022; epub ahead of print
Charate R, Ahmed A, Aedma SK, Singh V, ... Natale A, Lakkireddy D
J Cardiovasc Electrophysiol: 07 Sep 2022; epub ahead of print | PMID: 36069138
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Abstract

Cardiac tamponade as an inherent but potentially non-fatal complication of transvenous lead extraction. Experience with 1126 procedures performed using mechanical tools.

Nowosielecka D, Tułecki Ł, Jacheć W, Polewczyk A, ... Bródka J, Kutarski A
Background
Cardiac tamponade (CT) is one of the most common and dangerous complications of transvenous lead extraction (TLE). So far, however, there has been little discussion about the problem.
Methods
We analysed the occurrence of CT in a group of 1226 patients undergoing TLE at a single reference centre between June, 2015 and February, 2021. Using standard mechanical devices as first-line tools, a total of 2092 leads had been extracted.
Results
CT occurred in 18 patients (1.47%): due to injury to the wall of the right atrium in 14 patients (1.14%) and other cardiac walls in 4 patients (0.33%). Younger patient age at first implantation, female gender, high left ventricular ejection fraction (LVEF), lower NYHA class, low Charlson comorbidity index, longer implant duration and the number of previous procedures related to cardiac implantable electronic devices (CIED) are important patient-related risk factors for CT. Significant procedure-related risk factors include the number of extracted leads, extraction of atrial leads and longer dwell time of extracted leads. Intra-operative transoesophageal echocardiography (TEE) provides a lot of information about pulling on various cardiac structures and is able to detect a very early phase of bleeding to the pericardial sac. As a result of implementing best practices guidance in performing extraction procedures and close collaboration with cardiac surgeons that allowed immediate rescue intervention in our series of 18 CT cases, there were no procedure-related deaths (mortality 0%).
Conclusions
The need for rescue surgery due to CT has no influence on clinical and procedural success. Early diagnosed (TEE monitoring) and properly managed CT does not generate any additional risk in short- and long-term follow-up after TLE. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 02 Sep 2022; epub ahead of print
Nowosielecka D, Tułecki Ł, Jacheć W, Polewczyk A, ... Bródka J, Kutarski A
J Cardiovasc Electrophysiol: 02 Sep 2022; epub ahead of print | PMID: 36054327
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Abstract

Micra pacemaker in adult congenital heart disease patients: a case series.

Bassareo PP, Walsh KP
Introduction
implantation of transvenous endocardial or epicardial pacemakers presents specific challenges in adult congenital heart disease (ACHD) patients. Micra leadless pacemaker (Micra PPM) may overcome some of these difficulties.
Methods
15 ACHD patients who underwent Micra PPM insertion were retrospectively evaluated.
Results
males 53.3%. Mean age at study: 37.5±10.7 years. Mean age at Micra PPM insertion: 35.5±11.0 years. Mean follow-up so far: 2.0±0.3 years. Concerning the ACHD patients, 6.7% had a simple defect, 66.6% had a moderately complex defect, 26.7% were complex. Four patients (26.7%) had a previous PPM implantation. Three patients (20%) had a systemic right ventricle. Two patients (13.3%) had a single ventricle physiology. Five (33.3%) had Trisomy 21. The most commonly used Micra PPM modality was VVI (73.3%). Mean threshold post implantation was 0.48 V [range: 0.25-1.13 V], while mean threshold at 6 months control was 0.60 V [range: 0.38-1.13 V] (p=ns). Mean R wave post implantation was 10.3 V [range: 3.25-19.4 V], whilst mean R wave at 6 months follow-up was 10.1 V [range:3.5-19.0 V] (p=ns). No major peri and post-procedural complications were encountered.
Conclusions
since ACHD patients are living longer and surviving into adulthood, the incidence of conduction disorders continues to increase, as part of the natural history of some lesions or as early or late complication of surgery. The Micra leadless PPM can be successfully implanted in ACHD patients and have significant theoretical advantages. They should be considered when transvenous and epicardial pacing are either contraindicated or represent an otherwise suboptimal approach. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print
Bassareo PP, Walsh KP
J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print | PMID: 36041216
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Abstract

Ventricular Overdrive Pacing during Supraventricular Tachycardia with Alternating Cycle Length: What Is the Diagnosis?

Nakashima T, Nagase M, Shibahara T, Ono D, ... Takahashi S, Aoyama T
A 66-year-old woman with a history of palpitations and previously documented supraventricular tachycardia (SVT) was referred for an electrophysiological study. Transthoracic echocardiography revealed a structurally normal heart with an ejection fraction of 62% This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print
Nakashima T, Nagase M, Shibahara T, Ono D, ... Takahashi S, Aoyama T
J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print | PMID: 36041217
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Abstract

The High-Density Grid Catheter: a Safe Adjunctive Tool in Pediatric and Complex Congenital Heart Disease Patients.

Newlon C, Yukiko Asaki S, Pilcher TA, Ou Z, Etheridge SP, Niu MC
Introduction
The safety and utility of the Advisor™ High Density Grid mapping catheter (HDGC) in children and congenital heart disease (CHD) patients are not well described.
Methods
Single-center retrospective cohort study of pediatric and CHD patients undergoing electrophysiology study and ablation to determine the effect of HDGC use on outcomes including: acute ablation success, complications, arrhythmia recurrence, fluoroscopy use, and procedure duration.
Results
HDGC was used in 74/261 (28.3%) cases. HDGC subjects differed by median age (17 vs. 13 years; p < 0.001), weight (68 vs. 50 kg; p < 0.001), and prevalence of significant CHD (42% vs. 3%; p < 0.001). Arrhythmia substrates were dissimilar: HGDC cases had higher frequencies of intra-atrial re-entrant tachycardia (25.7% vs. 0.5%), atrial flutter (8.1% vs. 1.1%), ectopic atrial tachycardia (13.5% vs. 3.7%), and premature ventricular contractions (9.5% vs. 0.5%), and lower incidences of atrioventricular re-entrant tachycardia (16.2% vs. 46.1%). Complications were rare (n=5, 1.9%) with no significant difference between groups (p = 1.00). Procedure duration - but not fluoroscopy exposure - was significantly longer in HDGC cases (median 256 vs. 216 min, p < 0.001). Acute success was lower (93.2% vs. 99.4%; p = 0.01) and recurrences higher (13.2% vs. 3.8%; p = 0.016) in HDGC compared to non-HDGC cases.
Conclusion
HDGC use in children and CHD patients is safe and not associated with higher complication rates. The lower acute success and higher recurrence rates in HDGC cases likely reflects bias towards HDGC use in more complex arrhythmia substrates rather than less favorable ablation outcomes. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print
Newlon C, Yukiko Asaki S, Pilcher TA, Ou Z, Etheridge SP, Niu MC
J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print | PMID: 36041222
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Abstract

Feasibility and Safety of Laser Balloon Pulmonary Vein Isolation in Patients With Prior Left Atrial Appendage Occlusion Device Implantation.

Khalil C, Vipparthy SC, Kenigsberg D, Ravi V, ... Sharma PS, Huang HD
With increasing adoption of left atrial appendage occlusion (LAAO) procedures and eligibility of patients for PVI post-device placement, we examined the feasibility and safety of Laser balloon (LB) for pulmonary vein isolation (PVI) in patients with prior LAAO. We retrospectively examined consecutive patients with paroxysmal or persistent, drug resistant AF who underwent LB PVI, after Watchman FLX device implantation at Rush University Medical Center between January 2020 and December 2021. Seven patients (4 persistent, 3 Paroxysmal) with a mean age of 64 ±11 years, predominantly male sex (86%), were included in the study. Two (29%) patients had prior cryoablation PVI with recurrence of AF. The mean CHA2 DS2 VASc is 2.6 ± 0.5 and the mean HAS-BLED score is 3.4 ± 0.8. The mean follow-up duration was 10±7 months. The mean duration between Watchman FLX device implantation and LB PVI was 592 days. Acute first pass left pulmonary vein (PV) isolation was achieved in 100% of the procedures. There were no periprocedural complications such as death, pericardial tamponade or effusion, phrenic nerve injury, PV stenosis, device perforation or embolization or worsening peri-device leak in any of the patients. None of the patients had AF recurrence after the blanking period. In conclusion, LB PVI was safe and effective with 100% acute isolation of left sided veins in patients with prior LAAO device. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print
Khalil C, Vipparthy SC, Kenigsberg D, Ravi V, ... Sharma PS, Huang HD
J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print | PMID: 36041214
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Abstract

Reply to \"Is left ventricular septal pacing enough clinically, or must left bundle branch be captured absolutely?\"

Shimeno K, Tamura S, Hayashi Y, Abe Y, Naruko T, Fukuda D
We thank Drs Kailun Zhu and Qiang Li for their interest in our article and would like to reply to their interesting comment This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print
Shimeno K, Tamura S, Hayashi Y, Abe Y, Naruko T, Fukuda D
J Cardiovasc Electrophysiol: 30 Aug 2022; epub ahead of print | PMID: 36041215
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Abstract

Sex Differences in In-Hospital Outcomes of Catheter Ablation for Atrial Fibrillation.

