Topic: Electrophysiology

Abstract
<div><h4>Ex-vivo Histopathologic Examination of Irrigated Radiofrequency Ablation Utilizing Half-normal Saline of the Human Heart.</h4><i>Pillai A, Robila V, Kasirajan V, Ellenbogen KA, Koneru JN</i><br /><b>Introduction</b><br />Radiofrequency ablation (RFA) utilizing half-normal saline (HNS) irrigation is a promising intervention to circumvent commonly encountered limitations during radiofrequency ablation of deep myocardial substrate. Few studies to date have analyzed the morphologic changes in the human myocardium following HNS RFA.<br /><b>Methods and results</b><br />Three patients with symptomatic ventricular tachycardia (VT) who underwent RFA with HNS irrigation underwent pathological specimen examination at time of autopsy or following native heart explant at time of cardiac transplantation. Gross evaluation of the heart was performed fresh and after fixation in 10% formalin. Routine examination was performed with fixation in 10% formalin. Sections of lesioned tissue were paraffin embedded and evaluated using standard hematoxylin and eosin (H&E) staining.<br /><b>Conclusion</b><br />Irrigated RF ablation with HNS irrigant produces coagulative necrosis as well as several delayed histopathological changes with a deeper field of effective ablation. Transmurality may not be obtained in the ventricular myocardium with endocardial, epicardial, or sequential unipolar HNS ablation. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print</small></div>
Pillai A, Robila V, Kasirajan V, Ellenbogen KA, Koneru JN
J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print | PMID: 36738139
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<div><h4>Safety and Effect on Length of Stay of Intravenous Sotalol Initiation for Arrhythmia Management.</h4><i>Rizkallah DH, Refaat MM</i><br /><AbstractText>Sotalol is a class III antiarrhythmic drug with beta-adrenergic blocking activity, used to manage both supraventricular and ventricular arrhythmias. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print</small></div>
Rizkallah DH, Refaat MM
J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print | PMID: 36738140
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<div><h4>Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia with an Irrigated Contact Force Sensing Radiofrequency Ablation Catheter.</h4><i>Panday P, Holmes D, Park DS, Jankelson L, ... Chinitz LA, Barbhaiya CR</i><br /><b>Introduction</b><br />Radiofrequency ablation (RFA) slow pathway modification for catheter ablation of AV nodal reentrant tachycardia (AVNRT) is traditionally performed using a 4mm, non-irrigated (NI) RF ablation catheter. Slow pathway modification using irrigated, contact-force sensing (ICFS) RFA catheters has been described in case reports, but outcomes have not been systematically evaluated.<br /><b>Methods</b><br />Acute procedural outcomes of 200 consecutive patients undergoing slow pathway modification for AVNRT were analyzed. An ICFS 3.5mm RFA catheter (ThermoCool SmartTouch STSF, Biosense Webster, Inc.) was utilized in 134 patients, and a 4mm NI RFA catheter (EZ Steer, Biosense Webster, Inc.) was utilized in 66 patients. Electroanatomic maps were retrospectively analyzed in a blinded fashion to determine proximity of ablation lesions to the His region.<br /><b>Results</b><br />Baseline characteristics of patients in both groups were similar. Total RF time was significantly lower in the ICFS group compared to the NI group (5.53±4.6 vs. 6.24±4.9 min, p=0.03). Median procedure time was similar in both groups, ICFS 108.0 (87.5-131.5) vs. NI 100.0 (85.0-125.0) min, p=0.2). Ablation was required in closer proximity to the His region in the NI group compared to the ICFS group (14.4 ± 5.9 mm vs, 16.7 ± 6.4 mm, respectively, p=0.01). AVNRT was rendered non-inducible in all patients, and there was no arrhythmia recurrence during follow-up in both groups. Catheter ablation was complicated by AV block in one patient in the NI group.<br /><b>Conclusion</b><br />Slow pathway modification for catheter ablation of AVNRT using an irrigated, contact-force sensing RFA catheter is feasible, safe, and may facilitate shorter duration ablation while avoiding ablation in close proximity to the His region. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print</small></div>
Panday P, Holmes D, Park DS, Jankelson L, ... Chinitz LA, Barbhaiya CR
J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print | PMID: 36738141
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<div><h4>Impact of unipolar voltage criteria for left atrial posterior wall on atrial fibrillation recurrence after pulmonary vein isolation.</h4><i>Watanabe T, Watanabe H, Hachiya H, Sato M, ... Imai Y, Kario K</i><br /><b>Background</b><br />Beyond pulmonary vein isolation (PVI), additional therapeutic strategies for atrial fibrillation (AF) have not been established. Remodeling of the left atrium (LA) could impact AF recurrence post-PVI. We investigated the impact of unipolar voltage (UV) criteria for the LA posterior wall (LA-PW) on AF recurrence post-PVI.<br /><b>Methods</b><br />We reviewed the cases of 106 AF patients (mean age 63.8 years, non-paroxysmal AF: 59%) who underwent extensive encircling PVI by radiofrequency ablation guided by a 3-dimension mapping system, investigating the impact on AF recurrence of the UV criteria of the LA.<br /><b>Results</b><br />Out of all patients, 26 patients had AF recurrence during post-PVI follow-up [median 603 days]. They showed a higher percentage of non-paroxysmal AF (80.8 vs. 52.5%, P=0.011), longer AF duration (2.9±2.7 vs. 1.0±1.7years, P=0.002), and larger area size of UV < 2.0mV in LA-PW (2.8±1.8 vs. 1.0±1.5cm<sup>2</sup> , P<0.001) than those without recurrence. Cox Hazard analysis for AF recurrence adjusted by age, gender, AF duration, body mass index and left atrial volume index revealed that an area size over 2.0cm<sup>2</sup> of UV < 2.0mV in LA-PW (HR 6.9 [95% CI:1.3-35.5], P=0.021) posed independent risks for AF recurrence post-PVI. The atrial arrhythmia-free survival rate was higher in those with no area of UV < 3.0mV in LA-PW compared to those with a sizable area (>2.0cm<sup>2</sup> ) of UV <3.0mV and <2.0mV (95.0% vs. 74.2% vs. 57.1%, Log-Rank: P<0.001). In the AF etiology of patients with AF recurrence, 9 of 14 patients who underwent the 2<sup>nd</sup> procedure had no PV reconnection, and 8 patients required the LA-PW isolation for their non-PV AF.<br /><b>Conclusion</b><br />UV criteria of LA-PW is a useful parameter for AF-recurrence post-PVI. Lower UV in LA-PW as an indication of electrical remodeling could indicate a higher risk of AF recurrence and the need for further therapeutic strategies. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print</small></div>
Watanabe T, Watanabe H, Hachiya H, Sato M, ... Imai Y, Kario K
J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print | PMID: 36738145
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<div><h4>The Effect of Scar and His-Purkinje and Myocardium Conduction on Response to Conduction System Pacing.</h4><i>Strocchi M, Gillette K, Neic A, Elliott MK, ... Rinaldi CA, Niederer SA</i><br /><b>Introduction</b><br />Conduction system pacing (CSP), in the form of His bundle pacing (HBP) or left bundle branch pacing (LBBP), is emerging as valuable cardiac resynchronization therapy (CRT) delivery methods. However, patient selection and therapy personalization for CSP delivery remain poorly characterized. We aim to compare pacing-induced electrical synchrony during CRT, HBP, LBBP, HBP with left ventricular (LV) epicardial lead (HOT-CRT), and LBBP with LV epicardial lead (LOT-CRT) in patients with different conduction disease presentations using computational modeling.<br /><b>Methods</b><br />We simulated ventricular activation on twenty-four four-chamber heart geometries including His-Purkinje systems with proximal left bundle branch block (LBBB). We simulated septal scar, LV lateral wall scar, and mild and severe myocardium and LV His-Purkinje system conduction disease by decreasing the conduction velocity (CV) down to 70% and 35% of healthy CV. Electrical synchrony was measured by the shortest interval to activate 90% of the ventricles (BIVAT-90).<br /><b>Results</b><br />Severe LV His-Purkinje conduction disease favored CRT (BIVAT-90: HBP 101.5±7.8ms vs CRT 93.0±8.9ms, P<0.05), with additional electrical synchrony induced by HOT-CRT (87.6±6.7ms, P<0.05) and LOT-CRT (73.9±7.6ms, P<0.05). Patients with slow myocardium CV benefit more from CSP compared to CRT (BIVAT-90: CRT 134.5±24.1ms; HBP 97.1±9.9ms, P<0.01; LBBP: 101.5±10.7ms, P<0.01). Septal but not lateral wall scar made CSP ineffective, while CRT was able to resynchronize the ventricles in the presence of septal scar (BIVAT-90: baseline 119.1±10.8ms vs CRT 85.1±14.9ms, P<0.01).<br /><b>Conclusion</b><br />Severe LV His-Purkinje conduction disease attenuates benefits of CSP, with additional improvements achieved with HOT-CRT and LOT-CRT. Septal but not lateral wall scar make CSP ineffective. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print</small></div>
Strocchi M, Gillette K, Neic A, Elliott MK, ... Rinaldi CA, Niederer SA
J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print | PMID: 36738149
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<div><h4>Clinical use conditions of lead deployment and simulated lead fracture rate in left bundle branch area pacing.</h4><i>Zou J, Chen K, Liu X, Xu Y, ... Zhou X, Lu H</i><br /><b>Background</b><br />Left bundle branch area pacing (LBBAP) is achieved by advancing the lead tip deep in the septum. The most LBBAP implants are performed using the Medtronic SelectSecure™ MRI SecureScan™ Model 3830 featuring a unique 4 Fr fixed helix lumenless design. Details of lead use conditions and long-term reliability have not been reported.<br /><b>Objective</b><br />To quantify the mechanical use conditions for the 3830 lead during and after LBBAP implant, and to evaluate reliability using bench testing and simulation.<br /><b>Methods</b><br />Fifty bradycardia patients with implantation of the 3830 lead for LBBAP were enrolled. Use conditions of lead deployment at implantation were collected and CT scans were performed at 3-month follow-up. Curvature amplitude along the pacing lead was determined with CT images. Fatigue bending was performed using accelerated testing in a more severe environment than routine clinical use conditions. Conductor fracture rate in a simulated patient population was estimated based on clinical use conditions and fatigue test results.<br /><b>Results</b><br />The number of attempts to place the 3830 lead for LBBAP was 2.1±1.3 (range 1-7) with 13±6 lead rotations at the final attempt. Extreme implant conditions were simulated in bench testing with 5 applications of 20 turns followed by up to 400 million bending cycles. Reliability modeling predicted a 10-year fracture rate of 0.02%.<br /><b>Conclusion</b><br />LBBAP implants require more lead rotations than standard pacing implants and result in unique lead bending. Application of simulated LBBAP use conditions to the 3830 lead in an accelerated in-vitro model does not produce excess conductor fractures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print</small></div>
Zou J, Chen K, Liu X, Xu Y, ... Zhou X, Lu H
J Cardiovasc Electrophysiol: 04 Feb 2023; epub ahead of print | PMID: 36738153
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<div><h4>Catheter ablation improved ejection fraction in persistent AF patients: a DECAAF-II sub analysis.</h4><i>Mekhael M, Shan B, Noujaim C, Chouman N, ... Marrouche N, Donnellan E</i><br /><b>Aims</b><br />The aim of our study was to assess differences in post-ablation atrial fibrillation (AF) recurrence and burden and to quantify the change in LVEF across different congestive heart failure (CHF) subcategories of the DECAAF-II population.<br /><b>Methods and results</b><br />Differences in the primary outcome of AF recurrence between CHF and non-CHF groups was calculated. The same analysis was performed for the three subgroups of CHF and the non-CHF group. Differences in AF burden after the 3-month blanking period between CHF and non-CHF groups was calculated. Improvement in LVEF was calculated and compared across the three CHF groups. Improvement was also calculated across different fibrosis stages. There was no significant differences in AF recurrence and AF burden after catheter ablation between CHF and non-CHF patients and between different CHF subcategories. Patients with heart failure with reduced ejection fraction (HFrEF) experienced the greatest improvement in EF following catheter ablation (CA, 16.66% ± 11.98, P < 0.001) compared to heart failure with moderately reduced LVEF, and heart failure with preserved EF (10.74% ± 8.34 and 2.00 ± 8.34 respectively, P-value < 0.001). Moreover, improvement in LVEF was independent of the four stages of atrial fibrosis (7.71 vs. 9.53 vs. 5.72 vs. 15.88, from Stage I to Stage IV respectively, P = 0.115).<br /><b>Conclusion</b><br />Atrial fibrillation burden and recurrence after CA is similar between non-CHF and CHF patients, independent of the type of CHF. Of all CHF groups, those with HFrEF had the largest improvement in LVEF after CA. Moreover, the improvement in ventricular function seems to be independent of atrial fibrosis in patients with persistent AF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Feb 2023; epub ahead of print</small></div>
Mekhael M, Shan B, Noujaim C, Chouman N, ... Marrouche N, Donnellan E
Europace: 04 Feb 2023; epub ahead of print | PMID: 36738244
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<div><h4>Pulmonary vein isolation with the radiofrequency balloon catheter: a single centre prospective study.</h4><i>Del Monte A, Almorad A, Pannone L, Della Rocca DG, ... Chierchia GB, de Asmundis C</i><br /><b>Aims</b><br />The multielectrode radiofrequency balloon catheter (RFB) has been developed to achieve safe and effective pulmonary vein isolation (PVI) for atrial fibrillation (AF) ablation. This single-centre study aimed to evaluate the midterm clinical outcome and predictors of single-shot PVI with the novel RFB.<br /><b>Methods and results</b><br />All consecutive patients with symptomatic paroxysmal or persistent AF undergoing first-time PVI with the RFB were prospectively included. Clinical and procedural parameters were systematically collected. The primary safety endpoint was defined as any major periprocedural complications. The primary efficacy endpoint consisted of freedom from any atrial tachyarrhythmias (ATas) lasting >30 s during the follow-up after a 3-month blanking period. Persistent single-shot PVI was defined as PVI achieved with a single RFB application without acute reconnection.  A total of 104 consecutive patients (mean age 64.3 ± 11.4 years, 56.7% males) were included. 15 patients (14.4%) presented with persistent AF. The procedure time was 59.0 min with a dwell time of 20.0 min. One major complication occurred in one patient. At a mean follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. ATas occurred in 14 patients, 11/69 patients (15.9%) with paroxysmal AF and 3/13 (23.1%) with persistent AF. The best cut-offs to predict persistent single-shot PVI were impedance drop >19.2 Ω [area under the receiver operator characteristic curve (AUC) 0.74] and temperature rise >11.1° C (AUC 0.77).<br /><b>Conclusion</b><br />In a large cohort of patients undergoing PVI with the RFB, the complication rate was 1%. At a mid-term follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. Specific cut-offs of impedance drop and temperature rise may be useful to predict persistent single-shot isolation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Feb 2023; epub ahead of print</small></div>
Del Monte A, Almorad A, Pannone L, Della Rocca DG, ... Chierchia GB, de Asmundis C
Europace: 04 Feb 2023; epub ahead of print | PMID: 36738245
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<div><h4>360° Virtual reality to improve patient education and reduce anxiety towards atrial fibrillation ablation.</h4><i>Hermans ANL, Betz K, Verhaert DVM, den Uijl DW, ... Linz D, Weijs B</i><br /><b>Aims</b><br />Evaluation of (i) the effects of a virtual reality (VR) preprocedural patient education video on information provision, procedure-related knowledge, satisfaction, and the level of worries in patients planned for atrial fibrillation (AF) ablation and (ii) the feasibility of a disposable cardboard VR viewer for home use in this setting.<br /><b>Methods and results</b><br />In this prospective observational cohort study, patients were alternatively assigned in a 1:1 ratio to the control or VR group. Controls received standard preprocedural information. VR group received standard information and a VR video (via in-hospital VR headset and disposable cardboard). The Amsterdam Preoperative Anxiety and Information Scale (APAIS) together with additional questions concerning procedural experience and satisfaction was completed pre- and post-ablation. Of 134 patients [38.1% female, aged 66 (58-72) years] included, 49.2% were assigned to the control and 50.7% to the VR group. The number of patients that worried about the ablation procedure was lower in VR than in control patients (19.1% vs. 40.9%, P = 0.006). More VR females than males had worries about the procedure (34.8% vs. 11.1%, P = 0.026). The number of VR patients that were satisfied with the preprocedural information provision was higher post-ablation than pre-ablation (83.3% vs. 60.4%, P = 0.007). In total, 59.4% reported that the disposable cardboard was easy to use and led to a discussion with relatives in 68.8%.<br /><b>Conclusion</b><br />In patients scheduled for AF ablation, a VR preprocedural educational video led to better information provision and procedure-related knowledge, higher satisfaction, and less worries regarding the procedure. The disposable cardboard was feasible for home use.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 04 Feb 2023; epub ahead of print</small></div>
Hermans ANL, Betz K, Verhaert DVM, den Uijl DW, ... Linz D, Weijs B
Europace: 04 Feb 2023; epub ahead of print | PMID: 36738261