Thotamgari SR, Babbili A, Jakulla RS, Bhuiyan MAN, Dominic P
There is limited data on in-hospital outcomes of catheter ablation (CA) for atrial fibrillation (AF) compared between men and women. We investigated National Inpatient Sample database to examine gender differences on in-hospital outcomes of CA for AF. A total of 30,365 hospitalizations were identified and included in the final analysis. Multivariate analysis showed that women had lower in-hospital all-cause mortality (aOR 0.57, 95% CI 0.41-0.80, p=0.001) and acute HF (aOR 0.90, 95% CI 0.83-0.96, p=0.005) compared to men. While our study has limitations, future randomized trials are necessary to evaluate benefits of early CA for AF in females. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Aug 2022; epub ahead of print
Thotamgari SR, Babbili A, Jakulla RS, Bhuiyan MAN, Dominic P
J Cardiovasc Electrophysiol: 23 Aug 2022; epub ahead of print | PMID: 35998265
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Abstract

Electrogram-based AF ablation -finally, reproducibility!

Deisenhofer I
After several years with sobering experiences with electrogram-based AF ablation approaches, Seitz et al present with the VX1 software a reliable tool to map and ablate spatio-temporal dispersion. The presented multicenter study in persistent AF patients was conducted in 1 expert and 7 satellite centers with a total of 17 operators, using the VX1 software to detect and subsequently ablate spatiotemporal dispersion. While the AF termination rate (88%) and the freedom from AF in 12 months FU (82%) was very encouraging, the VX1 software, using AI enhanced electrogram adjudication, achieved very similar results in all centers, regardless of the centre`s or the operator`s experience. Thus, the biggest criticism of electrogram-based ablation strategies, i.e. the lack of reproducibility in \"non-expert\" centers, seems to be finally addressed. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print
Deisenhofer I
J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print | PMID: 35989539
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Abstract

Artificial Intelligence Software Standardizes Electrogram-based Ablation Outcome for Persistent Atrial Fibrillation.

Seitz J, Durdez TM, Albenque JP, Pisapia A, ... Bars C, Kalifa J
Introduction
Multiple groups have reported on the usefulness of ablating in atrial regions exhibiting abnormal electrograms during atrial fibrillation (AF). Still, previous studies have suggested that ablation outcomes are highly operator- and center-dependent. This study sought to evaluate a novel machine learning software algorithm named VX1 (Volta Medical), trained to adjudicate multipolar electrograms dispersion.
Methods
This study was a prospective, multicentric, non-randomized study conducted to assess the feasibility of generating VX1 dispersion maps. In 85 patients, 8 centers and 17 operators, we compared the acute and long-term outcomes after ablation in regions exhibiting dispersion between a primary and satellite centers. We also compared outcomes to a control group in which dispersion-guided ablation was performed visually by trained operators.
Results
The study population included 29% of long-standing persistent AF. AF termination occurred in 92% and 83% of the patients in primary and satellite centers, respectively, p=0.31. The average rate of freedom from documented AF, with or without AADs, was 86% after a single procedure, and 89% after an average of 1.3 procedures per patient (p=0.4). The rate of freedom from any documented atrial arrhythmia, with or without AADs, was 54% and 73% after a single or an average of 1.3 procedures per patient, respectively (p<0.001). No statistically significant differences between outcomes of the primary vs. satellite centers were observed for one (p=0.8) or multiple procedures (p=0.4), or between outcomes of the entire study population vs. the control group (p>0.2). Interestingly, intraprocedural AF termination and type of recurrent arrhythmia (i.e., AF vs. AT) appear to be predictors of the subsequent clinical course.
Conclusion
VX1, an expertise-based artificial intelligence software solution, allowed for robust center-to-center standardization of acute and long-term ablation outcomes after electrogram-based ablation.
Clinical trial registration
ClinicalTrials.gov NCT03434964 This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print
Seitz J, Durdez TM, Albenque JP, Pisapia A, ... Bars C, Kalifa J
J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print | PMID: 35989543
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Abstract

A systematic review of the use of 3D printing in left atrial appendage occlusion procedures.

Tarabanis C, Klapholz J, Zahid S, Jankelson L
The placement of a left atrial appendage occlusion (LAAO) device can be a technically challenging transcatheter-based procedure. Key challenges include accurate pre-procedural device sizing and proper device positioning at the LAA ostium to ensure sufficient device anchoring and avoid peri-device leaks. To address these challenges, 3D printing (3DP) of LAA models has recently emerged in the literature, first being described in 2015. We present a review of the benefits and drawbacks of employing this technology for LAAO procedures. Pre-procedurally the use of 3DP can consistently and accurately determine LAAO device size over standard of care approaches. Intra-procedurally 3DP\'s impact entailed a statistically significant decrease in the number of devices used per procedure, as well as in the fluoroscopic time and dose. Post-procedurally, there is some evidence that 3DP could reduce the rate of peri-device leaks, with limited data on its effect on complication rates. Based on existing evidence, we recommend the focused application of 3DP to cases of complex LAA anatomy and for the training of proceduralists. Lastly, we address the emergence of next generation LAAO devices and AR/VR systems that could limit even this narrow window of clinical benefit afforded by 3DP. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print
Tarabanis C, Klapholz J, Zahid S, Jankelson L
J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print | PMID: 35989544
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Impact:
Abstract

Causes and predictors of immediate and short-term readmissions following percutaneous left atrial appendage closure procedure.

Murthi M, Vardar U, Sana MK, Shaka H
Percutaneous Left atrial appendage device closure has been offered as an alternative to anticoagulation for high-risk patients with non-valvular atrial fibrillation. Given the relative novelty of the procedure, we aimed to analyze the rates and causes of immediate (30-days) and short-term (90 days) readmission after the procedure. We performed a retrospective observational study using the Nationwide Readmissions Database (NRD) for 2018. We studied 29,449 hospitalizations for percutaneous LAA device closure. In both the 30-day and 90-day cohorts, the most common causes of readmissions were gastrointestinal bleeding (16.1% & 14.8%), heart failure exacerbation (11.1 & 11.6%), and atrial fibrillation (6.2 & 7.2%). Female sex, liver disease, chronic kidney disease, chronic pulmonary disease, presence of heart failure, HIV/AIDS status, and diabetes mellitus were independently associated with higher odds of readmission in both cohorts. Our study highlights the need for further deliberation on the choice and duration of anticoagulation peri procedurally after percutaneous LAA closure, especially among those with high bleeding risk. It also highlights the need for optimization of heart failure status peri-procedurally to avoid readmissions for exacerbations. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print
Murthi M, Vardar U, Sana MK, Shaka H
J Cardiovasc Electrophysiol: 21 Aug 2022; epub ahead of print | PMID: 35989546
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Impact:
Abstract

Esophageal safety in CLOSE-guided 50W high-power-short-duration pulmonary vein isolation - The PREHEAT-PVI-Registry.

Francke A, Naumann G, Weidauer MC, Scharfe F, ... Wunderlich C, Christoph M
Aims
Pulmonary vein isolation (PVI) using high-power-short-duration (HPSD) radiofrequency ablation (RF) is emerging as the standard of care for treatment of atrial fibrillation (AF). While procedural short-term to mid-term efficacy and efficiency are very promising, this registry aims to investigate esopahgeal safety using an optimized ablation approach.
Methods
In a single-centre experience, 388 consecutive standardized first-time AF ablation were performed using a CLOSE-guided-fixed-50W-circumferential PVI and substrate modification without intraprocedural oesophageal temperature measurement. 300 patients underwent post-procedural esophageal endoscopy to diagnose and grade endoscopically detected esophageal lesions (EDEL) and were included in the analysis.
Results
EDEL were detected in 35 of 300 patients (11.6%), 25 of 35 were low-grade KCC 1 lesions with fast healing tendencies. 6 patients suffered KCC 2a lesions, 4 patients had KCC 2b lesions (1.3% of all patients). No esophageal perforation or fistula formation was observed. Patient baseline characteristics, especially patients age, gender and body-mass-index did not influence EDEL incidence. Additional posterior box isolation did not increase the incidence of EDEL. In patients diagnosed with EDEL, mean catheter contact force during posterior wall ablation was higher (11.9 ± 1.8 vs. 14.7 ± 3 grams, p<0.001), mean RF duration was shorter (11.9 ± 1 vs. 10.7 ± 1.2 sec., p<0.001), while achieved AI was not different between groups (434 ± 4.9 vs. 433 ± 9.5, n.s.).
Conclusions
Incidence of EDEL after CLOSE-guided-50W-HPSD PVI is lower compared to historical cohorts using standard-power RF settings. Catheter contact force during posterior HPSD ablation should not exceed 15 grams. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 Aug 2022; epub ahead of print
Francke A, Naumann G, Weidauer MC, Scharfe F, ... Wunderlich C, Christoph M
J Cardiovasc Electrophysiol: 18 Aug 2022; epub ahead of print | PMID: 35979645
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Abstract

Mitigating Esophageal Injury after Atrial Fibrillation Ablation Guided by Ablation Index; CLOSEr to goal.

Chinitz JS, Harris EQ
In the ongoing quest to optimize outcomes for atrial fibrillation ablation, efforts continue to balance the reliable creation of durable transmural ablation lesions, while minimizing risk to neighboring sensitive structures. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 18 Aug 2022; epub ahead of print
Chinitz JS, Harris EQ
J Cardiovasc Electrophysiol: 18 Aug 2022; epub ahead of print | PMID: 35979648
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Abstract

Validation of an electrocardiographic marker of low voltage areas in the right ventricular outflow tract in patients with idiopathic ventricular arrhythmias.

Parreira L, Marinheiro R, Carmo P, Chambel D, ... Reis RP, Adragao P
Background
Previous studies have reported the presence of subtle abnormalities in the right ventricular outflow tract (RVOT) in patients with apparently normal hearts and ventricular arrhythmias (VAs) from the RVOT, including the presence of low voltage areas (LVAs). This LVAs seem to be associated with the presence of ST-segment elevation in V1 or V2 leads at the level of the 2nd intercostal space (ICS).
Objective
Our aim was to validate an electrocardiographic marker of LVAs in the RVOT in patients with idiopathic outflow tract VAs.
Methods
120 patients were studied, 84 patients referred for ablation of idiopathic VAs with an inferior axis by the same operator, and a control group of 36 patients without VAs. Structural heart disease including arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An ECG was performed with V1-V2 at the 2nd ICS, and ST-segment elevation > 1mm and T-wave inversion beyond V1 were assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV were considered LVAs, and their presence was assessed. We compared three groups, VAs from the RVOT (n=66), VAs from the LVOT (n=18) and Control group (n=36). ST-elevation, T-wave inversion and left vs right side of the VAs were tested as predictors of LVAs, respective ORs (95% CI) and p values, were calculated with univariate logist regression. Variables with a p value<0.005 were included in the multivariate analysis.
Results
ST-segment elevation, T-wave inversion and LVAs were present in the RVOT group, LVOT group and Control group as follows: (62%, 17% and 6%, p <0.0001), (33%, 29% and 0%, p=0.001) and (62%, 25% and 14%, p<0.0001). The ST-segment elevation, T-wave inversion and right-sided VAs were all predictors of LVAs, respective unadjusted ORs (95% CI), p values were, 32.31 (11.33-92.13), p<0.0001, 4.137 (1.615-10.60), p=0.003 and 8.200 (3.309-20.32), p<0.0001. After adjustment, the only independent predictor of LVAs was the ST-segment elevation, with an adjusted OR (95% CI) of 20.94 (6.787-64.61), p<0.0001.
Conclusion
LVAs were frequently present in patients with idiopathic VAs. ST-segment elevation was the only independent predictor of their presence. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Aug 2022; epub ahead of print
Parreira L, Marinheiro R, Carmo P, Chambel D, ... Reis RP, Adragao P
J Cardiovasc Electrophysiol: 16 Aug 2022; epub ahead of print | PMID: 35971685
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Abstract

The Subtle Tine: Asymptomatic Micra Perforation Incidentally Discovered During Cardiac Surgery.

Tan NY, Madhavan M, Greason KL, Cha YM
A 70 year old woman with longstanding persistent atrial fibrillation underwent Micra leadless pacemaker implantation and atrioventricular nodal ablation. No postprocedural complications were noted. She subsequently underwent surgical mitral valve replacement four years later. During the surgery, Micra tine perforation of the right ventricular free wall was seen. No device revision was performed due to her asymptomatic status and stable pacemaker position/function. Pericardial effusion is a known complication of Micra implantation. The incidence of tine perforation is unknown as many patients may be asymptomatic. The clinical consequences regarding adverse events, device functionality, and explantation/extraction risk profile remain to be determined. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 10 Aug 2022; epub ahead of print
Tan NY, Madhavan M, Greason KL, Cha YM
J Cardiovasc Electrophysiol: 10 Aug 2022; epub ahead of print | PMID: 35946395
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Abstract

Optimal cut-off value for endocardial bipolar voltage mapping using a multipoint mapping catheter to characterize the scar regions described in cardio - CT with myocardial thinning.

Ene E, Halbfaß P, Nentwich K, Sonne K, ... Foldyna B, Deneke T
Introduction
To investigate whether the current standard voltage cut-off of < 0.5 for dense scar definition on endocardial bipolar voltage mapping (EBVM), using a high-resolution multipoint mapping catheter with microelectrodes (HRMMC), correctly identifies the actual scar area described on CT with myocardial thinning (CT MT).
Methods
Forty patients (39 men; 67.0±9.0 y/o) with a history of transmural myocardial infarction (mean time interval since MI 15.0±7.9 years) and sustained ventricular tachycardia (VT) were consecutively enrolled. A CT MT was performed in each patient before VT ablation. The CT MT 3D anatomical model including myocardial thinning layers was merged with the 3D electroanatomical and EBVM. Different predefined cut-off settings for scar definition on EBVM were used to identify the optimal ones, which showed the best overlap in terms of scar area with the different myocardial thinning layers.
Results
A cut-off value of < 0.2 mV demonstrated the best correlation in terms of scar area with the 2 mm thinning on CT MT (p=0.04) and a cut-off of < 1mV best overlapped with the 5 mm thinning (p=0.003). The currently used < 0.5 mV cut-off for scar definition on EBVM proved the best area correlation with 3 mm thinning (p=0.0002).
Conclusion
In order to better identify the real extent of scar areas after transmural MI as described on preprocedural CT MT, higher cut-off values for scar definition should be applied if the EBVM is performed using a HRMMC. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print
Ene E, Halbfaß P, Nentwich K, Sonne K, ... Foldyna B, Deneke T
J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print | PMID: 35938384
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Abstract

A simplified approach to radiofrequency catheter ablation of idiopathic ventricular outflow tract premature ventricular contractions.