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<div><h4>Comparison of methods for delivering cardiac resynchronization therapy: an acute electrical and haemodynamic within-patient comparison of left bundle branch area, His bundle, and biventricular pacing.</h4><i>Ali N, Arnold AD, Miyazawa AA, Keene D, ... Cole GD, Whinnett ZI</i><br /><b>Aims</b><br />Left bundle branch area pacing (LBBAP) is a promising method for delivering cardiac resynchronization therapy (CRT), but its relative physiological effectiveness compared with His bundle pacing (HBP) is unknown. We conducted a within-patient comparison of HBP, LBBAP, and biventricular pacing (BVP).<br /><b>Methods and results</b><br />Patients referred for CRT were recruited. We assessed electrical response using non-invasive mapping, and acute haemodynamic response using a high-precision haemodynamic protocol. Nineteen patients were recruited: 14 male, mean LVEF of 30%. Twelve had time for BVP measurements. All three modalities reduced total ventricular activation time (TVAT), (ΔTVATHBP -43 ± 14 ms and ΔTVATLBBAP -35 ± 20 ms vs. ΔTVATBVP -19 ± 30 ms, P = 0.03 and P = 0.1, respectively). HBP produced a significantly greater reduction in TVAT compared with LBBAP in all 19 patients (-46 ± 15 ms, -36 ± 17 ms, P = 0.03). His bundle pacing and LBBAP reduced left ventricular activation time (LVAT) more than BVP (ΔLVATHBP -43 ± 16 ms, P < 0.01 vs. BVP, ΔLVATLBBAP -45 ± 17 ms, P < 0.01 vs. BVP, ΔLVATBVP -13 ± 36 ms), with no difference between HBP and LBBAP (P = 0.65). Acute systolic blood pressure was increased by all three modalities. In the 12 with BVP, greater improvement was seen with HBP and LBBAP (6.4 ± 3.8 mmHg BVP, 8.1 ± 3.8 mmHg HBP, P = 0.02 vs. BVP and 8.4 ± 8.2 mmHg for LBBAP, P = 0.3 vs. BVP), with no difference between HBP and LBBAP (P = 0.8).<br /><b>Conclusion</b><br />HBP delivered better ventricular resynchronization than LBBAP because right ventricular activation was slower during LBBAP. But LBBAP was not inferior to HBP with respect to LV electrical resynchronization and acute haemodynamic response.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Abstract
<div><h4>Real-world clinical outcomes with a next-generation left atrial appendage closure device: the FLXibility Post-Approval Study.</h4><i>Betts TR, Grygier M, Kudsk JEN, Schmitz T, ... Allocco DJ, FLXibility investigators</i><br /><b>Aims</b><br />The FLXibility Post-Approval Study collected data on unselected patients implanted with a WATCHMAN FLX in a commercial clinical setting.<br /><b>Methods and results</b><br />Patients were implanted with a WATCHMAN FLX per local standard of care, with a subsequent first follow-up visit from 45 to 120 days post-implant and a final follow-up at 1-year post-procedure. A Clinical Event Committee adjudicated all major adverse events and TEE/CT imaging results were adjudicated by a core laboratory. Among 300 patients enrolled at 17 centres in Europe, the mean age was 74.6 ± 8.0 years, mean CHA2DS2-VASc score was 4.3 ± 1.6, and 62.1% were male. The device was successfully implanted in 99.0% (297/300) of patients. The post-implant medication regimen was DAPT for 87.3% (262/300). At first follow-up, core-lab adjudicated complete seal was 88.2% (149/169), 9.5% (16/169) had leak <3 mm, 2.4 (4/169) had leak ≥3 mm to ≤5 mm, and 0% had >5 mm leak. At 1 year, 93.3% (280/300) had final follow-up; 60.5% of patients were on a single antiplatelet medication, 21.4% were on DAPT, 5.6% were on direct oral anticoagulation, and 12.1% were not taking any antiplatelet/anticoagulation medication. Adverse event rates through 1 year were: all-cause death 10.8% (32/295); CV/unexplained death 5.1% (15/295); disabling and non-disabling stroke each 1.0% (3/295, all non-fatal); pericardial effusion requiring surgery or pericardiocentesis 1.0% (3/295); and device-related thrombus 2.4% (7/295).<br /><b>Conclusion</b><br />The WATCHMAN FLX device had excellent procedural success rates, high LAA seal rates, and low rates of thromboembolic events in everyday clinical practice.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Betts TR, Grygier M, Kudsk JEN, Schmitz T, ... Allocco DJ, FLXibility investigators
Europace: 03 Feb 2023; epub ahead of print | PMID: 36734247
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<div><h4>Rotor mechanism and its mapping in atrial fibrillation.</h4><i>Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M</i><br /><AbstractText>Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the \'leading circle\' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a \'spiral wave generator\' is a curved \'vortex\' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M
Europace: 03 Feb 2023; epub ahead of print | PMID: 36734272
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<div><h4>Epicardial vs. transvenous implantable cardioverter defibrillators in children.</h4><i>Le Bos PA, Pontailler M, Maltret A, Kraiche D, ... Bonnet D, Waldmann V</i><br /><b>Aims</b><br />The implantable cardioverter defibrillator (ICD) has been increasingly used in children. Both epicardial and transvenous approaches are used, with controversy regarding the best option with no specific recommendations. We aimed to compare outcomes associated with epicardial vs. transvenous ICDs in children.<br /><b>Methods and results</b><br />Data were analysed from a retrospective study including all patients <18-year-old implanted with an ICD in a tertiary centre from 2003 to 2021. Outcomes were compared between epicardial and transvenous ICDs. A total of 122 children with an ICD (mean age 11.5 ± 3.8 years, 57.4% males) were enrolled, with 84 (64.1%) epicardial ICDs and 38 (29.0%) transvenous ICDs. Early (<30 days) ICD-related complications were reported in 17 (20.2%) patients with an epicardial ICD vs. 0 (0.0%) with a transvenous ICD (P = 0.002). Over a mean follow-up of 4.8 ± 4.0 years, 25 (29.8%) patients with an epicardial ICD and 9 (23.7%) patients with a transvenous ICD experienced at least one late ICD-related complication [hazard ratio (HR) 1.8, 95% confidence interval (CI) 0.8-4.0]. Implantable cardioverter defibrillator lead dysfunction occurred in 19 (22.6%) patients with an epicardial ICD vs. 3 (7.9%) with a transvenous ICD (HR 5.7, 95% CI 1.3-24.5) and was associated with a higher incidence of ICD-related reintervention (HR 3.0, 95% CI 1.3-7.0). After considering potential confounders, especially age and weight at implantation, this association was no longer significant (P = 0.112). The freedom from ICD lead dysfunction was greater in patients with pleural coils than in those with epicardial coils (HR 0.38, 95% CI 0.15-0.96).<br /><b>Conclusion</b><br />In children, after a consideration of patient characteristics at implantation, the burden of complications and ICD lead dysfunction appears to be similar in patients with epicardial and transvenous devices. Pleural coils seem to be associated with better outcomes than epicardial coils in this population.<br /><b>Clinical trial registration</b><br />NCT05349162.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 03 Feb 2023; epub ahead of print</small></div>
Le Bos PA, Pontailler M, Maltret A, Kraiche D, ... Bonnet D, Waldmann V
Europace: 03 Feb 2023; epub ahead of print | PMID: 36735263
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<div><h4>Paroxysmal AF Ablation Using a Novel Variable-Loop Biphasic Pulsed Field Ablation Catheter Integrated With a 3D Mapping System: 1-Year Outcomes of the Multicenter inspIRE Study.</h4><i>Duytschaever M, De Potter T, Grimaldi M, Anic A, ... Jaïs P, Reddy VY</i><br /><AbstractText><br /><b>Background:</b><br/>- The inspIRE study evaluated safety and effectiveness of a fully integrated biphasic pulsed field ablation (PFA) system with a variable loop circular catheter for the treatment of drug-refractory paroxysmal atrial fibrillation (AF). <b>Methods</b> - Subjects underwent pulmonary vein isolation (PVI) with the PFA system, using at least 12 applications per vein; adenosine/isoproterenol was administered to confirm entrance block. Wave I assessed initial safety, including for esophageal lesions, silent cerebral lesions (SCLs), and PV stenosis. Wave II (pivotal phase) tested i) primary safety - incidence of early onset primary adverse events (PAEs), and primary effectiveness - confirmed PVI with freedom from documented atrial arrhythmia at 12-months (12M). The study design specified an interim analysis to determine early success once 30 subjects reached 12M follow-up (FU) and all subjects reached 3M FU. <b>Results</b> - Across 13 centers in Europe/Canada, 226 subjects were enrolled, met criteria for safety and effectiveness evaluations and received PFA (Wave I: 40; Wave II: 186). Wave I demonstrated no esophageal thermal lesions or PV stenosis. Among 39 subjects with cerebral MRI, SCLs were detected in 4 of the first 6 subjects, after which workflow enhancements, including a 10s pause between PFA applications was implemented; subsequently, only 4 of 33 subjects had SCLs. In the Wave II phase, no PAE was reported. Upon declaring early success, 83 subjects reached 12M FU. With 100% entrance block, PVI without acute reconnection was achieved in 97.1% of targeted veins. For Wave II, the primary effectiveness endpoint per Kaplan Meier at the time of interim analysis was 70.9%; 12M freedom from symptomatic AF/atrial flutter/atrial tachycardia recurrence and repeat ablation was 78.9% and 92.3%, respectively. Total procedure and transpired PFA times were 70.1 ± 27.7 min and 26.7 ± 14.0 min, respectively. <br /><b>Conclusions:</b><br/>- The inspIRE trial confirmed the safety and effectiveness of the novel mapping-integrated PFA system.</AbstractText><br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Duytschaever M, De Potter T, Grimaldi M, Anic A, ... Jaïs P, Reddy VY
Circ Arrhythm Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36735937
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<div><h4>Anticoagulation after pulmonary vein isolation for atrial fibrillation: associations with CHA₂DS₂-VASc score, sex and rhythm.</h4><i>Wang TKM, Chan N, Arockiam AD, Cremer PC, ... Wazni OM, Jaber WA</i><br /><b>Background</b><br />Guidelines recommend using the CHA₂DS₂-VASc score to determine anticoagulation decisions in atrial fibrillation (AF) patients, including those who undergo pulmonary vein isolation (PVI), however this may not consistently occur in the real-world setting because of other clinical factors. We sought to evaluate the anticoagulation prescription rates patterns in AF patients 1 year PVI at our institution.<br /><b>Methods</b><br />Consecutive AF patients undergoing PVI in our prospective registry during 2014-2018 who were alive at 1-year post-PVI were studied. Anticoagulation prescription rates at this time-point were adjudicated, and correlated to CHA₂DS₂-VASc score, sex and heart rhythm status at 1 year.<br /><b>Results</b><br />Amongst 4596 patients undergoing PVI, mean age was 64.2±10.0 years, 1328 (28.9%) were female, and based on CHA₂DS₂-VASc Score anticoagulation was not indicated, can be considered and indicated in 872 (19.0%), 1183 (25.7%) and 2541 (55.3%) patients respectively. At 1-year after PVI, 3504 (76.2%) patients were on anticoagulation, and 792 (17.2%) had recurrence of AF. Anticoagulation was continued in over half of AF patients without classic CHA₂DS₂-VASc indication particularly in those with AF recurrence and women, while they were mildly under-prescribed in those with indication, especially for those without AF recurrence and men.<br /><b>Conclusion</b><br />In a large real world cohort of patients after PVI, anticoagulation prescription is not solely depending on the CHA₂DS₂-VASc score and sex, but also heart rhythm status and other clinical or imaging factors. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Wang TKM, Chan N, Arockiam AD, Cremer PC, ... Wazni OM, Jaber WA
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738138
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<div><h4>Increasing Trend in Ventricular Tachycardia Related Mortality- Cause or Effect?</h4><i>Balakrishnan M, Hutchinson MD</i><br /><AbstractText>Ventricular tachycardia is a major cause of sudden death. Several pharmacological and device-based therapies in recent years have delayed the progression of heart failure and have improved survival. A new study reveals a significant increase in age-adjusted mortality from ventricular tachycardia over the past 13 years, with higher mortality in men, black Americans and patients from the Southern United States. These findings reinforce the previous observations made on the influence of age, gender, ethnicity and geography on cardiovascular outcomes. The use of ICD 10 codes to ascertain cause of death limits differentiation between ventricular tachycardia as the true underlying mechanism leading to death and the presence of ventricular tachycardia in patients dying from other causes. While the insights gained from the report on contemporary ventricular tachycardia related mortality in the general population with cardiovascular disease is hypothesis generating, further studies are needed to delineate ventricular tachycardia as a proximate cause of death from an association This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Balakrishnan M, Hutchinson MD
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738146
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<div><h4>Temporal Trends in Atrial fibrillation Ablation Procedures at an Academic Medical Center: 2011 - 2021.</h4><i>Kushnir A, Barbhaiya CR, Aizer A, Jankelson L, ... Bernstein S, Chinitz LA</i><br /><b>Introduction</b><br />Radiofrequency ablation technology for treating atrial fibrillation (AF) has evolved rapidly over the past decade. We investigated the impact of technological and procedural advances on procedure times and ablation outcomes at a major academic medical center over a ten-year period.<br /><b>Methods</b><br />Clinical data was collected from patients who presented to NYU Langone Health between 2011 and 2021 for a first-time AF ablation. Time to redo AF ablation or DCCV for recurrent AF during a three-year follow up period was determined and correlated with ablation technology and practices, anti-arrhythmic medications, and patient comorbid conditions.<br /><b>Results</b><br />From 2011-2021 the cardiac electrophysiology lab adopted irrigated-contact force ablation catheters, high-power short duration ablation lesions, steady-pacing, jet ventilation, and eliminated stepwise linear ablation for AF ablation. During this time the number of first time AF ablations increased from 403 to 1074, the percentage of patients requiring repeat AF-related intervention within three-years of the index procedure dropped from 22% to 14%, mean procedure time decreased from 271±65 to 135±36 minutes, and mean annual major adverse event rate remained constant at 1.1±0.5%. Patient comorbid conditions increased during this time period and anti-arrhythmic use was unchanged.<br /><b>Conclusion</b><br />Rates of redo-AF ablation or DCCV following an initial AF ablation at a single center decreased 36% over a ten-year period. Procedural and technological changes likely contributed to this improvement, despite increased AF related comorbidities. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Kushnir A, Barbhaiya CR, Aizer A, Jankelson L, ... Bernstein S, Chinitz LA
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738147
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<div><h4>Relationship Between Amiodarone Response prior to Ablation and One-Year Outcomes of Catheter Ablation for Atrial Fibrillation.</h4><i>Yadav R, Brilliant J, Akhtar T, Milstein J, ... Calkins H, Spragg D</i><br /><b>Background</b><br />Catheter ablation for atrial fibrillation (AF) is a common therapeutic strategy for patients with either paroxysmal or persistent AF, but long-term ablation success rates are imperfect. Maintenance of sinus rhythm immediately prior to ablation with anti-arrhythmic drug (AAD) therapy has been associated with improved outcomes in patients undergoing ablation. Amiodarone has superior efficacy relative to other AADs. Whether failure of amiodarone to maintain sinus rhythm prior to ablation for either paroxysmal or persistent AF is associated with poor outcomes is unknown.<br /><b>Methods</b><br />A total of 307 patients who received amiodarone in a one-year window before undergoing catheter ablation for AF were included. Patients were divided into amiodarone success (n=183) and amiodarone failure (n=124) groups based on the response to pre-ablation amiodarone treatment. Analysis of procedural outcomes as a function of response to amiodarone therapy was performed. Patients were followed for at least 12 months post-ablation to assess outcomes (adverse events and arrhythmia recurrence). Procedural success was defined by the absence of documented arrhythmia (>30s) without any anti-arrhythmic agents beyond a 90d blanking period.<br /><b>Results</b><br />Following ablation for either paroxysmal or persistent AF, freedom from any recurrent atrial arrhythmia at 1y was 57.7% for the entire cohort. One-year freedom from recurrent arrhythmia in the amiodarone success group was comparable to that in the amiodarone failure group (55.7% vs 60.5%; p=0.54). Success rates following ablation did not vary by the response to amiodarone when analyzed for paroxysmal or persistent AF subgroups.<br /><b>Conclusion</b><br />Failure to restore and maintain sinus rhythm with amiodarone prior to ablation for either paroxysmal or persistent AF is not a predictor of ablation procedural failure. Amiodarone failure alone should not deter practitioners from considering ablation therapy for patients with AF. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Yadav R, Brilliant J, Akhtar T, Milstein J, ... Calkins H, Spragg D
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738148
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<div><h4>Machine Learning in EP Research: New Tools for Old Problems.</h4><i>Figgett WA, Hawson J, Lee G</i><br /><AbstractText>The emerging use of Machine Learning (ML) approaches in biomedical and clinical research settings has demonstrated various advantages and opportunities in exploring large and complex data sets, and potentially supporting expert decision-making to benefit patients. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Figgett WA, Hawson J, Lee G
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738150
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<div><h4>Predictive Modeling of Lead Durability, An Important Step Forward.</h4><i>Crossley GH</i><br /><AbstractText>The authors present an eloquent description of an analysis of the durability of a cable-based lead for use in directly pacing the human conduction system. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Crossley GH
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738151
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<div><h4>Rates and Predictors Of Hospital And Emergency Department Care After Catheter Ablation Of Atrial Fibrillation.</h4><i>Friedman DJ, Freeman JV, Wong C, Febre J, ... Khanna R, Piccini JP</i><br /><b>Background</b><br />Although atrial fibrillation (AF) ablation has become increasingly safer, rehospitalization and emergency department (ED) evaluations can occur in the post-ablation period. Better understanding of the frequency, causes, and predictors for hospitalization and ED evaluation after ablation are needed, particularly as same-day discharge programs expand.<br /><b>Methods</b><br />The Optum Clinformatics database was used to define rates, causes, and predictors of hospital and ED care after AF ablation performed between January 2016 and May 2019. Primary outcomes were all-cause hospital and ED care within 30 days of discharge. Independent predictors of all-cause ED and hospital admissions care were determined via logistic regression.<br /><b>Results</b><br />Of the 18,848 patients in this study, the mean age was 67.5±10 years, 37.9% were female, and the mean CHA<sub>2</sub> DS<sub>2</sub> -VASc score was 3.27±1.84. Within 30 days of AF ablation, 1,440 of 18,848 patients (7.6%) required hospital care of which 15% had >1 admission; 7.9% required ED care of which 28.6% had >1 ED visit. The most common reasons for hospital admission (which occurred on average 12.3 days after discharge) were supraventricular tachycardia (SVT) or AF (33.2%), heart failure (12.7%), and infection (12.2%). The most common reasons for ED care were SVT/AF (15.0%), non-cardiac chest pain (13.3%), and non-infectious respiratory illness (12.2%). Age, female sex, ablation in an inpatient setting, and co-morbidities were associated with increased risk of rehospitalization. Age, female sex, patient comorbidities, and non-use of direct oral anticoagulation were associated with increased risk of ED visit.<br /><b>Conclusion</b><br />Approximately 7-8% of patients require unplanned hospitalization or ED care after AF ablation, most commonly due to SVT/AF. Predictors of unscheduled care include patient age, sex and several patient comorbidities. This study can inform quality improvement initiatives by identifying common causes for unscheduled care. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print</small></div>
Friedman DJ, Freeman JV, Wong C, Febre J, ... Khanna R, Piccini JP
J Cardiovasc Electrophysiol: 03 Feb 2023; epub ahead of print | PMID: 36738152
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<div><h4>Examining the Association Between Hospital-Documented Atrial Fibrillation and Central Retinal Artery Occlusion.</h4><i>Lusk JB, Song A, Unnithan S, Al-Khalidi HR, ... O\'Brien EC, Mac Grory B</i><br /><AbstractText><b>Background:</b> Carotid stenosis is thought to be the primary risk factor for central retinal artery occlusion (CRAO); however, it is not known whether atrial fibrillation (AF), a cardiac arrhythmia that underlies over 25% of cerebral ischemic strokes, predisposes patients to CRAO. <br /><b>Methods:</b><br/>A retrospective, observational, cohort study was performed using data from the State Inpatient Databases and State Emergency Department Databases from New York (2006-2015), California (2003-2011), and Florida (2005-2015) to determine the association between AF and CRAO. The primary exposure was hospital-documented AF. The primary endpoint was hospital-documented CRAO, defined as having an ICD-9-CM code 362.31 in the primary diagnosis position. Cause-specific hazard models were used to model CRAO-free survival among patients according to hospital-documented AF status. <br /><b>Results:</b><br/>Of 39,834,885 patients included in the study, 2,723,842 (median age: 72.7 years, 48.5% female) had AF documented during the exposure window. Patients with AF were older, more likely to be of non-Hispanic White race/ethnicity and had a higher burden of cardiovascular comorbidities compared to patients without AF. The cumulative incidence of CRAO was 7.09 per 100,000 at risk in those with AF and 2.34 per 100,000 at risk in those without AF over the study period. Before adjustment, AF was associated with higher risk of CRAO (HR 2.55, 95% CI 2.15-3.03). However, after adjustment for demographics, state, and cardiovascular comorbidities, there was an inverse association between AF and risk of CRAO (aHR 0.72, 95% CI 0.60-0.87). These findings were robust in our pre-specified sensitivity analyses. By contrast, positive control outcomes of embolic and ischemic stroke showed an expected strong relationship between AF and risk of stroke. <b>Conclusions:</b> We found an inverse association between AF and CRAO in a large, representative study of hospitalized patients; however, this cohort did not ascertain AF or CRAO occurring outside of hospital or emergency department settings.</AbstractText><br /><br /><br /><br /><small>Stroke: 02 Feb 2023; epub ahead of print</small></div>
Lusk JB, Song A, Unnithan S, Al-Khalidi HR, ... O'Brien EC, Mac Grory B
Stroke: 02 Feb 2023; epub ahead of print | PMID: 36729390
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<div><h4>Effect of Personalized Accelerated Pacing on Quality of Life, Physical Activity, and Atrial Fibrillation in Patients With Preclinical and Overt Heart Failure With Preserved Ejection Fraction: The myPACE Randomized Clinical Trial.</h4><i>Infeld M, Wahlberg K, Cicero J, Plante TB, ... Lustgarten DL, Meyer M</i><br /><b>Importance</b><br />Patients with heart failure with preserved ejection fraction (HFpEF) with a pacemaker may benefit from a higher, more physiologic backup heart rate than the nominal 60 beats per minute (bpm) setting.<br /><b>Objective</b><br />To assess the effects of a moderately accelerated personalized backup heart rate compared with 60 bpm (usual care) in patients with preexisting pacemaker systems that limit pacemaker-mediated dyssynchrony.<br /><b>Design, setting, and participants</b><br />This blinded randomized clinical trial enrolled patients with stage B and C HFpEF from the University of Vermont Medical Center pacemaker clinic between June 2019 and November 2020. Analysis was modified intention to treat.<br /><b>Interventions</b><br />Participants were randomly assigned to personalized accelerated pacing or usual care and were followed up for 1 year. The personalized accelerated pacing heart rate was calculated using a resting heart rate algorithm based on height and modified by ejection fraction.<br /><b>Main outcomes and measures</b><br />The primary outcome was the serial change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score. Secondary end points were changes in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, pacemaker-detected physical activity, atrial fibrillation from baseline, and adverse clinical events.<br /><b>Results</b><br />Overall, 107 participants were randomly assigned to the personalized accelerated pacing (n = 50) or usual care (n = 57) groups. The median (IQR) age was 75 (69-81) years, and 48 (48%) were female. Over 1-year follow-up, the median (IQR) pacemaker-detected heart rate was 75 (75-80) bpm in the personalized accelerated pacing arm and 65 (63-68) bpm in usual care. MLHFQ scores improved in the personalized accelerated pacing group (median [IQR] baseline MLHFQ score, 26 [8-45]; at 1 month, 15 [2-25]; at 1 year, 9 [4-21]; P < .001) and worsened with usual care (median [IQR] baseline MLHFQ score, 19 [6-42]; at 1 month, 23 [5-39]; at 1 year, 27 [7-52]; P = .03). In addition, personalized accelerated pacing led to improved changes in NT-proBNP levels (mean [SD] decrease of 109 [498] pg/dL vs increase of 128 [537] pg/dL with usual care; P = .02), activity levels (mean [SD], +47 [67] minutes per day vs -22 [35] minutes per day with usual care; P < .001), and device-detected atrial fibrillation (27% relative risk reduction compared with usual care; P = .04) over 1-year of follow-up. Adverse clinical events occurred in 4 patients in the personalized accelerated pacing group and 11 patients in usual care.<br /><br /><b>Conclusions:</b><br/>and relevance</b><br />In this study, among patients with HFpEF and pacemakers, treatment with a moderately accelerated, personalized pacing rate was safe and improved quality of life, NT-proBNP levels, physical activity, and atrial fibrillation compared with the usual 60 bpm setting.<br /><b>Trial registration</b><br />ClinicalTrials.gov Identifier: NCT04721314.<br /><br /><br /><br /><small>JAMA Cardiol: 01 Feb 2023; epub ahead of print</small></div>
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<div><h4>Clinical Features, Genetic Findings, and Risk Stratification in Arrhythmogenic Right Ventricular Cardiomyopathy: Data From a Brazilian Cohort.</h4><i>Olivetti NQS, Sacilotto L, Wulkan F, Pessente GD, ... da Costa Pereira A, da Costa Darrieux F</i><br /><b>Background</b><br />Arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare inherited disease, causes ventricular tachycardia, sudden cardiac death, and heart failure (HF). We investigated ARVC clinical features, genetic findings, natural history, and the occurrence of life-threatening arrhythmic events (LTAEs), HF death, or heart transplantation (HF-death/HTx) to identify risk factors.<br /><b>Methods</b><br />The clinical course of 111 consecutive patients with definite ARVC, predictors of LTAE, HF-death/HTx, and combined events were analyzed in the entire cohort and in a subgroup of 40 patients without sustained ventricular arrhythmia before diagnosis.<br /><b>Results</b><br />The 5-year cumulative probability of LTAE was 30%, and HF-death/HTx was 10%. Predictors of HF-death/HTx were reduced right ventricle ejection fraction (HR: 0.93; <i>P</i>=0.010), HF symptoms (HR: 4.37; <i>P</i>=0.010), epsilon wave (HR: 4.99; <i>P</i>=0.015), and number of leads with low QRS voltage (HR: 1.28; <i>P</i>=0.001). Each additional lead with low QRS voltage increased the risk of HF-death/HTx by 28%. Predictors of LTAE were prior syncope (HR: 1.81; <i>P</i>=0.040), number of leads with T wave inversion (HR: 1.17; <i>P</i>=0.039), low QRS voltage (HR: 1.12; <i>P</i>=0.021), younger age (HR: 0.97; <i>P</i>=0.006), and prior ventricular arrhythmia/ventricular fibrillation (HR: 2.45; <i>P</i>=0.012). Each additional lead with low QRS voltage increased the risk of LTAE by 17%. In patients without ventricular arrhythmia before clinical diagnosis of ARVC, the number of leads with low QRS voltage (HR: 1.68; <i>P</i>=0.023) was independently associated with HF-death/HTx.<br /><b>Conclusions</b><br />Our study demonstrated the characteristics of a specific cohort with a high prevalence of arrhythmic burden at presentation, male predominance, younger age and HF severe outcomes. Our main results suggest that the presence and extension of low QRS voltage can be a risk predictor for HF-death/HTx in ARVC patients, regardless of the arrhythmic risk. This study can contribute to the global ARVC risk stratification, adding new insights to the international current scientific knowledge.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 31 Jan 2023:e011391; epub ahead of print</small></div>
Olivetti NQS, Sacilotto L, Wulkan F, Pessente GD, ... da Costa Pereira A, da Costa Darrieux F
Circ Arrhythm Electrophysiol: 31 Jan 2023:e011391; epub ahead of print | PMID: 36720007
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<div><h4>Postoperative atrial fibrillation: from mechanisms to treatment.</h4><i>Gaudino M, Di Franco A, Rong LQ, Piccini J, Mack M</i><br /><AbstractText>Postoperative atrial fibrillation (POAF) is the most common type of secondary atrial fibrillation (AF) and despite progress in prevention and treatment, remains an important clinical problem for patients undergoing a variety of surgical procedures, and in particular cardiac surgery. POAF significantly increases the duration of postoperative hospital stay, hospital costs, and the risk of recurrent AF in the years after surgery; moreover, POAF has been associated with a variety of adverse cardiovascular events (including stroke, heart failure, and mortality), although it is still unclear if this is due to causal relation or simple association. New data have recently emerged on the pathophysiology of POAF, and new preventive and therapeutic strategies have been proposed and tested in randomized trials. This review summarizes the current evidence on the pathogenesis, incidence, prevention, and treatment of POAF and highlights future directions for clinical research.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J: 31 Jan 2023; epub ahead of print</small></div>
Gaudino M, Di Franco A, Rong LQ, Piccini J, Mack M
Eur Heart J: 31 Jan 2023; epub ahead of print | PMID: 36721960
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<div><h4>Improved prognosis with integrated care management including early rhythm control and healthy lifestyle modification in patients with concurrent atrial fibrillation and diabetes mellitus: a nationwide cohort study.</h4><i>Lee SR, Ahn HJ, Choi EK, Lee SW, ... Oh S, Lip GYH</i><br /><b>Background</b><br />Patients with concurrent atrial fibrillation (AF) and diabetes mellitus (DM) [AF-DM] have a high risk of cardiovascular and diabetes-related complications, but are less engaged in a comprehensive treatment approach. We evaluated the association of early rhythm control (ERC), lifestyle modification (LSM), and a combination of ERC and LSM with cardiovascular or diabetes-related complication risk in patients with AF-DM (type 2).<br /><b>Methods</b><br />From the National Health Information Database, 47,940 patients diagnosed with AF-DM in 2009-2016 were included. We defined ERC as rhythm control therapy within two years of AF diagnosis and LSM as adherence to ≥ 2 of the healthy behaviors among non-current smoking, non-drinking, and regular exercise. We compared the primary (ischemic stroke) and secondary (macro- and microvascular complications, glycemic emergency, and all-cause death) outcomes in four groups: non-ERC and non-LSM (group 1), LSM only (group 2), ERC only (group 3), and both ERC and LSM (group 4).<br /><b>Results</b><br />Of total, 10,617 (22%), 26,730 (55.8%), 2,903 (6.1%), and 7,690 (16.0%) were classified into groups 1 to 4, in sequence. The mean duration from AF diagnosis to ERC was 25.6 ± 75.5 days. During 4.0 (interquartile range: 2.5-6.2) years\' follow-up, groups 2 and 3 were associated with 23% and 33% lower risks of stroke than group 1, respectively. Group 4 was associated with the lowest risk of stroke: hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51-0.67, p < 0.001. Regarding secondary outcomes, the lowest risks were also observed in group 4; macro- and microvascular complications, glycemic emergency, and all-cause death had HRs (95% CIs) of 0.63 (0.56-0.70), 0.88 (0.82-0.94), 0.72 (0.62-0.84), and 0.80 (0.73-0.87), respectively, all p < 0.001.<br /><b>Conclusions</b><br />For AF-DM patients, ERC and LSM exert a synergistic effect in preventing cardiovascular and diabetes-related complications with the greatest lowered risk of stroke. A comprehensive treatment approach should be pursued in AF-DM patients.<br /><br />© 2023. The Author(s).<br /><br /><small>Cardiovasc Diabetol: 30 Jan 2023; 22:18</small></div>
Abstract
<div><h4>Structural characteristics of patients with superior vena cava foci initiating atrial fibrillation: analysis with electrocardiogram-triggered computed tomography.</h4><i>Oka S, Yamagata K, Nishii T, Tonegawa-Kuji R, ... Aiba T, Kusano K</i><br /><b>Introduction</b><br />The superior vena cava is the most common source of non-pulmonary vein foci in atrial fibrillation; therefore, predicting the existence of non-pulmonary vein foci prior to the catheter ablation procedure helps construct a proper ablation strategy in preparation for superior vena cava isolation. This study aimed to clarify the structural characteristics of patients with superior vena cava foci initiating atrial fibrillation.<br /><b>Methods</b><br />We enrolled 331 consecutive patients with atrial fibrillation who underwent cardiac computed tomography imaging before radiofrequency catheter ablation treatment, and they were divided into superior vena cava (+) and (-) groups based on the presence or absence of superior vena cava foci initiating atrial fibrillation.<br /><b>Results</b><br />The superior vena cava (+) group (n=27) exhibited superior vena cava crescent signs-defined as a curve-shaped superior vena cava with two narrow pointed ends-more frequently (37% vs. 9%, P<0.001), and larger right atrial volume (95.6 ± 20.8 vs. 80.5 ± 26.1 mL, P=0.004) than the superior vena cava (-) group (n=304). Multivariate logistic regression analysis revealed that the superior vena cava crescent sign (odds ratio, 8.88; 95% confidence interval, 3.21-24.60) and right atrial volume (odds ratio, 1.03; 95% confidence interval, 1.01-1.04) were independent predictors of superior vena cava foci.<br /><b>Conclusion</b><br />Patients with superior vena cava foci exhibited more frequent superior vena cava crescent signs and larger right atrial volumes, and these characteristics may help clinicians choose the appropriate ablation technology. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 30 Jan 2023; epub ahead of print</small></div>
Oka S, Yamagata K, Nishii T, Tonegawa-Kuji R, ... Aiba T, Kusano K
J Cardiovasc Electrophysiol: 30 Jan 2023; epub ahead of print | PMID: 36718076
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<div><h4>Functional Characterization and Identification of a Therapeutic for a Novel SCN5A-F1760C Variant Causing Type 3 Long QT Syndrome Refractory to All Guideline-Directed Therapies.</h4><i>Stutzman MJ, Gao X, Kim M, Ye D, ... Shannon K, Ackerman MJ</i><br /><b>Background</b><br />Pathogenic variants in the SCN5A-encoded Nav1.5 sodium channel cause type 3 long QT syndrome (LQT3). Here, we present an infant with severe LQT3 who was refractory to multiple pharmacological therapies as well as bilateral stellate ganglionectomy. The patient\'s novel variant, p.F1760C-SCN5A, involves a critical residue of the Nav1.5\'s local anesthetic binding domain.<br /><b>Objective</b><br />To characterize functionally the p.F1760C-SCN5A variant using TSA-201 and patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs).<br /><b>Methods</b><br />Whole-cell patch clamp was used to assess p.F1760C-SCN5A associated sodium currents with/without lidocaine (Lido), flecainide (Flec), and phenytoin (PHT) in TSA-201 cells. p.F1760C-SCN5A and CRISPR-Cas9 variant corrected isogenic control (IC) iPSC-CMs were generated. FluoVolt voltage dye was used to measure the action potential duration (APD) with/without mexiletine or PHT.<br /><b>Results</b><br />V<sub>1/2</sub> of inactivation was right-shifted significantly in F1760C cells (-72.2±0.7 mV) compared to wild-type (WT) cells (-86.3±0.9 mV; p<0.0001) resulting in a marked increase in window current. F1760C increased sodium late current 2-fold from 0.18±0.04% of peak in WT to 0.49±0.07% of peak in F1760C (p=0.0005). Baseline APD to 90% repolarization (APD<sub>90</sub>) was increased markedly in F1760C iPSC-CMs (601±4 ms) compared to IC iPSC-CMs (423±15 ms; p<0.0001). While, 4-hour treatment with 10 μM mexiletine failed to shorten the APD<sub>90</sub>, treatment with 5μM PHT significantly decreased APD<sub>90</sub> of F1760C iPSC-CMs (453±6 ms; p<0.0001).<br /><b>Conclusion</b><br />Phenytoin rescued electrophysiological phenotype and APD of a novel p.F1760C-SCN5A variant. The antiepileptic drug, phenytoin, may be an effective alternative therapeutic for the treatment of LQT3, especially for variants that disrupt the lidocaine/mexiletine binding site.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 30 Jan 2023; epub ahead of print</small></div>
Stutzman MJ, Gao X, Kim M, Ye D, ... Shannon K, Ackerman MJ