Parreira L, Carmo P, Marinheiro R, Chambel D, ... Reis RP, Adragao P
Background
Frequently, low voltage areas (LVAs) and diastolic potentials (DPs) are present at ablation site in sinus rhythm in patients with idiopathic premature ventricular contractions (PVCs).
Objective
Validate these findings as substrate for PVCs and evaluate the feasibility of a simplified substrate approach based on LVAs and DPs for ablation of idiopathic outflow tract PVCs, in patients with a low PVC burden during the procedure.
Methods
Prospective single-arm clinical trial at two centers with comparison with a historical group, matched to age and gender. The study group consisted of consecutive patients referred for ablation of frequent idiopathic PVCs with inferior axis, that presented with less than 2 PVCs/min in first 5 minutes of the procedure. The ablation was based on fast mapping of the RVOT in sinus rhythm looking for LVAs and DPs, defined as isolated small amplitude potentials occurring after the T wave of the surface ECG. The area with LVAs and DPs was tagged, and a simplified activation mapping of the PVCs was done in that area. The procedure time, success rate and recurrence rate were compared with the historical group in whom ablation was performed based on activation and pace mapping only. A validation group without PVCs was also studied to assess the prevalence of LVAs and DPs in the general population.
Results
The study (n=38), historical (n=38) and validation (n=38) groups did not differ in relation to age or gender. Prevalence of LVAs and DPs was significantly higher in the study group in comparison with the validation group, respectively, 71% vs 11%, p<0.0001 and 87% vs 8%, p<0.0001. Procedure time was significantly lower in the study group when comparing to the historical group, 130 (100-164) vs 183 (160-203) min, p<0.0001 and the success rate was significantly higher, 90% vs 64%, p=0.013. The recurrence rate in patients with a successful ablation was not significantly different between both groups, Log-Rank=0.125.
Conclusion
Prevalence of LVAs and DPs was significantly higher in the study group than in the validation group. The proposed approach proved to be feasible, faster and more efficient than the historical approach. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print
Parreira L, Carmo P, Marinheiro R, Chambel D, ... Reis RP, Adragao P
J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print | PMID: 35938385
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Abstract

CT-imaging vs. high-density mapping in ischemic cardiomyopathy VT ablation: in whom do we trust?

Fink T, Sciacca V, Sommer P
Ablation of ventricular tachycardia (VT) has emerged an effective therapy in patients with ischemic heart disease. Electroanatomical mapping is currently considered the gold standard in terms of VT ablation This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print
Fink T, Sciacca V, Sommer P
J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print | PMID: 35938389
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Abstract

Unusual response to His-synchronous ventricular stimulation during a supraventricular tachycardia: Atrial advancement with or without resetting?

Merovci I, Gulcu O, Tuncez A, Kara M, ... Aras D, Topaloglu S
The delivery of ventricular extra-stimulus when the His bundle is refractory is the most important maneuver in the diagnosis of an accessory pathway conduction.The \"reset\" indicates that the extra-stimulus has penetrated the circuit to alter the \"subsequent cycle\'. The advanced atrial activation time is expected to affect (reset or terminate) the tachycardia to the next cycle. However, some pitfalls should be kept in mind in the evaluation of the resetting response. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print
Merovci I, Gulcu O, Tuncez A, Kara M, ... Aras D, Topaloglu S
J Cardiovasc Electrophysiol: 08 Aug 2022; epub ahead of print | PMID: 35938396
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Impact of atrioventricular junction ablation and CRT-D on long-term mortality in patients with left ventricular dysfunction, permanent, refractory atrial fibrillation and narrow QRS: results of a propensity matched analysis.

Palmisano P, Ziacchi M, Ammendola E, Dell\'Era G, ... Biffi M, Accogli M
Introduction
In patients with symptomatic permanent atrial fibrillation (PEAF) and narrow QRS, atrio-ventricular junction ablation (AVJA) plus cardiac resynchronization therapy (CRT) is superior to medical therapy in reducing heart failure (HF) hospitalization and all-cause mortality. To compare the mortality of a population of patients with HF, reduced EF (rEF) and PEAF treated with AVJA plus CRT with that of a contemporary cohort of patients in sinus rhythm (SR) with similar baseline characteristics.
Methods and results
In this prospective, multicentre, observational study, all-cause mortality in a group of consecutive patients undergoing AVJA and implantable cardioverter-defibrillator (ICD) combined with CRT implantation for HFrEF, narrow QRS, and PEAF with uncontrolled ventricular rate was compared with that of a contemporary cohort of patients in SR undergoing ICD implantation (not combined with CRT) for HFrEF and narrow QRS. Individual 1:1 propensity matching of baseline characteristics was performed. A total of 824 patients were enrolled. Propensity matching yielded 107 matched pairs. After a median follow-up of 52 months, all-cause mortality was similar in patients treated with AVJA plus CRT and in the control group (p=0.434). In AVJA plus CRT patients, mortality was significantly lower than in control group patients with a history of paroxysmal/persistent AF (n=45, p=0.020), and similar to that of patients without a history of AF (n=62, p=0.459).
Conclusions
After adjustment for patient characteristics, the long-term prognosis of patients with HFrEF, narrow QRS and PEAF who underwent AVJA plus CRT was similar to that of a population of patients in SR with similar characteristics. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Aug 2022; epub ahead of print
Palmisano P, Ziacchi M, Ammendola E, Dell'Era G, ... Biffi M, Accogli M
J Cardiovasc Electrophysiol: 05 Aug 2022; epub ahead of print | PMID: 35930617
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Abstract

Successful Ablation of a Wide Complex Tachycardia with Distinct Intra-Cardiac Electrograms.

Konstantino Y, Buturlin K, Westreich R, Bereza S, ... Slanovic L, Haim M
A 13-year-old boy was hospitalized after a syncopal episode that occurred during exercise. He suddenly felt chest tightness, sweating and palpitations, followed by a transient loss of consciousness. Upon emergency medical team arrival, he was awake and oriented. Baseline ECG showed sinus rhythm at a rate of 98 bpm, with narrow QRS, and no signs of long QT, Brugada, or pre-excitation. Physical examination, blood tests, 24 hours Holter monitoring, transthoracic echocardiography and stress test were all within normal limits. Eight days later he experienced a second episode of palpitations while walking to school. ECG revealed regular wide complex tachycardia (WCT) at a rate of 200 bpm, with LBBB morphology that terminated with Adenosine (Figure 1). The clinical tachycardia was easily induced by programmed electrical stimulation (Figure 2A). Diagnostic electrophysiological maneuver (Figure 2B) was followed by successful ablation, during which a unique phenomenon was noted (Figure 3). What is the diagnosis of the tachycardia and what are the unique findings noted during and after ablation? This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 05 Aug 2022; epub ahead of print
Konstantino Y, Buturlin K, Westreich R, Bereza S, ... Slanovic L, Haim M
J Cardiovasc Electrophysiol: 05 Aug 2022; epub ahead of print | PMID: 35930619
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Abstract

Sex differences and adherence of patients treated with wearable cardioverter-defibrillator: insights from an international multicenter register.

Abumayyaleh M, Dreher TC, Rosenkaimer S, Röger S, ... El-Battrawy I, Akin I
Aims
Treatment with the wearable cardioverter defibrillator (WCD) may protect against sudden cardiac death (SCD) as a bridging therapy until a cardioverter-defibrillator may be implanted. We analyzed in a multicenter setting a consecutive patient cohort wearing WCD to explore sex differences.
Methods and results
We analyzed 708 consecutive patients, 579 (81.8%) from whom were males and 129 (18.2%) females (age, 60.5±14 vs. 61.6±17 years old; p=0.44). While the rate of ischemic cardiomyopathy (ICM) as a cause of prescription of WCD was significantly higher in males as compared to females (42.7% vs. 26.4%; p=0.001), females received it more frequently due to non-ischemic cardiomyopathy (NICM) (55.8% vs. 42.7%); p=0.009). The wear time of WCD was equivalent in both groups (21.1±4.3 hours/days in males vs. 21.5±4.4 hours/days in females; p=0.27; and 62.6±44.3 days in males vs. 56.5±39 days in females; p=0.15). Mortality was comparable in both groups at 2-year-follow-up (6.8% in males vs. 9.7% in females; p=0.55). Appropriate WCD shocks and the incidence of ICD implantations were similar in both groups (2.4% in males vs. 3.9% in females; p=0.07) (35.1% in males vs. 31.8% in females; p=0.37), respectively. In age tertile analysis, compliance was observed more in 73-91 years old group as compared to 14-51 years old group (87.8% vs. 68.3%; p<0.001).
Conclusion
Compliance for wearing WCD was excellent regardless of sex. Furthermore, mortality and the incidence of ICD implantations were comparable in both sexes. Appropriate WCD shocks were similar in both sexes. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 05 Aug 2022; epub ahead of print
Abumayyaleh M, Dreher TC, Rosenkaimer S, Röger S, ... El-Battrawy I, Akin I
J Cardiovasc Electrophysiol: 05 Aug 2022; epub ahead of print | PMID: 35930623
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Abstract

ECG-I Phenotyping of Persistent AF Based on Driver Burden and Distribution to Predict Response to Pulmonary Vein Isolation (PHENOTYPE-AF).

Dhillon GS, Honarbakhsh S, Graham A, Abbass H, ... Schilling RJ, Hunter RJ
Background
This prospective trial sought to phenotype persistent AF based on AF mechanisms using ECGI mapping to determine whether this would predict long term freedom from arrhythmia after pulmonary vein isolation (PVI).
Methods
Patients with persistent AF of < 2 years duration underwent cryoballoon PVI. ECGI mapping was performed prior to PVI to determine potential drivers (PDs) defined as rotational activations completing ≥ 1.5 revolutions or focal activations. The co-primary end point was the association between (1) PD burden (defined as the number of PD occurrences) and (2) PD distribution (defined as the number of segments on an 18 segment model of the atria harbouring PDs) with freedom from arrhythmia at 1 year follow up.
Results
Of 100 patients, 97 completed follow up and 52 (53.6%) remained in sinus rhythm off antiarrhythmic drugs. Neither PD burden nor PD distribution predicted freedom from arrhythmia (HR 1.01, 95% CI 0.99 - 1.03, p = 0.164; and HR 1.04, 95% CI 0.91 - 1.17, p = 0.591 respectively). Otherwise, the burden of rotational PDs, rotational stability, and the burden of PDs occurring at the pulmonary veins and posterior wall all failed to predict arrhythmia recurrence (all p > 0.10).
Conclusions
AF mechanisms as determined using ECGI mapping do not predict outcome after PVI for persistent AF. Further studies using different methodologies to characterise AF mechanisms are warranted. (NCT03394404) This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Dhillon GS, Honarbakhsh S, Graham A, Abbass H, ... Schilling RJ, Hunter RJ
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924481
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Abstract

Fever, Covid-19 vaccination and Brugada syndrome: incidence and management: correspondence.

Sookaromdee P, Wiwanitkit V
We would like to share ideas on \"Fever following Covid-19 vaccination in subjects with Brugada syndrome: incidence and management [1] This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Sookaromdee P, Wiwanitkit V
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924467
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Abstract

Transient Fetal Atrioventricular Block: A Series of Four Cases and Approach to Management.

Kikano SD, Killen SAS
Fetal atrioventricular block (AVB) is a failure of conduction from atria to ventricles. Immune- and non-immune-mediated forms occur, especially in association with congenital heart disease. Second-degree (2°) AVB may be reversible with dexamethasone and IVIG in immune-mediated disease. However, once third-degree (3°) AVB develops, it is deemed irreversible with need for a pacemaker and risk for cardiomyopathy. Rarely, 2° AVB is a transient, benign phenomenon in the immature conduction system. Few case series of transient AVB have been reported, but a management approach has not been defined. We report four patients with self-resolving, non-immune fetal AVB and outline a management strategy. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Kikano SD, Killen SAS
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924469
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Abstract

Establishing electroporation thresholds for targeted cell specific cardiac ablation in a 2D culture model.

Avazzadeh S, Hosseinzahdehkordi M, Owens P, Jalali A, ... Keane D, Quinlan LR
Background
Irreversible electroporation has emerged as a new modality to overcome issues associated with other energy sources for cardiac ablation. Strong evidence on the optimal, effective, and selective voltage threshold is lacking for both in-vitro and pre-clinical in-vivo studies. The aim of this study is to examine the optimal threshold for selective cell ablation on cardiac associated cell types.
Methods
Conventional monophasic and biphasic pulses of different field strength were delivered in a monolayer culture system of cardiomyocytes, neurons and adipocytes. The dynamics of cell death mechanisms were examined at different time points.
Results
Neurons exhibit higher susceptibility to electroporation and cell death at higher field strength of 1250 V/cm in comparison to cardiomyocytes. Cardiac adipocytes showed lower susceptibility to electroporation in comparison to other cell types. A significant proportion of cardiomyocytes recovered after 24 hours post-electroporation, while neuronal cell death remained consistent but with a significant delayed cell death at a higher voltage threshold. Caspase 3/7 activity was observed in both cardiomyocytes and neurons, with a higher level of activity in cardiomyocytes in response to electroporation. Biphasic and monophasic pulses showed no significant difference in both cell types, and significantly lower cell death in neurons when inter pulse interval was reduced.
Conclusions
This study presents important findings on the differences in the susceptibility of neurons and cardiomyocytes to IRE. Cell type alone yielded selective and different dynamics in terms of the evolution and signaling mechanism of cell death in response to electroporation. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Avazzadeh S, Hosseinzahdehkordi M, Owens P, Jalali A, ... Keane D, Quinlan LR
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924470
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Abstract

The advantage of mini electrode-equipped catheter for the radiofrequency ablation of paroxysmal supraventricular tachycardia.

Choi Y, Kim SH, Kim H, Park JW, ... Jang SW, Oh YS
Introduction
Novel ablation catheters equipped with mini-electrodes (ME) offer high resolution mapping for target tissue. This study aimed to evaluate the mapping performance and efficacy of ME catheters in radiofrequency ablation (RFA) of paroxysmal supraventricular tachycardias (PSVTs).
Methods
We prospectively enrolled 136 patients undergoing RFA of PSVT including 76 patients with atrioventricular nodal reentrant tachycardia (AVNRT) and 60 patients with atrioventricular reentrant tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome. Patients were randomized to the ME group (ablation using ME catheters) or the control group (ablation using conventional catheters). The number of ablation attempt and cumulative ablation time to ablation endpoints, which was defined as an emergence of junctional rhythm in AVNRT or accessory pathway (AP) block in AVRT/WPW syndromes were compared.
Results
During ablation procedures, discrete slow pathway or AP electrograms were found in 27 (39.7%) patients in the ME group and 13 (19.1%) patients in the control group. The primary study outcomes were significantly lower in the ME group (ablation attempt number: 2.0 [1-4] vs. 3.0 [2-7] in the ME and control group, p=0.032; ablation time: 23.5 [5.0-111.5] vs. 64.5 [16.0-185.0] seconds, p=0.013). According to the PSVT diagnosis, ablation time to junctional rhythm was significantly shorter in the ME group in AVNRT. In AVRT/WPW syndrome, both ablation attempt number and ablation time to AP block were non-significantly lower in the ME group.
Conclusion
The novel ME catheter was advantageous for identifying pathway potentials and reducing initial ablation attempt number and ablation time to reach acute ablation endpoint for PSVTs. (ClinicalTrials.gov number, NCT04215640) This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Choi Y, Kim SH, Kim H, Park JW, ... Jang SW, Oh YS
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924472
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Abstract

The Mini Electrode-equipped Catheter: Utility for Paroxysmal Supraventricular Tachycardia Ablation.

Iwasawa J, Koruth JS
The role of catheter ablation for paroxysmal supraventricular arrhythmias (PSVT) is well established given that it is often a simple, safe, and successful procedure. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Iwasawa J, Koruth JS
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924477
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Abstract

Focal and Rotational Drivers in Persistent Atrial Fibrillation: Are We Chasing Ghosts?

Gasperetti A, Santangeli P
It is no secret that a reproducible and actionable understanding of persistent atrial fibrillation (AF) would represent the Holy Grail for cardiac electrophysiology in the 21st century. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print
Gasperetti A, Santangeli P
J Cardiovasc Electrophysiol: 04 Aug 2022; epub ahead of print | PMID: 35924479
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Abstract

Rare Left-Sided Accessory Pathway Successfully Ablated with Atrial Insertion Site at the Left-side Fossa Ovalis.

Yang H, Sun H, Li Y, Si D, Zhang W, He Y
Left-sided accessory pathways (APs) with atrial insertion away from the annulus is an atypical variation. Conventional mapping and ablation performed along mitral annulus (MA) is usually ineffective. A 14-year-old girl without structural heart disease presented with recurrent episodes of sudden onset palpitations and electrocardiogram showed a narrow QRS complex tachycardia. Electrophysiology study was done and anterograde atrioventricular reentrant tachycardia with AP was diagnosed. Conventional mapping and ablation along tricuspid annulus and MA respectively were all ineffective. 3D-activation mapping found the retrograde atrial insertion site of AP at the left-side fossa ovalis (FO), and AP was successfully abolished by radiofrequency ablation at that site. As reported, this patient is the first report of ablating a left-sided AP with retrograde atrial insertion at the left-side FO. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 28 Jul 2022; epub ahead of print
Yang H, Sun H, Li Y, Si D, Zhang W, He Y
J Cardiovasc Electrophysiol: 28 Jul 2022; epub ahead of print | PMID: 35900296
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Abstract

Cardiac Resynchronization Therapy Response in Cardiac Sarcoidosis.