Heart Rhythm: 30 Jan 2023; epub ahead of print | PMID: 36731785
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Abstract
<div><h4>Coronary arterial injury during right ventricular outflow tract ablation: Know your neighbors.</h4><i>Sridharan A, Hutchinson MD</i><br /><AbstractText>Left anterior descending (LAD) coronary arterial injury is an underappreciated and rare consequence of ablation in the right ventricular outflow tract (RVOT). The authors present five cases of acute or subacute LAD injury after RVOT ablation. Most patients had fairly extensive ablation and two had coincident cardiac perforation. The patients reported also had a strikingly similar ECG morphology of their spontaneous ventricular arrhythmias. The authors\' report serves an important cautionary tale regarding ablation of intramural septal VAs This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print</small></div>
Sridharan A, Hutchinson MD
J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print | PMID: 36709466
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<div><h4>Temporal association between drops in thoracic impedance and malignant ventricular arrhythmia: A longitudinal analysis of remote monitoring trends.</h4><i>Rodio G, Iacopino S, Pisanò EC, Calvi V, ... Gargaro A, D\'Onofrio A</i><br /><b>Introduction</b><br />Thoracic impedance (TI) drops measured by implantable cardioverter-defibrillators (ICDs) have been reported to correlate with ventricular tachycardia/fibrillation (VT/VF). The aim of our study was to assess temporal association of decreasing TI trends with VT/VF episodes through a longitudinal analysis of daily remote monitoring data from ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds).<br /><b>Methods and results</b><br />Retrospective data from 2,384 patients were randomized 1:1 into a derivation or validation cohort. The TI decrease rate was defined as the percentage of rolling weeks with a continuously decreasing TI trend. The derivation cohort was used to determine a TI decrease rate threshold for a ≥99% specificity of arrhythmia prediction. The associated risk of VT/VF episodes was estimated in the validation cohort by dividing the available follow-up into 60-day assessment intervals. Analyses were performed separately for 1,354 ICD and 1,030 CRT-D patients. During a median follow-up of 2.0 years, 727 patients (30.4%) experienced 3,298 confirmed VT/VF episodes. In the ICD group, a TI decrease rate of >60% was associated with a higher risk of VT/VF episode in a 60-day assessment interval (stratified hazard ratio, 1.42; 95% CI, 1.05-1.92; p=0.023). The TI decrease preceded (40.8%) or followed (59.2%) the VT/VF episodes. In the CRT-D group, no association between TI decrease and VT/VF episodes was observed (p=0.84).<br /><b>Conclusion</b><br />In our longitudinal analysis, TI decrease was associated with VT/VF episodes only in ICD patients. Preventive interventions may be difficult since episodes can occur before or after TI decrease. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print</small></div>
Rodio G, Iacopino S, Pisanò EC, Calvi V, ... Gargaro A, D'Onofrio A
J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print | PMID: 36709469
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<div><h4>Lesion Size Index-guided high-power ablation for atrial fibrillation: opening the therapeutic window.</h4><i>Hanley A</i><br /><AbstractText>Radiofrequency (RF) ablation for the treatment of atrial fibrillation has gained widespread acceptance since the concept was introduced by Haissaguerre et al a quarter of a century ago. High power short duration ablation has been widely adopted in the management of atrial fibrillation. Evidence for combining lesion size index and high power short duration ablation is lacking. In this issue of the journal, Cai et al evaluated the combination of HPSD with LSI with a focus on long-term efficacy. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print</small></div>
Hanley A
J Cardiovasc Electrophysiol: 29 Jan 2023; epub ahead of print | PMID: 36709478
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<div><h4>Implementation of a Regional Extracorporeal Membrane Oxygenation Program for Refractory Ventricular Fibrillation Out-of-Hospital Cardiac Arrest.</h4><i>Bosson N, Kazan C, Sanko S, Abramson T, ... Gausche-Hill M, Shavelle D</i><br /><b>Background</b><br />eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR.<br /><b>Methods</b><br />The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome.<br /><b>Results</b><br />From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs.<br /><b>Conclusion</b><br />We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 28 Jan 2023:109711; epub ahead of print</small></div>
Bosson N, Kazan C, Sanko S, Abramson T, ... Gausche-Hill M, Shavelle D
Resuscitation: 28 Jan 2023:109711; epub ahead of print | PMID: 36720300
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<div><h4>Reduction in Junctophilin 2 Expression in Cardiac Nodal Tissue Results in Intracellular Calcium-Driven Increase in Nodal Cell Automaticity.</h4><i>Landstrom AP, Yang Q, Sun B, Perelli RM, ... Kim JJ, Wehrens XHT</i><br /><b>Background</b><br />Spontaneously depolarizing nodal cells comprise the pacemaker of the heart. Intracellular calcium (Ca<sup>2+</sup>) plays a critical role in mediating nodal cell automaticity and understanding this so-called Ca<sup>2+</sup> clock is critical to understanding nodal arrhythmias. We previously demonstrated a role for Jph2 (junctophilin 2) in regulating Ca<sup>2+</sup>-signaling through inhibition of RyR2 (ryanodine receptor 2) Ca<sup>2+</sup> leak in cardiac myocytes; however, its role in pacemaker function and nodal arrhythmias remains unknown. We sought to determine whether nodal Jph2 expression silencing causes increased sinoatrial and atrioventricular nodal cell automaticity due to aberrant RyR2 Ca<sup>2+</sup> leak.<br /><b>Methods</b><br />A tamoxifen-inducible, nodal tissue-specific, knockdown mouse of Jph2 was achieved using a Cre-recombinase-triggered short RNA hairpin directed against Jph2 (Hcn4:shJph2). In vivo cardiac rhythm was monitored by surface ECG, implantable cardiac telemetry, and intracardiac electrophysiology studies. Intracellular Ca<sup>2+</sup> imaging was performed using confocal-based line scans of isolated nodal cells loaded with fluorescent Ca<sup>2+</sup> reporter Cal-520. Whole cell patch clamp was conducted on isolated nodal cells to determine action potential kinetics and sodium-calcium exchanger function.<br /><b>Results</b><br />Hcn4:shJph2 mice demonstrated a 40% reduction in nodal Jph2 expression, resting sinus tachycardia, and impaired heart rate response to pharmacologic stress. In vivo intracardiac electrophysiology studies and ex vivo optical mapping demonstrated accelerated junctional rhythm originating from the atrioventricular node. Hcn4:shJph2 nodal cells demonstrated increased and irregular Ca<sup>2+</sup> transient generation with increased Ca<sup>2+</sup> spark frequency and Ca<sup>2+</sup> leak from the sarcoplasmic reticulum. This was associated with increased nodal cell AP firing rate, faster diastolic repolarization rate, and reduced sodium-calcium exchanger activity during repolarized states compared to control. Phenome-wide association studies of the <i>JPH2</i> locus identified an association with sinoatrial nodal disease and atrioventricular nodal block.<br /><b>Conclusions</b><br />Nodal-specific Jph2 knockdown causes increased nodal automaticity through increased Ca<sup>2+</sup> leak from intracellular stores. Dysregulated intracellular Ca<sup>2+</sup> underlies nodal arrhythmogenesis in this mouse model.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 27 Jan 2023:e010858; epub ahead of print</small></div>
Landstrom AP, Yang Q, Sun B, Perelli RM, ... Kim JJ, Wehrens XHT
Circ Arrhythm Electrophysiol: 27 Jan 2023:e010858; epub ahead of print | PMID: 36706317
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<div><h4>How to Implant Leadless Pacemakers and Mitigate Major Complications.</h4><i>El-Chami MF, Sha A</i><br /><AbstractText>Leadless pacemakers (LP) were introduced into clinical practice in 2016 when the Micra LP received FDA approval. Since then, more than 150,000 Micra have been implanted worldwide. In April 2022, the AVEIR LP was FDA approved. Implantation of these LPs requires a special set of skills that is different than the skill set required for implantation of traditional pacemakers. In this hands-on manuscript we detail the steps required for LP implantation while focusing on mitigating major complications.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 27 Jan 2023; epub ahead of print</small></div>
El-Chami MF, Sha A
Heart Rhythm: 27 Jan 2023; epub ahead of print | PMID: 36717008
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<div><h4>A comprehensive meta-analysis comparing radiofrequency ablation versus pharmacological therapy for the treatment of atrial fibrillation in patients with heart failure.</h4><i>Casula M, Pignalosa L, Quilico F, Scajola LV, Rordorf R</i><br /><b>Background</b><br />Atrial fibrillation (AF) and heart failure (HF) are both associated with worse prognosis and often coexist in the same patients. Whether catheter ablation (CA) is superior to pharmacological therapy in reducing major clinical endpoints in patients with AF and HF is still unsettled.<br /><b>Objective</b><br />To conduct a comprehensive meta-analysis comparing CA with medical therapy (MT) in this population.<br /><b>Methods</b><br />We systematically searched for randomized and observational studies comparing clinical outcomes between patients with AF and HF treated with CA or MT. The studied outcomes were mortality, hospitalization, left ventricle ejection fraction (LVEF) and 6-min walking test (6MWT) improvement.<br /><b>Results</b><br />A total of 12 studies counting 41,377 patients (3611 treated with CA and 37,766 with MT) were included in the analysis. The random-effect model revealed a clear trend in favor of CA in reducing unexpected HF hospitalization (RR 0.72; 95%CI 0.51-1.00; P = 0.05), all-cause death (RR 0.77; 95%CI 0.59-1.01; P = 0.06), all-cause hospitalization (RR 0.84; 95%CI 0.68-1.03; P = 0.09), and the composite of HF hospitalization and death (RR 0.77; 95%CI 0.58-1.02; P = 0.07), compared with MT. Patients treated with CA experienced a better improvement in LVEF (mean difference 6.17; 95%CI 2.98-9.37; P = 0.0002) and 6MWT (mean difference 13.70; 95%CI 3.95-23.45; P = 0.006). When the analysis was limited to randomized controlled trial, CA was found to significantly reduce all-cause death (RR 0.68; 95%CI 0.54-0.86; P = 0.001).<br /><b>Conclusion</b><br />As compared to MT, CA is associated with a better improvement in functional capacity and LVEF, and with a reduction in major clinical endpoints in patients with HF and AF.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 26 Jan 2023; epub ahead of print</small></div>
Casula M, Pignalosa L, Quilico F, Scajola LV, Rordorf R
Int J Cardiol: 26 Jan 2023; epub ahead of print | PMID: 36709925
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<div><h4>Impact of Achieving Blood Pressure Targets and High Time in Therapeutic Range on Clinical Outcomes in Patients With Atrial Fibrillation Adherent to the Atrial Fibrillation Better Care Pathway: A Report From the COOL-AF Registry.</h4><i>Krittayaphong R, Winijkul A, Methavigul K, Lip GYH</i><br /><AbstractText><br /><b>Background:</b><br/>We aimed to determine the effect of integrating Atrial Fibrillation Better Care pathway compliance in relation to achievement of systolic blood pressure (SBP) targets and good control of time in therapeutic range (TTR) on clinical outcomes in patients with atrial fibrillation. Methods and Results We prospectively enrolled patients with nonvalvular atrial fibrillation  from 27 hospitals in Thailand. All clinical outcomes were recorded. Main outcomes were the composite of all-cause death or ischemic stroke/systemic embolism (SSE), as well as secondary outcomes of all-cause death, SSE, major bleeding, intracranial hemorrhage, and heart failure. An SBP of 120 to 140 mm Hg was considered good blood pressure control. Target TTR was a TTR ≥65%. A total of 3405 patients were studied (mean age 67.8 years, 41.8% female). Full ABC pathway compliance was evident in 42.7%. For blood pressure control, 41.9% had SBP within target, whereas 35.9% of those on warfarin had TTR within target. The incidence rates of all-cause death/SSE, all-cause death, SSE, major bleeding, intracranial hemorrhage, and heart failure were 5.29, 4.21, 1.51, 2.25, 0.78, and 2.84 per 100 person-years respectively. Adjusted hazard ratios and 95% CI of Atrial Fibrillation Better Care pathway compliance for all-cause death/SSE, all-cause death, and heart failure were 0.76 (0.62-0.94), 0.79 (0.62-0.99), and 0.69 (0.51-0.94), respectively, compared with noncompliance. Patients with Atrial Fibrillation Better Care compliance and SBP within target had a better outcome or TTR within target had better outcomes. <br /><b>Conclusions:</b><br/>In COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Level in Patients With Non-Valvular Atrial Fibrillation in Thailand), a multicenter nationwide prospective cohort of patients with atrial fibrillation, achieving SBP within target and TTR ≥ 65% has added value to Atrial Fibrillation Better Care pathway compliance in the reduction of adverse clinical outcomes in patients with atrial fibrillation.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 25 Jan 2023:e028463; epub ahead of print</small></div>
Abstract
<div><h4>Major gaps in the information provided to patients before implantation of cardioverter defibrillators: a prospective patient European evaluation.</h4><i>Januszkiewicz Ł, Barra S, Marijon E, Providencia R, ... Conte G, Boveda S</i><br /><b>Aims</b><br />Information provided to patients prior to implantable cardioverter-defibrillator (ICD) insertion and their participation in the decision-making process are crucial for understanding ICD function and accepting this lifelong therapy. The aim of this study is to evaluate the extent to which different aspects related to ICD and quality of life were transmitted to patients prior to ICD implantation.<br /><b>Methods and results</b><br />Prospective, multicenter European study with an online questionnaire initiated by the European Heart Rhythm Association. The questionnaire was filled-in directly and personally by the ICD patients who were invited to participate. A total of 1809 patients (majority in their 40s-70s, with 624 women, 34.5%) from 10 European countries participated in the study. The median time from first ICD implantation was 5 years (interquartile range 2-10). Overall, 1155 patients (71.5%) felt optimally informed at the time of device implantation, however many respondents received no information about ICD-related complications (n = 801, 49.6%), driving restrictions (n = 718, 44.5%), and possibility of end-of-life ICD deactivation (n = 408, 25.4%). Of note, women were less frequently involved in the decision-making process than men (47.3% vs. 55.9%, P = 0.003) and reported to be less often optimally informed before ICD implantation than men (61.2% vs. 76.8%, P < 0.001). More women mentioned the desire to have learned more about ICD therapy and the benefit/risk balance (45.4% vs. 33.7% of men; P < 0.001).<br /><b>Conclusions</b><br />This patient-based evaluation provides alarming findings on the lack of information provided to patients prior ICD implantation, particularly for women.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Januszkiewicz Ł, Barra S, Marijon E, Providencia R, ... Conte G, Boveda S
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691111
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<div><h4>Combination of current and new electrocardiographic-based criteria: a novel score for the discrimination of left bundle branch capture.</h4><i>Briongos-Figuero S, Estévez-Paniagua Á, Sánchez-Hernández A, Muñoz-Aguilera R</i><br /><b>Aims</b><br />Most of the criteria used to diagnose direct capture of the left bundle branch (LBB) have never been validated in an external sample. We hypothesized that lead aVL might add relevant information, and the combination of several electrocardiograph (ECG)-based criteria might discriminate better LBB capture from left ventricular septal (LVS) capture, than each criterion separately.<br /><b>Methods and results</b><br />Single-centre study involving all consecutive patients who received LBB area pacing. LBB capture was defined according to QRS morphology transition criteria during decremental pacing. Multivariate logistic regression analysis was performed to develop a predictive score for LBB capture. A total of 71 patients with confirmed LBB capture were analysed. The optimal cut-off values of R wave peak time (RWPT) in lead V6 (V6-RWPT) and V6-V1 interpeak interval for the discrimination of LBB capture were <83 ms and ≥33 ms, respectively. The RWPT in lead aVL (aVL-RWPT) showed a good discrimination power for the differential diagnosis of LBB capture and LVS capture. The optimal value for aVL-RWPT was 79 ms [sensitivity (SN) and specificity (SP) of 71.2% and 88.4%, respectively]. A new score, with a good diagnostic performance (area under the curve of 0.976), was constructed gathering the information from V6-RWPT, aVL-RWPT, and V6-V1 interpeak interval. The optimal score of 3 points showed a SN and SP of 89.2% and 100%, respectively for the differentiation of LBB capture.<br /><b>Conclusions</b><br />ECG-based criteria are useful to confirm the capture of the LBB. The combination of V6-RWPT, aVL-RWPT, and V6-V1 interpeak interval values demonstrated better diagnostic performance than isolated measurements.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Briongos-Figuero S, Estévez-Paniagua Á, Sánchez-Hernández A, Muñoz-Aguilera R
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691717
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<div><h4>Non-continuous mobile electrocardiogram monitoring for post-transcatheter aortic valve replacement delayed conduction disorders put to the test.</h4><i>De Lucia R, Giannini C, Parollo M, Barletta V, ... Bongiorni MG, Petronio AS</i><br /><b>Aims</b><br />Permanent pacemaker implantation (PPM-I) remains nowadays the most important drawback of transcatheter aortic valve replacement (TAVR) procedure and the optimal strategy of delayed conduction disturbances (CDs) in these patients is unclear. The study aimed to validate an ambulatory electrocardiogram (ECG) monitoring through a 30 s spot ambulatory digital mobile ECG (AeECG), by using KardiaMobile-6L device in a 30-day period after TAVR procedure.<br /><b>Methods and results</b><br />Between March 2021 and February 2022, we consecutively enrolled all patients undergoing TAVR procedure, except pacemaker (PM) carriers. At discharge, all patients were provided of a KardiaMobile-6L device and a spot digital ECG (eECG) recording 1 month schedule. Clinical and follow-up data were collected, and eECG schedule compliance and recording quality were explored. Among 151 patients without pre-existing PM, 23 were excluded for pre-discharge PPM-I, 18 failed the KardiaMobile-6L training phase, and 10 refused the device. Delayed CDs with a Class I/IIa indication for PPM-I occurred in eight patients (median 6 days). Delayed PPM-I vs. non-delayed PPM-I patients were more likely to have longer PR and QRS intervals at discharge. PR interval at discharge was the only independent predictor for delayed PPM-I at multivariate analysis. The overall eECG schedule compliance was 96.5%. None clinical adverse events CDs related were documented using this new AeECG monitoring modality.<br /><b>Conclusion</b><br />A strategy of 30 s spot AeECG is safe and efficacious in delayed CDs monitoring after TAVR procedure with a very high eECG schedule level of compliance.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
De Lucia R, Giannini C, Parollo M, Barletta V, ... Bongiorni MG, Petronio AS
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691737
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<div><h4>Cost-effectiveness analysis of cardiac implantable electronic devices with reactive atrial-based antitachycardia pacing.</h4><i>Noda T, Ueda N, Tanaka Y, Ishiguro Y, ... Myung JE, Kusano K</i><br /><b>Aims</b><br />Reactive atrial-based anti-tachycardia pacing (rATP) in pacemakers (PMs) and cardiac resynchronization therapy defibrillators (CRT-Ds) has been reported to prevent progression of atrial fibrillation, and this reduced progression is expected to decrease the risk of complications such as stroke and heart failure (HF). This study aimed to assess the cost-effectiveness of rATP in PMs and CRT-Ds in the Japanese public health insurance system.<br /><b>Methods and results</b><br />We developed a Markov model comprising five states: bradycardia, post-stroke, mild HF, severe HF, and death. For devices with rATP and control devices without rATP, we compared the incremental cost-effectiveness ratio (ICER) from the payer\'s perspective. Costs were estimated from healthcare resource utilisation data in a Japanese claims database. We evaluated model uncertainty by analysing two scenarios for each device. The ICER was 763 729 JPY/QALY (5616 EUR/QALY) for PMs and 1,393 280 JPY/QALY (10 245 EUR/QALY) for CRT-Ds. In all scenarios, ICERs were below 5 million JPY/QALY (36 765 EUR/QALY), supporting robustness of the results.<br /><b>Conclusion</b><br />According to a willingness to pay threshold of 5 million JPY/QALY, the devices with rATP were cost-effective compared with control devices without rATP, showing that the higher reimbursement price of the functional categories with rATP is justified from a healthcare economic perspective.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Noda T, Ueda N, Tanaka Y, Ishiguro Y, ... Myung JE, Kusano K
Europace: 24 Jan 2023; epub ahead of print | PMID: 36691793
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<div><h4>Network Meta-Analysis and Systematic Review Comparing Efficacy and Safety between Very high Power Short Duration, High Power Short Duration, and Conventional Radiofrequency Ablation of Atrial Fibrillation.</h4><i>Tokavanich N, Prasitlumkum N, Kewcharoen J, Chokesuwattanaskul R, ... Bunch TJ, Navaravong L</i><br /><b>Background</b><br />High-power short-duration (HPSD) atrial fibrillation (AF) ablation with a power of 40-50 watts was proved to be safe and effective. Very high-power short-duration (vHPSD) AF ablation is a novel method using >50 watts to obtain more durable AF ablation. This study aimed to evaluate the efficacy and safety of vHPSD ablation compared with HPSD ablation and conventional power ablation.<br /><b>Methods</b><br />A literature search for studies that reported AF ablation outcomes, including short-term freedom from atrial arrhythmia, first-pass isolation (FPI) rate, procedure time, and major complications, was conducted utilizing MEDLINE, EMBASE, and Cochrane databases. All relevant studies were included in this analysis. A random-effects model of network meta-analysis and surface under cumulative ranking curve (SUCRA) were used to rank the treatment for all outcomes.<br /><b>Results</b><br />A total of 29 studies with 9,721 patients were included in the analysis. According to the SUCRA analysis, HPSD ablation had the highest probability of maintaining sinus rhythm. Point estimation showed an odds ratio of 1.5 (95% confidence interval [CI] 1.2-1.9) between HPSD ablation and conventional power ablation and an odds ratio of 1.3 (95% CI 0.78-2.2) between vHPSD ablation and conventional power ablation. While the odds ratio of FPI between HPSD ablation and conventional power ablation was 3.6 (95% CI 1.5-8.9), the odds ratio between vHPSD ablation and conventional power ablation was 2.2 (95% CI 0.61-8.6). The procedure times of vHPSD and HPSD ablations were comparable and, therefore, shorter than that of conventional power ablation. Major complications were low in all techniques.<br /><b>Conclusion</b><br />vHPSD ablation did not yield higher efficacy than HPSD ablation and conventional power ablation. With the safety concern, vHPSD ablation outcomes were comparable with those of other techniques. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print</small></div>
Tokavanich N, Prasitlumkum N, Kewcharoen J, Chokesuwattanaskul R, ... Bunch TJ, Navaravong L
J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print | PMID: 36691892
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<div><h4>Substrate Modification of Ventricular Tachycardia: Can Ripple Mapping help improve success rates by identifying critical channels?</h4><i>Katritsis G, Linton NW, Kanagaratnam P</i><br /><AbstractText>Ablation of ventricular tachycardia (VT) has been shown to reduce VT recurrence more favourably than drug therapy in a number of trials This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print</small></div>
Katritsis G, Linton NW, Kanagaratnam P
J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print | PMID: 36691897
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<div><h4>In which patients with heart failure should ablation of atrial fibrillation not be performed?</h4><i>Hachiya H</i><br /><AbstractText>Catheter ablation of atrial fibrillation (AF) in patients with heart failure associated with a reduced EF (HFrEF) was associated with a significantly lower rate of a composite endpoint of death from any cause or hospitalization for worsening heart failure (HF) than medical therapy in the CASTLE-AF trial. In patients with HF and also with a preserved EF (HFpEF), AF is known to be associated with increased mortality. Although the particular benefit in patients with an EF >35% may suggest the need for prospective randomized control trial data in patients with HF to assess the role of ablation as a first-line therapy as Sessions AJ, et al. stated, we believe at present that 1) whether there is structural heart disease detected by cardiac images and 2) whether the left atrial voltage is generally low, should be assessed \"before ablation\" in each patient with HF to achieve a successful ablation. This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print</small></div>
Hachiya H
J Cardiovasc Electrophysiol: 24 Jan 2023; epub ahead of print | PMID: 36691910
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<div><h4>Outcomes after cryoballoon ablation of paroxysmal atrial fibrillation with the PolarX or the Arctic front advance pro: a prospective multicentre experience.</h4><i>Tanese N, Almorad A, Pannone L, Defaye P, ... de Asmundis C, Boveda S</i><br /><b>Aims</b><br />The aim of this study was to compare procedural efficacy and safety, including 1-year freedom from AF recurrence, between the novel cryoballoon system PolarX (Boston Scientific) and the Arctic Front Advance Pro (AFA-Pro) (Medtronic), in patients with paroxysmal AF undergoing PVI.<br /><b>Methods and results</b><br />This multicentre prospective observational study included 267 consecutive patients undergoing a first cryoablation procedure for paroxysmal AF (137 PolarX, 130 AFA-Pro). KM curves with the log-rank test was used to compare the 1-year freedom from AF recurrence between both groups. Multivariate Cox model was performed to evaluate whether the type of procedure (PolarX vs. AFA-Pro) had an impact on the occurrence of AF recurrences after adjustment on potentially confounding factors. The PolarX reaches lower temperatures than the AFA-Pro (LSPV 52 ± 5, vs. 59 ± 6; LIPV 49 ± 6 vs. 56 ± 6; right superior pulmonary vein: 49 ± 6 vs. 57 ± 7; right inferior pulmonary vein: 52 ± 6 vs. 59 ± 6; P < 0.0001). A higher rate of transient phrenic nerve palsy was found in patients treated with the PolarX system (15% vs. 7%, P = 0.05). After a mean follow-up of 15 ± 5 months, 20 patients (15%) had recurrences in AFA-Pro group and 27 patients (19%) in PolarX group (P = 0.35). Based on survival analysis, no significant difference was observed between both groups with a 12-month free of recurrence survival of 91.2% (85.1-95.4%) vs. 83.7% (76.0%-89.1%) (log-rank test P = 0.11). In multivariate Cox model hazard ratio of recurrence for PolarX vs. AFA-Pro was not significant [HR = 1.6 (0.9-2.8), P = 0.12].<br /><b>Conclusion</b><br />PolarX and AFA-Pro have comparable efficacy and safety profiles for pulmonary veins isolation in paroxysmal atrial fibrillation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 24 Jan 2023; epub ahead of print</small></div>
Tanese N, Almorad A, Pannone L, Defaye P, ... de Asmundis C, Boveda S
Europace: 24 Jan 2023; epub ahead of print | PMID: 36695332
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<div><h4>Effects of Ablation Versus Drug Therapy on Quality of Life by Sex in Atrial Fibrillation: Results From the CABANA Trial.</h4><i>Zeitler EP, Li Y, Silverstein AP, Russo AM, ... Mark DB, CABANA Investigators</i><br /><AbstractText><br /><b>Background:</b><br/>Women with atrial fibrillation (AF) demonstrate more AF-related symptoms and worse quality of life (QOL). Whether increased use of ablation in women reduces sex-related QOL differences is unknown. Sex-related outcomes for ablation versus drug therapy was a prespecified analysis in the CABANA (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial. Methods and Results Symptoms were assessed periodically over 60 months with the Mayo AF-Specific Symptom Inventory (MAFSI) frequency score, and QOL was assessed with the Atrial Fibrillation Effect on Quality of Life (AFEQT) summary and component scores. Women had lower baseline QOL scores than men (mean AFEQT scores 55.9 and 65.6, respectively). Ablation patients improved more than drug therapy patients with similar treatment effect by sex: AFEQT 12-month mean adjusted treatment difference in women 6.1 points (95% CI, 3.5-8.6) and men 4.9 points (95% CI, 3.0-6.9). Participants with baseline AFEQT summary scores <70 had greater QOL improvement, with a mean treatment difference at 12 months of 7.6 points for women (95% CI, 4.3-10.9) and 6.4 points for men (95% CI, 3.3-9.4). The mean adjusted difference in MAFSI frequency score between women randomized to ablation versus drug therapy at 12 months was -2.5 (95% CI, -3.4 to -1.6); for men, the difference was -1.3 (95% CI, -2.0 to -0.6). <br /><b>Conclusions:</b><br/>Compared with drug therapy for AF, ablation resulted in more QOL improvement in both sexes, primarily driven by improvements in those with lower baseline QOL. Ablation did not eliminate the AF-related QOL gap between women and men. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00911508.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 23 Jan 2023:e027871; epub ahead of print</small></div>
Zeitler EP, Li Y, Silverstein AP, Russo AM, ... Mark DB, CABANA Investigators
J Am Heart Assoc: 23 Jan 2023:e027871; epub ahead of print | PMID: 36688367
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<div><h4>Abnormal Conduction Zone Detected by Isochronal Late Activation Mapping Accurately Identifies the Potential Atrial Substrate and Predicts the Atrial Fibrillation Ablation Outcome After Pulmonary Vein Isolation.</h4><i>Kuo MJ, Ton AK, Lo LW, Lin YJ, ... Hsu CY, Chen SA</i><br /><b>Background</b><br />The presence of abnormal substrate of left atrium is a predictor of atrial fibrillation (AF) recurrence after pulmonary vein isolation. We aimed to investigate the isochronal late activation mapping to access the abnormal conduction velocity for predicting AF ablation outcome.<br /><b>Methods</b><br />Forty-five paroxysmal AF patients (30 males, 57.8±8.7 years old) who underwent pulmonary vein isolation were enrolled. Isochronal late activation mapping was retrospectively constructed with 2 different windows of interest: from onset of P wave to onset of QRS wave on surface electrocardiography (W1) and 74 ms tracking back from the end of P wave (W2). Deceleration zone was defined as regions with 3 isochrones (DZa) or ≥4 isochrones (DZb) within a 1 cm radius on the isochronal late activation mapping, and the estimated conduction velocity (ECV) are 0.27 m/s and <0.20 m/s for DZa and DZb, respectively in W2. The distribution of deceleration zone was compared with the location of low-voltage zone (bipolar voltage ≤0.5 mV). Any recurrence of atrial arrhythmias was defined as the primary end point during follow ups after a 3-month blanking period.<br /><b>Results</b><br />Pulmonary vein isolation was performed in all patients, and there were 2 patients (4.4%) received additional extrapulmonary vein ablation. After a mean follow-up of 12.7±4.5 months, recurrence of AF occurred in 14 patients (31.1%). Patients with the presence of DZb in W2 had higher AF recurrence (Kaplan-Meier event rate estimates: HR, 9.41 [95% CI, 2.61-33.90]; log-rank <i>P</i><0.0001). 52.6% of the DZb locations in W2 were comparable to the distributions of low-voltage zone, and 47.4% DZb were distributed in the area without low-voltage zone.<br /><b>Conclusions</b><br />Deceleration zone detected by isochronal late activation mapping represents a critical AF substrate, it accurately predicts the AF recurrence following ablation in patients with paroxysmal AF.<br /><br /><br /><br /><small>Circ Arrhythm Electrophysiol: 23 Jan 2023:e011149; epub ahead of print</small></div>
Kuo MJ, Ton AK, Lo LW, Lin YJ, ... Hsu CY, Chen SA
Circ Arrhythm Electrophysiol: 23 Jan 2023:e011149; epub ahead of print | PMID: 36688314
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<div><h4>Right bundle branch pacing: criteria, characteristics and outcomes.</h4><i>Jastrzębski M, Kiełbasa G, Moskal P, Bednarek A, ... Burri H, Vijayaraman P</i><br /><b>Background</b><br />Targets for right-sided conduction system pacing (CSP) include His bundle and right bundle branch. ECG patterns, diagnostic criteria and outcomes of right bundle branch pacing (RBBP) are not known.<br /><b>Objective</b><br />Our aims were to delineate electrocardiographic and electrophysiological characteristics of RBBP and to compare outcomes between RBBP and His bundle pacing (HBP).<br /><b>Methods</b><br />Patients with confirmed right CSP were divided according to the conduction system potential to QRS interval at the pacing lead implantation site. Six hypothesized RBBP criteria as well as pacing parameters, echocardiographic outcomes and all-cause mortality were analyzed.<br /><b>Results</b><br />All analyzed criteria discriminated between HBP and RBBP: double QRS transition during threshold test, selective paced QRS different from conducted QRS, stimulus to selective QRS > potential-QRS, small increase in V<sub>6</sub>RWPT during QRS transition, equal capture thresholds of CSP and myocardium, and stimulus-V<sub>6</sub> R-wave peak time (V<sub>6</sub>RWPT) > potential-V<sub>6</sub>RWPT (adopted as diagnostic standard). Per this last criterion, RBBP was observed in 19.2% (64/326) patients who had been targeted for HBP, present mainly among patients with potential to QRS < 35 ms (90.6%, 48/53) and occasionally in the remaining patients (5.6%, 16/273). RBBP was characterized by longer QRS (by 10.5 ms), longer V<sub>6</sub>RWPT (by 11.6 ms) and better sensing (by 2.6 mV) compared to HBP. During median follow-up of 29 months, no differences in capture threshold, echocardiographic outcomes or mortality were found.<br /><b>Conclusions</b><br />RBBP has distinct features that separate it from HBP and is observed in approximately a fifth of patients in whom HBP is intended.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 23 Jan 2023; epub ahead of print</small></div>
Jastrzębski M, Kiełbasa G, Moskal P, Bednarek A, ... Burri H, Vijayaraman P
Heart Rhythm: 23 Jan 2023; epub ahead of print | PMID: 36702391
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<div><h4>Rationale For and Use of the Lumenless 3830 Pacing Lead.</h4><i>Richardson TD, Adam Himes MS, Marshall M, Crossley GH</i><br /><b>Introduction</b><br />Most currently available pacing and defibrillation leads utilize a stylet-based design that facilitates implantation. This has advantages, but also increases the lead diameter and adds the potential for metal fatigued-based conductor failure.<br /><b>Methods</b><br />A systematic literature search was conducted, and the authors add their twenty-year experience with this lead design.<br /><b>Results</b><br />The global experience with lumenless leads was reviewed both for \"standard\" positioning and with conduction system pacing. Methods for both placement and system modification are reviewed.<br /><b>Conclusions</b><br />Lumenless leads have the potential to improve the durability of endocardial pacing and facilitate conduction system pacing. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print</small></div>
Richardson TD, Adam Himes MS, Marshall M, Crossley GH
J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print | PMID: 36682066