Shabtaie SA, Sehrawat O, Lee JZ, Cha YM, ... DeSimone CV, Deshmukh AJ
Introduction
Cardiac Sarcoidosis (CS) is a non-ischemic cardiomyopathy (NICM) characterized by infiltration of non-caseating granulomas involving the heart with highly variable clinical manifestations that can include conduction abnormalities and systolic heart failure. Cardiac resynchronization therapy (CRT) has shown significant promise in NICM, though little is known about its efficacy in patients with CS.
Objective
To determine if CRT improved cardiac remodeling in patients with CS.
Methods
We retrospectively reviewed all patients with a clinical or histological diagnosis of CS who underwent CRT implantation at the Mayo Clinic enterprise from 2000-2021. Baseline characteristics, imaging parameters, heart failure hospitalizations and need for advanced therapies, and major adverse cardiac events (MACE) were assessed.
Results
Our cohort was comprised of 55 patients with 61.8% male and a mean age of 58.7 ± 10.9 years. 18 (32.7%) patients had definite CS, 21 (38.2%) had probable CS, while 16 (29.1%) had presumed CS, and 26 (47.3%) with extracardiac sarcoidosis. The majority underwent CRT-D implantation (n=52, 94.5%) and 3 (5.5%) underwent CRT-P implantation with 67.3% of implanted devices being upgrades from prior pacemakers or implantable cardioverter defibrillators. At 6 months post-implantation there was no significant improvement in ejection fraction (34.8 ± 10.9 % vs. 37.7 ± 14.2 %, p = 0.331) or left ventricular end-diastolic diameter (58.5 ± 10.2 mm vs. 57.5 ± 8.1 mm, p = 0.236), though mild improvement in left ventricular end systolic diameter (49.1 ± 9.9 mm vs. 45.7 ± 9.9 mm, p < 0.0001). Within the first 6 months post-implantation, 5 (9.1%) patients sustained a heart failure hospitalization. At a mean follow up of 4.1 ± 3.7 years, 14 (25.5%) patients experienced a heart failure hospitalization, 11 (20.0%) underwent cardiac transplantation, 1 (1.8%) underwent LVAD implantation and 7 (12.7%) patients died.
Conclusions
Our findings suggest variable response to CRT in patients with CS with no overall improvement in ventricular function within six months and a substantial proportion of patients progressing to advanced heart failure therapies. This article is protected by copyright. All rights reserved.

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J Cardiovasc Electrophysiol: 23 Jul 2022; epub ahead of print
Shabtaie SA, Sehrawat O, Lee JZ, Cha YM, ... DeSimone CV, Deshmukh AJ
J Cardiovasc Electrophysiol: 23 Jul 2022; epub ahead of print | PMID: 35870183
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Abstract

Reducing Permanent Pacemaker Requirements Following Concomitant Surgery for Atrial Fibrillation.

McCarthy PM, Churyla A, Kruse J, Cox JL
The need for a permanent pacemaker after cardiac surgery is significant, and related to preexisting conduction abnormalities, the type of cardiac operation, and other factors such as advanced age. Also, concomitant surgical ablation for preexisting atrial fibrillation has been identified as a risk factor for new pacemaker implant. That need varies considerably however. The risk may increase from the national average of approximately 6-7% for all cardiac operations to 15-20% in prospective studies, but per the national database is 25% higher for concomitant ablation patients. Properly applied surgical ablation lesions should not cause heart block as there are no ablations near the atrioventricular node. There may be a lack of awareness of the location of the atrial pacemaker complex which may jeopardized by some right atrial lesions. Furthermore, the pressure for early discharge may lead to the implantation of a pacemaker before the sinus mechanism has recovered. This paper reviews the anatomy relevant to the ablation lesions sets, the literature reporting pacemaker rates, and techniques to reduce the need for a new pacemaker after ablation surgery. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Jul 2022; epub ahead of print
McCarthy PM, Churyla A, Kruse J, Cox JL
J Cardiovasc Electrophysiol: 23 Jul 2022; epub ahead of print | PMID: 35870187
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Abstract

Does Cardiac Resynchronization Help Patients with Cardiac Sarcoidosis?

Chicos AB
In this issue of the journal, Shabtaie et al present a retrospective cohort study of the effects of cardiac resynchronization (CRT) in cardiac sarcoidosis (CS) in 55 patients managed at the Mayo Clinic enterprise from 2000-2021. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 23 Jul 2022; epub ahead of print
Chicos AB
J Cardiovasc Electrophysiol: 23 Jul 2022; epub ahead of print | PMID: 35870191
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Abstract

Hemodynamic Response and Safety of Vasodilator Stress Cardiovascular Magnetic Resonance in Patients with Permanent Pacemakers or Implantable Cardioverter-Defibrillators.

Miller L, Airapetov S, Pillai A, Kalahasty G, ... Gregory Hundley W, Trankle CR
Introduction
Vasodilator stress cardiovascular magnetic resonance (CMR) is a powerful diagnostic modality, but data toward its use in patients with permanent pacemakers (PPMs) or implantable cardioverter-defibrillators (ICDs) is limited.
Methods and results
Patients with ICDs (>1% pacing) or PPMs who underwent regadenoson single photon emission computed tomography (SPECT) and all patients with ICDs or PPMs who underwent stress CMR were retrospectively identified. SPECT tests were analyzed for hemodynamic responses and new pacing requirements; CMR studies were examined for safety, device characteristics and programming, hemodynamic responses, and image quality. Changes from baseline were evaluated with the Related-Samples Wilcoxon Signed Rank Test. Of 67 patients (median age 65 [IQR 58-72] years, 31 (46%) female, 31 (46%) Black), 47 underwent SPECT and 20 CMR. With regadenoson SPECT, 89% of patients experienced tachycardic responses above resting heart rates (+19 [13-32] beats per minute, p<0.01). During stress CMR, 10 (50%) devices were asynchronously paced approximately 10 beats per minute above resting rates, and the remaining were temporarily deactivated. Those with asynchronous pacing had no changes in heart rates, whereas patients with deactivated devices had near uniform heart rate accelerations. Image quality was diagnostic in the majority of stress CMR sequences, with non-conditional ICDs contributing 40 of 57 (70%) of nondiagnostic segments.
Conclusion
This data supports the safety of vasodilator stress CMR with promising diagnostic quality images in patients with CMR conditional ICDs and PPMs. Despite a near uniform tachycardic response to regadenoson in the SPECT environment, high rates of asynchronous pacing during vasodilator stress CMR did not result in competitive pacing or adverse arrhythmic events. Further studies are needed to validate these findings and confirm the diagnostic and prognostic performance of stress CMR in these individuals. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Miller L, Airapetov S, Pillai A, Kalahasty G, ... Gregory Hundley W, Trankle CR
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842792
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Abstract

Percutaneous Jugular Leadless Pacemaker Implantation in a Pediatric Patient.

Kumthekar RN, Augostini RS, Kamp AN, Kertesz NJ
Leadless cardiac pacing has not been widely utilized in pediatric patients, in part due to concerns regarding size of the delivery sheath and the potential for vascular injury. We present a case of leadless pacemaker implantation via internal jugular vein without a surgical cutdown. This is a novel approach to leadless pacemaker implantation that could broaden the utilization of this technology to the vulnerable population of children, especially those with congenital heart disease. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Kumthekar RN, Augostini RS, Kamp AN, Kertesz NJ
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842796
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Abstract

Considerations for Stress Perfusion Cardiac Magnetic Resonance Imaging in Patients with Cardiac Implantable Electronic Devices.

Chyou JY, Axel L
With increasing collective experience with cardiac magnetic resonance (CMR) imaging in patients with cardiac implantable electronic devices (CIEDs), guided by published safety data and professional society scientific documents,1 there has been growing interest in extending the application of CMR imaging in patients with CIEDs This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Chyou JY, Axel L
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842797
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Abstract

From Minimally to Maximally Invasive; VT Ablation in the setting of Mechanical Aortic and Mitral Valves.