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<div><h4>Evaluating Temperature Gradients Across the Posterior Left Atrium with Radiofrequency Ablation.</h4><i>Sandhu A, Holman B, Lammers S, Cerbin L, ... Sauer WH, Tzou WS</i><br /><b>Introduction</b><br />Esophageal injury is a well-known complication associated with catheter ablation. Though novel methods to mitigate esophageal injury have been developed, few studies have evaluated temperature gradients with catheter ablation across the posterior wall of the left atrium, interstitium and esophagus.<br /><b>Methods</b><br />To investigate temperature gradients across tissue, we developed a porcine heart-esophageal model to perform ex vivo catheter ablation on the posterior wall of the LA, with juxtaposed interstitial tissue and esophagus. Circulating saline (5 L/min) was used to mimic blood flow along the LA and alteration of ionic content to modulate impedance. Thermistors along the region of interest were used to analyze temperature gradients. Varying time and power, radiofrequency (RF) ablation lesions were applied with an externally irrigated ablation catheter. Ablation strategies were divided into standard approaches (SA, 10-15g, 25-35W, 30s) or high-power short duration (HPSD, 10-15g, 40-50W, 10s). Temperature gradients, time to maximum measured temperature and the relationship between measured temperature as a function of distance from the site of ablation were analyzed.<br /><b>Results</b><br />In total, 5 experiments were conducted each utilizing new porcine posterior LA wall-esophageal specimens for RF ablation (n=60 lesions each for SA and HPSD). For both SA and HPSD, maximum temperature rise from baseline was markedly higher at the anterior wall (AW) of the esophagus compared to the esophageal lumen (SA: 4.29°C vs. 0.41°C, p<0.0001 and HPSD: 3.13°C vs. 0.28°C, p<0.0001). Across ablation strategies, the average temperature rise at the anterior wall of the esophagus was significantly higher with SA relative to HPSD ablation (4.29°C vs. 3.13°C, p=0.01). From start of ablation, the average time to reach maximum temperature as measured at the anterior wall of the esophagus with SA was 36.49 +/- 12.12 sec, compared to 16.57 +/- 4.54 sec with HPSD ablation, p<0.0001. Fit to a linear scale, a 0.37°C drop in temperature was seen for every 1 cm increase in distance from the site of ablation and thermistor location at the anterior wall of the esophagus.<br /><b>Conclusion</b><br />Both SA and HPSD ablation strategies resulted in markedly higher temperatures measured at the anterior wall of the esophagus compared to the esophageal lumen, raising concern about the value of clinical intraluminal temperature monitoring. The temperature rise at the anterior wall was lower with HPSD. Significant time delay was seen to reach maximum measured temperature and a modest increase in distance between site of ablation and thermistor location impacted accuracy of monitored temperatures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print</small></div>
Sandhu A, Holman B, Lammers S, Cerbin L, ... Sauer WH, Tzou WS
J Cardiovasc Electrophysiol: 22 Jan 2023; epub ahead of print | PMID: 36682068
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<div><h4>Pre-clinical Evaluation of a Third Generation Absorbable Antibacterial Envelope.</h4><i>Love CJ, Hanna I, Thomas G, Greenspon AJ, ... Kirchhof N, Sohail MR</i><br /><b>Background</b><br />The TYRX absorbable antibacterial envelope has been shown to stabilize implantable cardiac devices and reduce infection. A third-generation envelope was developed to reduce surface roughness with a redesigned multifilament mesh and enhanced form-factor but identical polymer coating and antibiotic concentrations as the currently available second-generation envelope.<br /><b>Objective</b><br />To compare drug elution, bacterial challenge efficacy, stabilization, and absorption of second- vs. third-generation envelopes.<br /><b>Methods</b><br />Antibiotic elution was assessed in vitro and in vivo. For efficacy against gram+/gram- bacteria, 40 rabbits underwent device insertions with or without third-generation envelopes. For stabilization (migration, rotation), 5 sheep were implanted with 6 devices each in second- or third-generation envelopes. Pre-specified acceptance criteria were <83 mm migration and <90 degrees rotation. Absorption was assessed via gross pathology.<br /><b>Results</b><br />Elution curves were equivalent (similarity factors ≥50 per FDA guidance). Third-generation envelopes eluted antibiotics above minimal inhibitory concentration (MIC) in vivo at 2hr post-implant through 7d, consistent with second-generation envelopes. Bacterial challenge showed reductions (p<0.05) in infection with second- and third-generation envelopes. Device migration was 5.5±3.5 (third-generation) vs. 9.9±7.9 mm (second-generation) (p<0.05). Device rotation was 18.9±11.4 (third-generation) vs. 17.6±15.1 degrees (second-generation) and did not differ (p=0.79). Gross pathology confirmed absence of luminal mesh remainders and no differences in peri-device fibrosis at 9 or 12wks.<br /><b>Conclusion</b><br />The third-generation TYRX absorbable antibacterial envelope demonstrated equivalent pre-clinical performance to the second-generation envelope: antibiotic elution curves were similar, elution was above MIC for 7d, infections were reduced compared to no envelope, and acceptance criteria for migration, rotation, and absorption were met.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 21 Jan 2023; epub ahead of print</small></div>
Love CJ, Hanna I, Thomas G, Greenspon AJ, ... Kirchhof N, Sohail MR
Heart Rhythm: 21 Jan 2023; epub ahead of print | PMID: 36693614
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<div><h4>Mechanical extraction of implantable cardioverter-defibrillator leads with a dwell time of more than 10 years: insights from a single high-volume centre.</h4><i>Ząbek A, Boczar K, Ulman M, Holcman K, ... Lelakowski J, Małecka B</i><br /><b>Aims</b><br />To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems.<br /><b>Methods and results</b><br />Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B.<br /><b>Conclusion</b><br />The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 20 Jan 2023; epub ahead of print</small></div>
Ząbek A, Boczar K, Ulman M, Holcman K, ... Lelakowski J, Małecka B
Europace: 20 Jan 2023; epub ahead of print | PMID: 36660771
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<div><h4>Cross-ancestry genome-wide analysis of atrial fibrillation unveils disease biology and enables cardioembolic risk prediction.</h4><i>Miyazawa K, Ito K, Ito M, Zou Z, ... Kamatani Y, Komuro I</i><br /><AbstractText>Atrial fibrillation (AF) is a common cardiac arrhythmia resulting in increased risk of stroke. Despite highly heritable etiology, our understanding of the genetic architecture of AF remains incomplete. Here we performed a genome-wide association study in the Japanese population comprising 9,826 cases among 150,272 individuals and identified East Asian-specific rare variants associated with AF. A cross-ancestry meta-analysis of >1 million individuals, including 77,690 cases, identified 35 new susceptibility loci. Transcriptome-wide association analysis identified IL6R as a putative causal gene, suggesting the involvement of immune responses. Integrative analysis with ChIP-seq data and functional assessment using human induced pluripotent stem cell-derived cardiomyocytes demonstrated ERRg as having a key role in the transcriptional regulation of AF-associated genes. A polygenic risk score derived from the cross-ancestry meta-analysis predicted increased risks of cardiovascular and stroke mortalities and segregated individuals with cardioembolic stroke in undiagnosed AF patients. Our results provide new biological and clinical insights into AF genetics and suggest their potential for clinical applications.</AbstractText><br /><br />© 2023. The Author(s).<br /><br /><small>Nat Genet: 19 Jan 2023; epub ahead of print</small></div>
Miyazawa K, Ito K, Ito M, Zou Z, ... Kamatani Y, Komuro I
Nat Genet: 19 Jan 2023; epub ahead of print | PMID: 36653681
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<div><h4>Comparison of Warfarin with Direct Oral Anticoagulants for Thromboembolic Prophylaxis after Catheter Ablation of Ventricular Tachycardia.</h4><i>Deshmukh A, Gunda S, Ghannam M, Liang J, ... Morady F, Bogun F</i><br /><b>Introduction</b><br />Thromboembolic events after catheter ablation of ventricular tachycardia (VT) can result in significant morbidity. Thromboembolic prophylaxis after catheter ablation can be achieved by the use of antiplatelet agents, vitamin K antagonists, or direct oral anticoagulants (DOACs). The relative safety and efficacy of these modes of prophylaxis are uncertain. We sought to compare the outcomes of patients who received warfarin or DOACs for thromboembolic prophylaxis after catheter ablation of VT.<br /><b>Methods and results</b><br />Anticoagulation with DOACS was started after left ventricular VT ablation in a series of 42 consecutive patients with structural heart disease (67±11 years, 3 women, ejection fraction 32±14%). Duration of hospital stay, bleeding episodes, and thromboembolic events were compared to a historic consecutive group of patients (n=38, 65±13 years, 14 women, ejection fraction 36±13%) in whom anticoagulation with a formerly described protocol of heparin and vitamin K antagonist was used after VT ablation procedures. Hospital stay was significantly shorter in the group where DOACs were used as compared to vitamin K antagonists (3.3±1.8 vs. 5.0 ±2.5 days post ablation; p=0.001) without an increase of bleeding or thromboembolic events.<br /><b>Conclusion</b><br />Anticoagulation with DOACs is safe and shortens hospital stay in patients with structural heart disease undergoing left ventricular VT ablation procedures. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Jan 2023; epub ahead of print</small></div>
Deshmukh A, Gunda S, Ghannam M, Liang J, ... Morady F, Bogun F
J Cardiovasc Electrophysiol: 19 Jan 2023; epub ahead of print | PMID: 36655538
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<div><h4>Accumulated hypertension burden on atrial fibrillation risk in diabetes mellitus: a nationwide population study.</h4><i>Choi J, Lee SR, Choi EK, Lee H, ... Oh S, Lip GYH</i><br /><b>Background</b><br />Patients with diabetes mellitus have an increased risk of incident atrial fibrillation (AF). The effect of accumulated hypertension burden is a less well-known modifiable risk factor. We explored the relationship between accumulated hypertension burden and incident AF in these patients.<br /><b>Methods</b><br />We evaluated data for 526,384 patients with diabetes who underwent three consecutive health examinations, between 2009 and 2012, from the Korean National Health Insurance Service. Hypertension burden was calculated by assigning points to each stage of hypertension in each health examination: 1 for stage 1 hypertension (systolic blood pressure [SBP] 130-139 mmHg; diastolic blood pressure [DBP] 80-89 mmHg); 2 for stage 2 (SBP 140-159 mmHg and DBP 90-99 mmHg); and 3 for stage 3 (SBP ≥ 160 mmHg or DBP ≥ 100 mmHg). Patients were categorized into 10 hypertensive burden groups (0-9). Groups 1-9 were then clustered into 1-3, 4-6, and 7-9.<br /><b>Results</b><br />During a mean follow-up duration of 6.7 ± 1.7 years, AF was newly diagnosed in 18,561 (3.5%) patients. Compared to patients with hypertension burden 0, those with burden 1 to 9 showed a progressively increasing risk of incident AF: 6%, 11%, 16%, 24%, 28%, 41%, 46%, 57%, and 67% respectively. Clusters 1-3, 4-6, and 7-9 showed increased risks by 10%, 26%, and 45%, respectively, when compared to a hypertension burden of 0.<br /><b>Conclusions</b><br />Accumulated hypertension burden was associated with an increased risk of incident AF in patients with diabetes. Strict BP control should be emphasized for these patients.<br /><br />© 2023. The Author(s).<br /><br /><small>Cardiovasc Diabetol: 19 Jan 2023; 22:12</small></div>
Choi J, Lee SR, Choi EK, Lee H, ... Oh S, Lip GYH
Cardiovasc Diabetol: 19 Jan 2023; 22:12 | PMID: 36658574
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<div><h4>You won\'t see me: can pacing correlation maps be used to assess scar location?</h4><i>Gianni C, Burkhardt JD</i><br /><AbstractText>In ventricular tachycardia (VT) ablation, substrate-based approaches have emerged as an alternative approach to activation-based VT ablation, which is often limited when clinical arrhythmias are non-inducible, non-sustained, and/or hemodynamically compromising. Traditionally, substrate mapping is performed in sinus or paced rhythm, and comprises of annotation of abnormal electrograms, including low voltage, fractionated, and late potentials This article is protected by copyright. All rights reserved.</AbstractText><br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Gianni C, Burkhardt JD
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651345
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<div><h4>A novel practical algorithm using machine learning to differentiate outflow tract ventricular arrhythmia origins.</h4><i>Shimojo M, Inden Y, Yanagisawa S, Suzuki N, ... Tsuji Y, Murohara T</i><br /><b>Introduction</b><br />Diagnosis of outflow tract ventricular arrhythmia (OTVA) localization by an electrocardiographic complex is key to successful catheter ablation for OTVA. However, diagnosing the origin of OTVA with a precordial transition in lead V3 (V3TZ) is challenging. This study aimed to create the best practical electrocardiogram algorithm to differentiate the left ventricular outflow tract (LVOT) from the right ventricular outflow tract (RVOT) of OTVA origin with V3TZ using machine learning.<br /><b>Methods</b><br />Of 498 consecutive patients undergoing catheter ablation for OTVA, we included 104 patients who underwent ablation for OTVA with V3TZ and identified the origin of LVOT (n=62) and RVOT (n=42) from the results. We analyzed the standard 12-lead electrocardiogram preoperatively and measured 128 elements in each case. The study population was randomly divided into training group (70%) and testing group (30%), and decision tree analysis was performed using the measured elements as features. The performance of the algorithm created in the training group was verified in the testing group.<br /><b>Results</b><br />Four measurements were identified as important features: the aVF/II R-wave ratio, the V2S/V3R index, the QRS amplitude in lead V3, and the R-wave deflection slope in lead V3. Among them, the aVF/II R-wave ratio and the V2S/V3R index had a particularly strong influence on the algorithm. The performance of this algorithm was extremely high, with an accuracy of 94.4%, precision of 91.5%, recall of 100%, and an F1-score of 0.96.<br /><b>Conclusions</b><br />The novel algorithm created using machine learning is useful in diagnosing the origin of OTVA with V3TZ. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Shimojo M, Inden Y, Yanagisawa S, Suzuki N, ... Tsuji Y, Murohara T
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651347
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<div><h4>Damage to the left descending coronary artery due to radiofrequency ablation in the right ventricular outflow tract: Clinical case series and anatomical considerations.</h4><i>Dilling-Boer D, Nof E, Beinaert R, Wakili R, ... Didenko M, Vijgen J</i><br /><AbstractText>The purpose of this paper was to highlight the importance of the anatomy of the right ventricular outflow tract (RVOT) and the proximity of the mid segment of the left anterior descending coronary artery (LAD) to the RVOT in the setting of ablation of ventricular arrhythmias in the RVOT. During the period from 2014 till 2017, five patients with injury to the LAD during ablation within RVOT were identified in three centers, in Belgium, Germany and Israel. The clinical characteristics, procedural data and follow up data, where available, are reported. The literature review over coronary artery damage during radiofrequency ablation procedures is provided and the anatomy of the RVOT and the neighboring vascular structures is discussed. We present five patients who underwent radiofrequency ablation of ventricular arrhythmias mapped to the inferior and anterior part of the RVOT, at the insertion of the right ventricular wall to the septum, whereby ablation resulted in occlusion in four and severe stenosis in one, of the mid segment of the LAD coronary artery. All patients underwent percutaneous coronary intervention and stenting, four of them immediately during the same procedure and one 3 days later because of lack of signs and symptoms of acute coronary occlusion. In conclusion, the mid segment of the LAD at the level of the second septal perforator/second diagonal branch runs in very close proximity to the endocardial aspect of the lower part of the RVOT and care should be taken during ablation of ventricular arrhythmias in this region. Additional imaging such as intracardiac echocardiography and coronary angiography may be helpful in avoiding complications.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Dilling-Boer D, Nof E, Beinaert R, Wakili R, ... Didenko M, Vijgen J
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651349
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<div><h4>Catheter Ablation of Idiopathic Left Fascicular Ventricular Tachycardia: Implications of False Tendons for Mapping and Ablation.</h4><i>Ma W, Qiu J, Lu F, Michael Shehata MD, ... Wang Z, Xu J</i><br /><b>Background</b><br />The anatomical substrate for idiopathic left ventricular tachycardia (ILVT) remains speculative. Purkinje networks surrounding false tendons (FTs) might be involved in the reentrant circuit of ILVT.<br /><b>Objectives</b><br />The objective was to evaluate the anatomical and electrophysiological features of false tendons FTs in relation to ILVT.<br /><b>Methods</b><br />Intracardiac echocardiography (ICE) was conducted on patients with ILVT. The relationship of the FTs with ILVT was determined using electro-anatomical mapping.<br /><b>Results</b><br />Electrophysiological evaluation and radiofrequency ablation were conducted in 23 consecutive patients with ILVT. FTs were identified in 19/23 cases (82.6%) with P1 potentials during VT recorded at the FT in fourteen of these patients (73.7%). Three FT types were identified. In type 1, the FT attached the septum to the base of the posteromedial papillary muscle (PPM) (4/19); type 2 FTs ran between the septum and the PPM apex (3/19), while in type 3, the connection occurred between the septum and apex (11/19) or between the septum and the LV free wall (1/19). The effective ILVT ablation sites were situated at the FT-PPM (3/19) and the FT-septum (16/19) attachment sites.<br /><b>Conclusions</b><br />This series demonstrates the association between Purkinje fibers and FTs during catheter ablation of ILVT and verifies that left ventricular FTs are an important substrate in this type of tachycardia. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print</small></div>
Ma W, Qiu J, Lu F, Michael Shehata MD, ... Wang Z, Xu J
J Cardiovasc Electrophysiol: 18 Jan 2023; epub ahead of print | PMID: 36651353
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<div><h4>Interhospital Variability in Utilization of Cardioversion for Atrial Fibrillation in the Emergency Department.</h4><i>Mazzella AJ, Hendrickson MJ, Glorioso TJ, Sherwood D, ... Rosman L, Gehi AK</i><br /><AbstractText>The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 18 Jan 2023; 191:101-109</small></div>
Mazzella AJ, Hendrickson MJ, Glorioso TJ, Sherwood D, ... Rosman L, Gehi AK
Am J Cardiol: 18 Jan 2023; 191:101-109 | PMID: 36669379
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<div><h4>Syncope in ICD recipients: a single centre experience.</h4><i>Khan P, Selvarajah K, Gohel S, Sidhu BS, ... Murgatroyd F, Scott PA</i><br /><b>Aims</b><br />There is little evidence of the impact of syncope in implantable cardioverter-defibrillator (ICD) patients in routine community hospital care. This single-centre retrospective study sought to evaluate the incidence and prognostic significance of syncope in consecutive ICD patients.<br /><b>Methods and results</b><br />Data were collected on consecutive patients undergoing first ICD implantation between January 2009 and December 2019. The primary endpoints were the first occurrence of all-cause syncope, all-cause mortality, and all-cause hospitalization. Multivariate Cox proportional hazard models were used to identify risk factors associated with syncope and to analyse the subsequent risk of mortality and hospitalization. 1003 patients (58% primary prevention) were included in the final analysis. During a mean follow-up of 1519 ± 1055 days, 106 (10.6%) experienced syncope, 304 died (30.3%), and 477 (47.5%) were hospitalized for any cause. In an analysis adjusted for baseline variables, the first occurrence of syncope was associated with a significantly increased risk of mortality (HR 2.82, P < 0.001) and the first occurrence of hospitalization (HR 2.46, P = 0.002).<br /><b>Conclusion</b><br />Syncope in ICD recipients is common and associated with a poor prognosis irrespective of baseline variables and ICD programming. The occurrence of syncope is associated with a significant increase in the risk of mortality and hospitalization.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 14 Jan 2023; epub ahead of print</small></div>
Khan P, Selvarajah K, Gohel S, Sidhu BS, ... Murgatroyd F, Scott PA
Europace: 14 Jan 2023; epub ahead of print | PMID: 36638366
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<div><h4>Unipolar voltage mapping in right ventricular cardiomyopathy: pitfalls, solutions and advantages.</h4><i>Hoogendoorn JC, Venlet J, de Riva M, Wijnmaalen AP, Piers SRD, Zeppenfeld K</i><br /><b>Aims</b><br />Endocardial unipolar and bipolar voltage mapping (UVM/BVM) of the right ventricle (RV) are used for transmural substrate delineation. However, far-field electrograms (EGMs) and EGM changes due to injury current may influence automatically generated UVM. Epicardial BVM is considered less accurate due to the impact of fat thickness (FT). Data on epicardial UVM are sparse. The aim of the study is two-fold: to assess the influence of the manually corrected window-of-interest on UVM and the potential role of epicardial UVM in RV cardiomyopathies.<br /><b>Methods and results</b><br />Consecutive patients who underwent endo-epicardial RV mapping with computed-tomography (CT) integration were included. Mapping points were superimposed on short-axis CT slices and correlated with local FT. All points were manually re-analysed and the window-of-interest was adjusted to correct for false high unipolar voltage (UV). For opposite endo-epicardial point-pairs, endo-epicardial bipolar voltage (BV) and UV were correlated for different FT categories. A total of 3791 point-pairs of 33 patients were analysed. In 69% of endocardial points and 63% of epicardial points, the window-of-interest needed to be adjusted due to the inclusion of far-field EGMs, injury current components, or RV-pacing artifacts. The Pearson correlation between corrected endo-epicardial BV and UV was lower for point-pairs with greater FT; however, this correlation was much stronger and less influenced by fat for UV.<br /><b>Conclusion</b><br />At the majority of mapping sites, the window-of-interest needs to be manually adjusted for correct UVM. Unadjusted UVM underestimates low UV regions. Unipolar voltage seems to be less influenced by epicardial fat, suggesting a promising role for UVM in epicardial substrate delineation.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 14 Jan 2023; epub ahead of print</small></div>
Hoogendoorn JC, Venlet J, de Riva M, Wijnmaalen AP, Piers SRD, Zeppenfeld K
Europace: 14 Jan 2023; epub ahead of print | PMID: 36639881
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<div><h4>Implementation of an Intravenous Sotalol Initiation Protocol: Implications for Feasibility, Safety, and Length of Stay.</h4><i>Liu AY, Charron J, Fugaro D, Spoolstra S, ... Knight BP, Verma N</i><br /><b>Introduction</b><br />Oral sotalol initiation requires a multiple-day, inpatient admission to monitor for QT prolongation during loading. A one-day intravenous (IV) sotalol loading protocol was approved by the FDA in March 2020, but limited data on clinical use and administration currently exists. This study describes implementation of an IV sotalol protocol within an integrated health system, provides initial efficacy and safety outcomes, and examines length of stay compared to oral sotalol initiation.<br /><b>Methods</b><br />IV sotalol was administered according to a pre-specified initiation protocol to adult patients with refractory atrial or ventricular arrhythmias. Baseline characteristics, safety and feasibility outcomes, and length of stay (LOS) were compared to patients receiving oral sotalol over a similar time period.<br /><b>Results</b><br />From January 2021 to June 2022, a total of 29 patients (average age 66.0 ± 8.6 years, 27.6% women) underwent IV sotalol load and 20 patients (average age 60.4 ± 13.9 years, 65.0% women) underwent oral sotalol load. The load was successfully completed in 22/29 (75.9%) patients receiving IV sotalol and 20/20 (100%) of patients receiving oral sotalol, although 7/20 of the oral sotalol patients (35.0%) required dose reduction. Adverse events interrupting IV sotalol infusion included bradycardia (7 patients, 24.1%) and QT prolongation (3 patients, 10.3%). No patients receiving IV or oral sotalol developed sustained ventricular arrhythmias prior to discharge. LOS for patients completing IV load was 2.6 days shorter (mean 1.0 vs 3.6, p < 0.001) compared to LOS with oral load.<br /><b>Conclusion</b><br />Intravenous sotalol loading has a safety profile that is similar to oral sotalol. It significantly shortens hospital LOS, potentially leading to large cost savings. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Liu AY, Charron J, Fugaro D, Spoolstra S, ... Knight BP, Verma N
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640424
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<div><h4>A Single-Lead ECG Algorithm to Differentiate Right from Left Manifest Accessory Pathways: A Reappraisal of the P-Delta Interval.</h4><i>Ali H, De Lucia C, Cristiano E, Lupo P, ... Francia P, Cappato R</i><br /><b>Background</b><br />Despite numerous ECG algorithms being developed to localize the site of manifest accessory pathways (AP), they often require stepwise multiple-lead analysis with variable accuracy, limitations, and reproducibility.<br /><b>Objectives</b><br />The study aimed to develop a single-lead ECG algorithm incorporating the P-Delta interval (PDI) as an adjunct criterion to discriminate between right and left manifest AP.<br /><b>Methods</b><br />Consecutive WPW patients undergoing electrophysiological study (EPS) were retrospectively recruited and split into a derivation and validation group (1:1 ratio). Sinus rhythm ECG analysis in lead V1 was performed by three independent investigators blinded to the EPS results. Conventional ECG parameters and PDI were assessed through the global cohort.<br /><b>Results</b><br />140 WPW patients were included (70 for each group). A score-based, single-lead ECG algorithm was developed through derivation analysis incorporating the PDI, R/S ratio, and QRS onset polarity in lead V1. The validation group analysis confirmed the proposed algorithm\'s high accuracy (95%), which was superior to the previous ones in predicting the AP side (P-values <0.05). A score of ≤+1 was 96.5% accurate in predicting right AP while a score of ≥+2 was 92.5% accurate in predicting left AP. The new algorithm maintained optimal performance in specific subgroups of the global cohort showing an accuracy rate of 90%, 92%, and 96% in minimal preexcitation, posteroseptal AP, and pediatric patients, respectively.<br /><b>Conclusions</b><br />A novel single-lead ECG algorithm incorporating the PDI interval with previous conventional criteria showed high accuracy in differentiating right from left manifest AP comprising pediatric and minimal preexcitation subgroups in the current study. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Ali H, De Lucia C, Cristiano E, Lupo P, ... Francia P, Cappato R
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640425
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<div><h4>Effect of Contact Force on Pulsed Field Ablation Lesions in Porcine Cardiac Tissue.</h4><i>Mattison L, Verma A, Tarakji KG, Reichlin T, ... Miklavčič D, Sigg DC</i><br /><b>Background</b><br />Contact force has been used to titrate lesion formation for radiofrequency ablation. Pulsed Field Ablation (PFA) is a field-based ablation technology for which limited evidence on the impact of contact force on lesion size is available.<br /><b>Methods</b><br />Porcine hearts (n=6) were perfused using a modified Langendorff set-up. A prototype focal PFA catheter attached to a force gauge was held perpendicular to the epicardium and lowered until contact was made. Contact force was recorded during each PFA delivery. Matured lesions were cross-sectioned, stained, and the lesion dimensions measured.<br /><b>Results</b><br />A total of 82 lesions were evaluated with contact forces between 1.3 g and 48.6 g. Mean lesion depth was 4.8 ± 0.9 mm (standard deviation), mean lesion width was 9.1 ± 1.3 mm and mean lesion volume was 217.0. ± 96.6 mm<sup>3</sup> . Linear regression curves showed an increase of only 0.01 mm in depth (Depth = 0.01*Contact Force + 4.41, R<sup>2</sup> = 0.05), 0.03 mm in width (Width = 0.03*Contact Force + 8.26, R<sup>2</sup> = 0.13) for each additional gram of contact force, and 2.20 mm<sup>3</sup> in volume (Volume = 2.20*Contact Force + 162, R<sup>2</sup> = 0.10).<br /><b>Conclusions</b><br />Increasing contact force using a bipolar, biphasic focal PFA system has minimal effects on acute lesion dimensions in an isolated porcine heart model and achieving tissue contact is more important than the force with which that contact is made. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Mattison L, Verma A, Tarakji KG, Reichlin T, ... Miklavčič D, Sigg DC
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640426
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<div><h4>Risk Factors Associated with Higher Mortality in Patients with Cardiac Implantable Electronic Device Infection.</h4><i>Kalot MA, Bahuva R, Pandey R, Farooq W, ... Amuthan R, Sharma UC</i><br /><b>Background</b><br />Cardiac Implantable Electronic Devices (CIEDs) are widely used for the management of advanced heart failure and ventricular arrhythmias. CIED-Infection (CIED-I) has very high mortality, especially in the subsets of patients with limited health-care access and delayed presentation. The purpose of this study is to identify the risk-predictors mortality in subjects with CIED-I.<br /><b>Methods</b><br />We performed a retrospective cohort study of a regional database in patients presenting with CIED infections to tertiary care medical centers across Western New York, USA from 2012 - 2020. The clinical outcomes included recurrent device infection (any admission for CIED-I after the first hospitalization for device infection), septic complications (pulmonary embolism, respiratory failure, septic shock, decompensated HF, acute kidney injury) and mortality outcomes (death during hospitalization, within 30 days from CIED-I, and within 1 year from CIED-I). We studied associations between categorical variables and hard outcomes using chi-square tests and used one-way analysis of variance to measure between-groups differences.<br /><b>Results</b><br />We identified 296 patients with CIED-I, among which 218 (74%) were male, 237 (80%) were white and the mean age at the time of infection was 69.2±13.7 years. One-third of the patients were referred from the regional facilities. Staphylococcus aureus was responsible for most infections, followed by Enterococcus fecalis. On multivariate analysis, the covariates associated with significantly increased mortality risk included referral from regional facility (OR: 2.0;1.0-4.0), hypertension (Odds ratio, OR: 3.2;1.3-8.8), right ventricular dysfunction (OR: 2.6;1.2-5.1), end-stage renal disease (OR: 2.6;1.1-6.2), immunosuppression (OR: 11.4;2.5-53.3), and septic shock as a complication of CIED-I (OR: 3.9;1.3-10.8).<br /><b>Conclusion</b><br />Hypertension, right ventricular dysfunction, immunosuppression, and end-stage renal disease are associated with higher mortality after CIED-I. Disproportionately higher mortality was also noted in subjects referred from the regional facilities. This underscores the importance of early clinical risk-assessment, and the need for a robust referral infrastructure to improve patient outcomes. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Kalot MA, Bahuva R, Pandey R, Farooq W, ... Amuthan R, Sharma UC
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640427
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<div><h4>Performance of an Implantable Cardioverter Defibrillator Lead Family.</h4><i>Klampfleitner S, Mundel M, Schinke K, Neuberger HR</i><br /><b>Background</b><br />Lead failure is the major limitation in implantable cardioverter-defibrillator (ICD) therapy. Long-term follow-up data for Biotronik Linox ICD leads are limited. Therefore, we analyzed the performance of all these leads implanted at our institution.<br /><b>Materials & methods</b><br />All Linox and Linox Smart ICD leads implanted between 2006 and 2015 were identified. Lead failure was defined as electrical dysfunction (oversensing, abnormal impedance, exit-block). Lead survival was described, according to Kaplan-Meier. Associations between lead failure and specific variables were examined. P-value <0.05 was considered significant.<br /><b>Results</b><br />We included 417 ICD leads. The median follow-up time for Linox (n=205) was 81 months and for Linox Smart (n=212) 75 months. During that follow-up time 30 Linox (14.6%) and 16 Linox Smart leads (7.6 %) showed a malfunction. The 5-year lead survival probability was 97.4% for Linox and 95.2% for Linox Smart (log-rank test, p=0.19). The 6- and 8-year lead survival probability for Linox was 93.6% and 84.6%, and for Linox Smart 93% and 91.9%. The only factor significantly associated with lead failure was younger patient age at implantation (HR/year: 0.97, 95% KI: 0.95-0.99, p=0.005).<br /><b>Conclusion</b><br />This relatively large study with a long follow-up period highlights a relevant failure rate of Biotronik Linox leads. The performance of Linox vs. Linox Smart ICD leads was comparable. Although we show an acceptable 5-year lead survival probability, we observed a marked drop after just one more year of follow-up. In an era of improving heart failure survival probability a prolonged follow-up of ICD leads is increasingly clinically relevant. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Klampfleitner S, Mundel M, Schinke K, Neuberger HR
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640428
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<div><h4>Clinical Outcome of Lesion Size Index-Guided High-Power Radiofrequency Catheter Ablation for Pulmonary Vein Isolation in Patients with Atrial Fibrillation: 2-Year Follow-Up.</h4><i>Cai C, Wang J, Niu HX, Chu JM, ... Zhang S, Yao Y</i><br /><b>Background</b><br />The long-term efficacy of high-power (50 W) ablation guided by lesion size index (LSI-guided HP) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) remains undetermined. Our study sought to assess the clinical efficacy of LSI-guided HP ablation for PVI in patients with AF and explore the potential predictors associated with clinical outcomes.<br /><b>Methods</b><br />We consecutively included 186 patients with AF who underwent LSI-guided HP (50 W) ablation at Fuwai Hospital from June 2019 to October 2021. The target LSI values of 4.5-5.5 and 4.0-4.5 at the anterior and posterior walls, respectively, were used in our study. The baseline clinical characteristics, procedural and ablation data, and clinical outcomes were evaluated. The independent potential predictors associated with AF recurrence were further evaluated.<br /><b>Results</b><br />The incidence rate of first-pass PVI was 83.9% (156/186). A total of 11883 lesions were analyzed, and compared with posterior walls of pulmonary veins, anterior walls had significantly lower mean contact force (8.2 ± 3.0 vs. 8.3 ± 2.3 g, P =0.015), longer mean radiofrequency duration (16.9 ± 7.2 vs. 12.9 ± 4.5 s, P <0.001) and higher mean LSI (4.8 ± 0.2 vs. 4.4 ± 0.2, P <0.001). The overall incidence of periprocedural complications was 3.7%, and steam pops without pericardial effusion occurred in three patients (1.6%). During a mean follow-up of 24.0 ± 8.4 months, the overall AF recurrence-free survival was 87.1% after a single procedure. Patients with paroxysmal AF had a higher incidence of freedom from AF recurrence than those with persistent AF (91.2% vs. 80.8%, log-rank P =0.034). Higher LSI (HR 0.50, P <0.001) and paroxysmal AF (HR0.39, P =0.029) were significantly associated with decreased AF recurrence. By receiver operating characteristic analysis, the LSI of 4.7 and 4.3 for the anterior and posterior walls of the PVs had the highest predictive value for AF recurrence, respectively.<br /><b>Conclusion</b><br />LSI-guided HP (50 W) ablation for PVI was an efficient and safe strategy and led to favorable single-procedure 2-year AF recurrence-free survival in patients with AF. Higher LSI and paroxysmal AF were independent predictors of decreased 2-year AF recurrence. The LSI of 4.7 for the anterior wall and 4.3 for the posterior wall of the PVs were the best cutoff values for predicting AF recurrence after LSI-guided HP ablation. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Cai C, Wang J, Niu HX, Chu JM, ... Zhang S, Yao Y
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640429