Hawson J, Kalman J, Goldblatt J, Anderson RD, ... Kumar S, Lee G
Double mitral and aortic mechanical valves present an access challenge when planning a ventricular tachycardia (VT) ablation. In this case report we describe a patient who was considered for stereotactic ablative radiotherapy but was unable to proceed due to unfavourable anatomy making them high risk of fistula formation. The patient went on to have an endocardial VT ablation via mini thoracotomy and transapical access without complication. This case highlights the need for careful consideration when planning treatment for patients with double mechanical valves. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Hawson J, Kalman J, Goldblatt J, Anderson RD, ... Kumar S, Lee G
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842799
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Abstract

A 15-year follow-up study of Radiofrequency Catheter Ablation for Atrial Fibrillation in Patients with Tachycardia-Bradycardia Syndrome.

Tokuda M, Yamashita S, Hachisuka E, Sato H, ... Yoshimura M, Yamane T
Introduction
Catheter ablation for atrial fibrillation (AF) in patients with tachycardia-bradycardia syndrome (TBS) can be major therapeutic option to replace permanent pacemaker implantation (PMI). However, the very long-term outcome more than 15 years in these patients has not been elucidated.
Methods
From 2002 to 2008, 25 consecutive TBS patients (62 ± 7.9 years old, 68% male) with both AF and symptomatic sinus pauses (>3.0 sec) were performed radiofrequency AF ablation. These patients were followed for 15 ± 2.7 years.
Results
The median longest sinus pause before ablation procedure was 6.0 (4.4-8.0) seconds. Following 1.6±0.8 ablation procedures, 18(72%) patients remained free from AF. Three (12%) patients died due to non-cardiovascular causes, and 7(28%) patients underwent PMI due to symptomatic sinus pause after recurrent AF in 5 patients and progression of sinus node dysfunction in 2 patients. The median duration from the first AF ablation to PMI was 6.3 years (range 9 days to 11.0 years). Five and 2 patients required PMI more than 5 and 10 years after the first ablation procedure, respectively.
Conclusions
AF ablation prevented PMI in the 72% of TBS patients for 15 years follow up. However, in consideration of long duration to PMI, a continuous careful long-term follow-up was warranted. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Tokuda M, Yamashita S, Hachisuka E, Sato H, ... Yoshimura M, Yamane T
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842800
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Abstract

Achievement rate and learning curve of left bundle branch capture in left bundle branch area pacing procedure performed to demonstrate output-dependent QRS transition.

Shimeno K, Tamura S, Hayashi Y, Abe Y, Naruko T, Fukuda D
Introduction
Recently, output-dependent QRS transition was reported to be required to confirm left bundle branch (LBB) capture in LBB area pacing (LBBAP) procedure. This study aimed to evaluate the achievement rate and the learning curve of LBB capture in LBBAP procedure performed with the goal of demonstrating output-dependent QRS transition, and investigate predictors of LBB capture.
Methods and results
The LBBAP procedure was performed in 126 patients with bradyarrhythmia. LBB capture was defined as a demonstration of output-dependent QRS transition. The following pacing definitions were used for evaluation: a) LBBAP, which met the previously reported LBBAP criteria, b) LBB pacing (LBBP), LBB capture was confirmed, and c) available LBBP, LBB threshold was clinically usable (<3 V at 0.4 ms). The learning curve was evaluated by division into three time-periods. The achievement rates of LBBAP, LBBP, and available LBBP were 88.1%, 41.2%, and 35.7%, respectively. The achievement rates of all three pacing definitions significantly increased with experience (p < 0.01), but the achievement rate of available LBBP was still 50% in the third period. As predictors of LBB capture, the interval between LBB-Purkinje potential and QRS onset ≥22 ms had high specificity of 98.3%, while R wave peak time in V6 <68 ms had insufficient sensitivity of 79% and specificity of 68%.
Conclusion
Even if LBB capture was aimed in LBBAP procedure, it was not easy to achieve, and there was a clear learning curve. Much of LBBAP may be left ventricular septal pacing that does not capture LBB. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Shimeno K, Tamura S, Hayashi Y, Abe Y, Naruko T, Fukuda D
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842801
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Abstract

Employing New Criteria for Confirmation of Conduction Pacing - Achieving True Left Bundle Branch Pacing May Be Harder Than Meets the Eye.

Sink J, Verma N
In recent years, conduction system pacing (CSP) has garnered significant attention from the electrophysiology (EP) community This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Sink J, Verma N
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842803
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Abstract

Improved Survival in Patients with Atrial Fibrillation and Heart Failure Undergoing Catheter Ablation Compared to Medical Treatment: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Romero J, Gabr M, Alviz I, Briceno D, ... Natale A, Di Biase L
Introduction
Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy.
Methods and results
A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% CI 0.51-0.83, P=0.0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of atrial-arrhythmia recurrence were significantly lower in the CA group (39.9% vs 69.6%, RR 0.55, 95% CI 0.40-0.76, P=0.0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ±7.6%) as compared to conventional treatment (+3.3±8%) (Mean difference 6.2, 95% CI 3.6-8.8, P<0.00001).
Conclusion:
CA for AF in patients with HF decreases all-cause mortality, improves atrial-arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and NYHA class IV heart failure has not been clearly elucidated. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Romero J, Gabr M, Alviz I, Briceno D, ... Natale A, Di Biase L
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842804
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Abstract

Lead-related infective endocarditis with vegetations: prevalence and impact of pulmonary embolism in patients undergoing transvenous lead extraction.

Bontempi L, Arabia G, Salghetti F, Cerini M, ... Muneretto C, Curnis A
Introduction
The prevalence and impact of pulmonary embolism (PE) in patients with lead-related infective endocarditis undergoing transvenous lead extraction (TLE) are unknown.
Methods and results
Twenty-five consecutive patients with vegetations ≥10 mm at transoesophageal echocardiography were prospectively studied. Contrast-enhanced chest computed tomography (CT) was performed before (pre-TLE) and after (post-TLE) the lead extraction procedure. Pre-TLE CT identified 18 patients (72%) with subclinical PE. The size of vegetations in patients with PE did not differ significantly from those without (median 20.0 mm [interquartile range, 13.0-30.0] vs. 14.0 mm [6.0-18.0], p=0.116). Complete TLE success was achieved in all patients with 3 (2-3) leads extracted per procedure. There were no post-procedure complications related to the presence of PE and no differences in terms of fluoroscopy time and need for advanced tools. In the group of positive pre-TLE CT, post-TLE scan confirmed the presence of silent PE in 14 patients (78%). There were no patients with new PE formation. Large vegetations (≥20 mm) tended to increase the risk of post-TLE subclinical PE (odds ratio 5.99 [95% CI: 0.93-38.6], p=0.059). During a median 19.4 months follow-up, no re-infection of the implanted system was reported. Survival rates in patients with and without post-TLE PE were similar (hazard ratio: 1.11 [95% CI: 0.18-6.67], p=0.909).
Conclusion
Subclinical PE detected by CT was common in patients undergoing TLE with lead-related infective endocarditis and vegetations but was not associated with the complexity of the procedure or adverse outcomes. TLE procedure seems safe and feasible even in patients with large vegetations. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Bontempi L, Arabia G, Salghetti F, Cerini M, ... Muneretto C, Curnis A
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842805
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Abstract

Percutaneous Lead Extraction in Patients with Large Vegetations: Limiting our Aspirations.

Schaller RD
Transvenous lead extraction (TLE) in the 1960\'s involved orthopedic-style pulley systems that joined the exposed portion of the lead to progressively heavier weights hanging from the bed This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print
Schaller RD
J Cardiovasc Electrophysiol: 16 Jul 2022; epub ahead of print | PMID: 35842810
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Abstract

Distinct propagation patterns of right pulmonary veins through multiple epicardial connections during right atrial pacing and sinus rhythm.

Kitamura T, Hayashi K, Ohta M, Izumi C, ... Ogata N, Isshiki T
A 47-year-old man with symptomatic paroxysmal atrial fibrillation (AF) underwent AF ablation. Activation maps during right atrial pacing and sinus rhythm before the ablation revealed distinctive left atrial (LA) propagations with multiple LA breakthrough sites via epicardial connections. A wide area circumferential ablation was not able to achieve a right pulmonary vein (RPV) isolation and required an inner PV ablation to isolate the RPV. Activation maps during different rhythms before the ablation may be helpful to unmask multiple epicardial connections between the RPV and right atrium. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Jul 2022; epub ahead of print
Kitamura T, Hayashi K, Ohta M, Izumi C, ... Ogata N, Isshiki T
J Cardiovasc Electrophysiol: 01 Jul 2022; epub ahead of print | PMID: 35775820
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Abstract

Coronary sinus electrogram characteristics predicts termination of AF with ablation and long-term clinical outcome.

Honarbakhsh S, Schilling RJ, Keating E, Finlay M, Hunter RJ
Aims
Markers predicting AF termination and freedom from AF/atrial tachycardia (AT) has been proposed. This study aimed to evaluate the role of novel CS electrogram characteristics in predicting the acute ablation response and freedom from AF/AT during follow-up.
Methods
Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals mapping study were included. Novel CS electrogram characteristics including CS cycle length variability (CLV) and CS activation pattern stability (APS) and proportion of low voltage zones (LVZs) were reviewed as potential predictors for AF termination on ablation and freedom from AF/AT during follow-up. The relationship between localized driver characteristics and CS electrogram characteristics were also assessed.
Results
Sixty-five patients were included. AF termination was achieved in 51 patients and 80% of patients were free from AF/AT during a follow-up of 29.5±3.7 months. CS CLV of <30ms, CS APS of ≥30% and proportion of LVZ <30% showed a high diagnostic accuracy in predicting AF termination on ablation and freedom from AF/AT during follow-up (CS CLV OR 25.6, AUC 0.91; CS APS OR 15.9, AUC 0.94; proportion of LVZs OR 21.4, AUC 0.88). These markers were independent predictors of AF termination on ablation and AF/AT recurrence during follow-up. Ablation of a smaller number of drivers that demonstrate greater dominance strongly correlate with greater CS organization.
Conclusion
Novel CS electrogram characteristics were independent predictors of AF termination and AF/AT recurrence during follow-up. These markers can potentially aid in predicting outcomes and guide ablation and follow-up strategies. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 01 Jul 2022; epub ahead of print
Honarbakhsh S, Schilling RJ, Keating E, Finlay M, Hunter RJ
J Cardiovasc Electrophysiol: 01 Jul 2022; epub ahead of print | PMID: 35775822
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Abstract

Surgical versus catheter ablation in atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials.

Rattanawong P, Kanitsoraphan C, Kewcharoen J, Sriramoju A, ... Vutthikraivit W, Shen WK
Background
Atrial fibrillation (AF) is the most common cardiac arrhythmia with a high stroke and mortality rate. The video-assisted thoracoscopic radiofrequency pulmonary vein ablation is a treatment option for patients who fail catheter ablation. Randomized data comparing surgical versus catheter ablation are limited. We performed a meta-analysis of randomized control trials to explore the outcome efficacy between surgical and catheter radiofrequency pulmonary vein ablation in patients with AF.
Methods
We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2020. Included studies were published randomized control trials that compared video-assisted thoracoscopic and catheter radiofrequency pulmonary vein ablation. Data from each study were combined using the fixed-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratios and 95% confidence intervals.
Results
Six studies from November 2013 to 2020 were included in this meta-analysis involving 511 AF patients (79% paroxysmal) with 263 catheter ablation (mean age 56±3 years) and 248 surgical ablations (mean age 52 ±4 years). Catheter ablation was associated with increased atrial arrhythmias recurrence when compared to surgical ablation (pooled relative risk=1.85, 95 % confidence interval: 1.44-2.39, p<0.001, I2 =0.0%) but associated with less total major adverse events (pooled relative risk=0.29, 95 % confidence interval: 0.16-0.53, p<0.001, I2 =0.0%). In subgroup analysis, catheter ablation was associated with increased AF recurrence in refractory paroxysmal AF when compared to surgical ablation (pooled relative risk=2.47, 95 % confidence interval: 1.31-4.65, p=0.005, I2 =0.0%) but not in persistent AF (relative risk=1.09, 95 % confidence interval: 0.60-2.0, p=0.773).
Conclusion
Catheter ablation was associated with higher atrial arrhythmia recurrence when compared with surgical ablation. However, our study suggests that the benefit of surgical ablation in patients with persistent AF is unclear. More studies and alternative ablation strategies investigation in persistent AF are warranted. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Jun 2022; epub ahead of print
Rattanawong P, Kanitsoraphan C, Kewcharoen J, Sriramoju A, ... Vutthikraivit W, Shen WK
J Cardiovasc Electrophysiol: 30 Jun 2022; epub ahead of print | PMID: 35771487
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Abstract

Defining Electrocardiographic Criteria to differentiate Non-Type 1 Brugada ECG variants from normal incomplete RBBB patterns in the young SCD-SOS cohort.

Carrington M, Creta A, Young WJ, Carrington M, ... Lambiase PD, Providência R
Introduction
We assessed the prevalence of non-type 1 Brugada pattern (T1BrP) in children and young adults from the SCD-SOS cohort and the diagnostic yield of non-expert manual and automatic algorithm ECG measurements.
Methods
Cross-sectional study. We reviewed 14662 ECGs and identified 2226 with a rSr\'-pattern in V1-V2. Among these, 115 were classified by experts in hereditary arrhythmic-syndromes as having or not non-T1BrP, and were compared with measurements of 5 ECG-derived parameters based on a triangle formed by r\'-wave (d(A), d(B), d(B)/h, β-angle) and ST-ascent, assessed both automatically and manually by non-experts. We estimated intra and interobserver concordance for each criterion, calculated diagnostic accuracy and defined the most appropriate cut-off values.
Results
A rSr\'-pattern in V1-V2 was associated with higher PQ interval and QRS duration, male gender and lower BMI. The manual measurements of non-T1BrP criteria were moderately reproducible with high intra-observer and moderate interobserver concordance coefficients (ICC:0.72-0.98, and 0.63-0.76). Criteria with higher discriminatory capacity were: distance d(B) (0.72;95%CI0.65-0.80) and ST-ascent (0.87;95%CI0.82-0.92), which was superior to the 4 r\'-wave criteria together (AUC0.74). We suggest new cut-offs with improved combination of sensitivity and specificity: d(B)≥1.4mm and ST-ascent≥0.7mm (Sensitivity1-82%;Specificity71-84%), that can be automatically measured to allow classification in 4 morphologies with increasing non-T1BrP probability.
Conclusion
rSr\'-pattern in precordial leads V1-V2 is a frequent finding and the detection of non-T1BrP by using the aforementioned 5 measurements is reproducible and accurate. In this study, we describe new cut-off values that may help untrained clinicians to identify young individuals who may require further work-up for a potential Brugada Syndrome diagnosis. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Jun 2022; epub ahead of print
Carrington M, Creta A, Young WJ, Carrington M, ... Lambiase PD, Providência R
J Cardiovasc Electrophysiol: 30 Jun 2022; epub ahead of print | PMID: 35771489
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Abstract

Metabolic Effects of the Left Atrial Appendage Exclusion (THE HEART HORMONE STUDY).

Bartus K, Elbey MA, Kanuri SH, Lee R, ... Malecki MT, Lakkireddy D
Objective
The effect of epicardial LAA occlusion therapy on lipid and glucose metabolism in AF patients over the long term follow up is unclear.
Methods
In a single-center prospective observational study, 60 patients with longstanding persistent AF with cardiovascular risk factors had undergone an epicardial exclusion procedure. Anthropometric parameters and glucose, glycated hemoglobin (HbA1c), insulin, leptin, adiponectin, free fatty acids, beta-hydroxybutyrate, and total cholesterol levels were evaluated on fasting at baseline before the procedure and compared with levels at 24 hours, 7 days, 1 month, 3 months, 6 months, and 24 months follow the procedure.
Results
The mean age of the patients was 67.5 ± 8.1. Insulin levels significantly increased at 7 days, 1 month, 3 months, 6 months, 12 months, and 24 months follow-up. The leptin levels showed a significant increase in 6 months, 12 months, and 24 months when compared to baseline. Whereas the adiponectin levels showed a significant decrease at 3 months, 6 months, 12 months, and 24 months when compared to baseline levels. In patients with the epicardial procedure, when compared to baseline, glucose, glycated hemoglobin, total cholesterol, and beta-hydroxybutyrate levels did not show any significant changes at baseline and 24 months follow up.
Conclusion
The epicardial exclusion ligation in AF patients was associated with significant changes in insulin, leptin, and adiponectin over long follow up. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 30 Jun 2022; epub ahead of print
Bartus K, Elbey MA, Kanuri SH, Lee R, ... Malecki MT, Lakkireddy D
J Cardiovasc Electrophysiol: 30 Jun 2022; epub ahead of print | PMID: 35771566
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Impact:

This program is still in alpha version.