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<div><h4>Ripple mapping in ventricular tachycardia substrate mapping and ablation of nonischemic ventricular tachycardia.</h4><i>Gilge JL, Joshi SA, Nair GV, Clark BA, Prystowsky EN, Patel PJ</i><br /><b>Introduction</b><br />Substrate based ablation for ventricular tachycardia (VT) using ripple map (RM) is an effective treatment strategy for patients with ischemic cardiomyopathy but has yet to be evaluated in patients with nonischemic cardiomyopathy (NICMO). The aim of this study is to determine the feasibility and effectiveness of a RM based ablation for NICMO patients.<br /><b>Methods and results</b><br />This was a single center, retrospective study including all NICMO patients undergoing VT ablation at St Vincent Hospital between 1/1/2018 to 12/1/2019. Retrospective RM analysis was performed on those that had a substrate-based ablation to identify the location and number of ripple channels as well as their proximity to ablation lesions. Thirty-three patients met the inclusion criteria and had a median age of 65 (58, 73.5) with 15.2% of the population being female and were followed for a median duration of 451 (217.5, 586.5) days. Of these patients, 23 (69.7%) had a substrate-based ablation with a median procedural duration of 196.4 (186.8, 339) minutes, 1946 (517, 2750) point collected per map and 277 (141, 554) points were within scar. Two (8.6%) procedural complications occurred, and 7 (30.4%) patients had VT recurrence during follow-up. Ripple map analysis revealed an average of 2 ripple channels and the patients without VT recurrence had ablation performed closer to the ripple channels: 0 (0, 4.7) cm vs 14.3 (0, 23.5) cm; p = 0.02.<br /><b>Conclusion</b><br />A RM based substrate ablation can be performed in NICMO patients and ablation within ripple channels is a predictor of VT freedom. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Gilge JL, Joshi SA, Nair GV, Clark BA, Prystowsky EN, Patel PJ
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640431
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<div><h4>Correlation of spatial patterns of endocardial pace mapping to underlying scar topography in patients with scar-related ventricular tachycardia.</h4><i>Kotake Y, Bennett R, Silva K, Bhaskaran A, ... Kumar S, Campbell T</i><br /><b>Introduction</b><br />Endocardial pace-mapping (PM) can identify conducting channels for VT circuits in patients with structural heart disease (SHD). Recent findings show the temporal and spatial pattern of PM may aid identification of the surface harboring VT isthmii. The specific correlation of PM patterns to scar topography has not been examined.<br /><b>Objective</b><br />To correlate the pattern of endocardial PMs to underlying scar topography in SHD patients with VT.<br /><b>Methods</b><br />Data from patients undergoing VT ablation from August 2018 to February 2022 were reviewed.<br /><b>Results</b><br />Sixty-three patients with SHD-related VT (mean age 65±14 years) with 83 endocardial PM correlation maps were analysed. Two main correlation patterns were identified, an \"abrupt-change correlation pattern (AC-pattern)\" and \"centrifugal-attenuation correlation pattern (CA-pattern)\". AC-pattern had lower scar ratio (unipolar/bipolar % scar area; 1.1 vs 1.5, P<0.001), had longer maximal stimulus-QRS intervals (97.5ms vs 68ms, P=0.002), and higher likelihood of endocardial dominant scar (11/21 [52%] vs 3/38 [8%], P<0.001) than CA-pattern seen on intracardiac echocardiography (ICE). In contrast, CA-pattern was more likely to have epicardial dominant scar or mid-intramural scar on ICE (epicardial dominant scar; CA-pattern: 12/38 [32%] vs AC-pattern: 1/21 [5%], P=0.02, mid-intramural scar; CA-pattern: 15/38 [39%] vs AC-pattern: 1/21 [5%], P=0.005).<br /><b>Conclusions</b><br />The spatial pattern of endocardial PM in SHD-related VT directly correlates with scar topography. AC-pattern is associated with endocardial dominant scar on ICE with lower scar ratio and longer stimulus-QRS intervals, whereas CA-pattern is strongly associated with epicardial dominant or mid-intramural scar with higher scar ratio and shorter stimulus-QRS intervals. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Kotake Y, Bennett R, Silva K, Bhaskaran A, ... Kumar S, Campbell T
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640432
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<div><h4>Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes in patients with and without structural heart disease.</h4><i>Sessions AJ, May HT, Crandall BG, Day JD, ... Steinberg BA, Jared Bunch T</i><br /><b>Background</b><br />Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown.<br /><b>Methods</b><br />All patients that received a catheter ablation for AF(n=9,979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF≤35% (n=1024) and EF>35% (n=8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n=1747), 3:546-1825(n=2941), and 4:>1825(n=2602) days.<br /><b>Results</b><br />The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF >35%: 3.5±3.8 years, EF <35%: 3.4±3.8 years, p=0.66). In the EF >35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p<0.0001), 2.62(p<0.0001), and 4.39(p<0.0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:2-01-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24).<br /><b>Conclusion</b><br />Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Sessions AJ, May HT, Crandall BG, Day JD, ... Steinberg BA, Jared Bunch T
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640433
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<div><h4>Trends and Disparities in Ventricular Tachycardia Mortality in the United States.</h4><i>Ibrahim R, Sroubek J, Nakhla S, Lee JZ</i><br /><b>Introduction</b><br />We aimed to evaluate trends and disparities in mortality from ventricular tachycardia in patients with underlying cardiovascular disease.<br /><b>Methods and results</b><br />We performed cross-sectional analyses using publicly available data from the CDC Wide-Ranging Online Data for Epidemiologic Research database. We identified a total of 7,025 deaths from ventricular tachycardia between the years 2007 and 2020. Overall age-adjusted mortality rates increased from 0.22 in 1999 to 0.32 in 2020 [p <0.05]. Black female and male adults had higher age-adjusted mortality rates compared to White female and male adults, respectively [p <0.05]. Disproportionate age-adjusted mortality rates among male populations and Southern residents were also observed.<br /><b>Conclusion</b><br />This study demonstrated an increase in deaths related to ventricular tachycardia since 2007. Significant differences in mortality exist across racial, gender, and geographic subgroups. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Ibrahim R, Sroubek J, Nakhla S, Lee JZ
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640434
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<div><h4>Pulmonary Vein Isolation-induced Vagal Nerve Injury and Gastric Motility Disorders detected by Electrogastrography - The Side Effects of Pulmonary Vein Isolation in Atrial Fibrillation (SEPIA) Study: Discussion and Conclusion.</h4><i>Meininghaus DG, Freund R, Kleemann T, Christoph Geller J, Matthes H</i><br /><b>Background</b><br />Safety of pulmonary vein isolation (PVI) has been established in clinical studies. However, despite prevention efforts the incidence of damage to (peri)-esophageal tissue has not decreased, and the pathophysiology is incompletely understood.<br /><b>Objective</b><br />Damage to vagal nerve branches may be involved in lesion progression to atrio-esophageal fistula. Using electrogastrography, we assessed the incidence of periesophageal vagal nerve injury (VNI) following atrial fibrillation ablation and its association with procedural parameters and endoscopic results.<br /><b>Methods</b><br />Patients were studied using electrogastrography, endoscopy, and endoscopic ultrasound before and after cryoballoon (CB) or radiofrequency (RF) PVI. The incidence of ablation-induced neuropathic pattern (indicating VNI) in pre- and postprocedural electrogastrography was assessed and correlated with endoscopic results and ablation data.<br /><b>Results</b><br />Between February 2021 und January 2022, 85 patients (67±10 years, 53% male) were included, 33 were treated with CB and 52 with RF (38 with moderate power moderate duration [25-30W] and 14 with high power short duration [50W]). blation-induced VNI was detected in 27/85 patients independent of the energy form. Patients with VNI more frequently had postprocedural endoscopically detected pathology (8% mucosal esophageal lesions, 36% periesophageal edema, 33% food retention) but there was incomplete overlap. Preexisting esophagitis increased the likelihood of VNI. Ablation data and esophageal temperature data did not predict VNI. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Meininghaus DG, Freund R, Kleemann T, Christoph Geller J, Matthes H
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640436
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<div><h4>Assisted Reality Device to Guide Cardiac Implantable Device Programming in Distant Rural Areas.</h4><i>Diaz JC, Cañas F, Duque M, Aristizabal J, ... Martin DT, Romero J</i><br /><b>Background</b><br />Patients with cardiac implantable electronic devices (CIEDs) living in rural areas have difficulty obtaining follow-up visits for device interrogation and programming in specialized healthcare facilities.<br /><b>Objective</b><br />To describe the use of an assisted reality device designed to provide front-line workers with real-time online support from a remotely located specialist (Realwear HTM-1; Realwear, Vancouver, WA) during CIED assistance in distant rural areas.<br /><b>Methods</b><br />This is a prospective study of patients requiring CIED interrogation using the Realwear HMT-1 in a remote rural population in Colombia between April 2021 and June 2022. CIED interrogation and device programming were performed by a general practitioner and guided by a cardiac electrophysiologist. Non-CIED-related medical interventions were allowed and analyzed. The primary objective was to determine the incidence of clinically significant CIED alerts. Secondary objectives were the changes medical interventions used to treat the events found in the device interrogations regarding non-CIED related conditions.<br /><b>Results</b><br />A total of 205 CIED interrogations were performed on 139 patients (age 69±14 years; 54% female). Clinically significant CIED alerts were reported in 42% of CIED interrogations, consisting of the detection of significant arrhythmias (35%), lead malfunction (3%), and device in elective replacement interval (3.9%). OAC was initiated in 8% of patients and general medical/cardiac interventions unrelated to the CIED were performed in 52% of CIED encounters.<br /><b>Conclusion</b><br />Remote assistance using a commercially available assisted reality device has the potential to provide specialized health care to patients in difficult-to-reach areas, overcoming current difficulties associated with RM including the inability to change device programming. Additionally, these interactions provided care beyond CIED-related interventions, thus delivering significant social and clinical impact to remote rural populations. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print</small></div>
Diaz JC, Cañas F, Duque M, Aristizabal J, ... Martin DT, Romero J
J Cardiovasc Electrophysiol: 14 Jan 2023; epub ahead of print | PMID: 36640437
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<div><h4>Left atrial reservoir strain as a novel predictor of new-onset atrial fibrillation in light-chain-type cardiac amyloidosis.</h4><i>Choi YJ, Kim D, Rhee TM, Lee HJ, ... Choi JO, Kim HK</i><br /><b>Aims</b><br />To investigate whether left arterial reservoir strain (LASr) could predict new-onset atrial fibrillation (NOAF) in patients with light-chain-type cardiac amyloidosis (ALCA).<br /><b>Methods and results</b><br />This study enrolled 427 patients with CA from two tertiary centres between 2005 and 2019. LASr was measured using a vendor-independent analysis programme. The primary outcome was NOAF. A total of 287 patients with ALCA were included [median age 63.0 (56.0-70.0) years, 53.3% male]. The median LASr was 13.9% (10.5-20.8%). During the median follow-up of 0.85 years, AF occurred in 34 patients (11.8%). In the receiver operating characteristics curve analysis, the optimal cut-off of LASr for predicting NOAF was 14.4%. Patients with LASr ≤14.4% had a higher risk of NOAF than those with LASr >14.4% (18.1% vs. 5.1%, P < 0.010). In the multivariate analysis adjusting for confounding factors, including left arterial volume index and left ventricular global longitudinal strain (LV-GLS), higher LASr (%) was independently associated with lower risk for NOAF [adjusted hazard ratio (aHR): 0.936, 95% confidence interval (95% CI): 0.879-0.997, P = 0.039]. Furthermore, LASr ≤14.4% was an independent predictor for NOAF (aHR: 3.370, 95% CI: 1.337-8.492, P = 0.010). This remained true after accounting for all-cause death as a competing risk. Compared with Model 1 (LV-GLS) and Model 2 (LV-GLS plus LAVI), Model 3, including LASr showed a better reclassification ability for predicting NOAF (net reclassification index = 0.735, P < 0.001 compared with Model 1; net reclassification index = 0.514, P = 0.003 compared with Model 2).<br /><b>Conclusion</b><br />LASr was an independent predictor of NOAF in patients with ALCA.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 13 Jan 2023; epub ahead of print</small></div>
Choi YJ, Kim D, Rhee TM, Lee HJ, ... Choi JO, Kim HK
Eur Heart J Cardiovasc Imaging: 13 Jan 2023; epub ahead of print | PMID: 36637873
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<div><h4>Electrocardiographic findings in patients with arrhythmogenic cardiomyopathy and right bundle branch block ventricular tachycardia.</h4><i>Laredo M, Tovia-Brodie O, Milman A, Michowitz Y, ... Hauer R, Belhassen B</i><br /><b>Aims</b><br />Little is known about patients with right bundle branch block (RBBB)-ventricular tachycardia (VT) and arrhythmogenic cardiomyopathy (ACM). Our aims were: (i) to describe electrocardiogram (ECG) characteristics of sinus rhythm (SR) and VT; (ii) to correlate SR with RBBB-VT ECGs; and (iii) to compare VT ECGs with electro-anatomic mapping (EAM) data.<br /><b>Methods and results</b><br />From the European Survey on ACM, 70 patients with spontaneous RBBB-VT were included. Putative left ventricular (LV) sites of origin (SOOs) were estimated with a VT-axis-derived methodology and confirmed by EAM data when available.  Overall, 49 (70%) patients met definite Task Force Criteria. Low QRS voltage predominated in lateral leads (n = 37, 55%), but QRS fragmentation was more frequent in inferior leads (n = 15, 23%). T-wave inversion (TWI) was equally frequent in inferior (n = 28, 42%) and lateral (n = 27, 40%) leads. TWI in inferior leads was associated with reduced LV ejection fraction (LVEF; 46 ± 10 vs. 53 ± 8, P = 0.02). Regarding SOOs, the inferior wall harboured 31 (46%) SOOs, followed by the lateral wall (n = 17, 25%), the anterior wall (n = 15, 22%), and the septum (n = 4, 6%). EAM data were available for 16 patients and showed good concordance with the putative SOOs. In all patients with superior-axis RBBB-VT who underwent endo-epicardial VT activation mapping, VT originated from the LV.<br /><b>Conclusions</b><br />In patients with ACM and RBBB-VT, RBBB-VTs originated mainly from the inferior and lateral LV walls. SR depolarization and repolarization abnormalities were frequent and associated with underlying variants.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Laredo M, Tovia-Brodie O, Milman A, Michowitz Y, ... Hauer R, Belhassen B
Europace: 13 Jan 2023; epub ahead of print | PMID: 36635857
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<div><h4>Association of electrocardiographic spatial heterogeneity of repolarization and spatial heterogeneity of atrial depolarization with left ventricular fibrosis.</h4><i>Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, ... Huikuri HV, Perkiömäki JS</i><br /><b>Aims</b><br />To evaluate the relationship between spatial heterogeneity of electrocardiographic repolarization and spatial heterogeneity of atrial depolarization with arrhythmic substrate represented by left ventricular fibrosis.<br /><b>Methods and results</b><br />We assessed the associations of T- and P-wave morphology parameters analysed from the standard 12-lead electrocardiograms with left ventricular fibrosis in 378 victims of unexpected sudden cardiac death (SCD) who underwent medico-legal autopsy. Based on autopsy findings, the SCD victims were categorized into four different groups according to different stages of severity of left ventricular fibrosis (substantial fibrosis, moderate patchy fibrosis, scattered mild fibrosis, no fibrosis). T-wave and P-wave area dispersion (TWAd: 0.0841 ± 0.496, 0.170 ± 0.492, 0.302 ± 404, 0.296 ± 0.476, P = 0.008; PWAd: 0.574 ± 0.384, 0.561 ± 0.367, 0.654 ± 0.281, 0.717 ± 0.257, P = 0.011, respectively; low values abnormal), non-dipolar components of T-wave and P-wave morphology (T_NonDipolarABS: 0.0496 ± 0.0377, 0.0571 ± 0.0487, 0.0432 ± 0.0476, 0.0380 ± 0.0377, P = 0.027; P_NonDipolarABS: 0.0132 ± 0.0164, 0.0130 ± 0.0135, 0.0092 ± 0.0117, 0.0069 ± 0.00472, P = 0.005, respectively, high values abnormal), T-wave morphology dispersion (TMD: 45.9 ± 28.3, 40.5 ± 25.8, 35.5 ± 24.9, 33.0 ± 24.6, P = 0.030, respectively, high values abnormal), and P-wave heterogeneity (PWH: 20.0 ± 9.44, 19.7 ± 8.87, 17.9 ± 9.78, 15.4 ± 4.60, P = 0.019, respectively, high values abnormal) differed significantly between the groups with different stages of left ventricular fibrosis. After adjustment with heart weight, T_NonDipolarABS [standardized β (sβ) = 0.131, P = 0.014], PWAd (sβ = -0.161, P = 0.003), P_NonDipolarABS (sβ = 0.174, P = 0.001), and PWH (sβ = 0.128, P = 0.015) retained independent association, and TWAd (sβ = -0.091, P = 0.074) and TMD (sβ = 0.097, P = 0.063) tended to retain their association with the degree of myocardial fibrosis.<br /><b>Conclusion</b><br />Our findings suggest that abnormal values of T- and P-wave morphology are associated with arrhythmic substrate represented by ventricular fibrosis partly explaining the mechanism behind their prognostic significance.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, ... Huikuri HV, Perkiömäki JS
Europace: 13 Jan 2023; epub ahead of print | PMID: 36635858
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<div><h4>Anterior vs. posterior position of dispersive patch during radiofrequency catheter ablation: insights from in silico modelling.</h4><i>Irastorza RM, Maher T, Barkagan M, Liubasuskas R, Berjano E, d\'Avila A</i><br /><b>Aims</b><br />To test the hypothesis that the dispersive patch (DP) location does not significantly affect the current distribution around the catheter tip during radiofrequency catheter ablation (RFCA) but may affect lesions size through differences in impedance due to factors far from the catheter tip.<br /><b>Methods</b><br />An in silico model of RFCA in the posterior left atrium and anterior right ventricle was created using anatomic measurements from patient thoracic computed tomography scans and tested the effect of anterior vs. posterior DP locations on baseline impedance, myocardial power delivery, radiofrequency current path, and predicted lesion size.<br /><b>Results</b><br />For posterior left atrium ablation, the baseline impedance, total current delivered, current distribution, and proportion of power delivered to the myocardium were all similar with both anterior and posterior DP locations, resulting in similar RFCA lesion sizes (< 0.2 mm difference). For anterior right ventricular (RV) ablation, an anterior DP location resulted in slightly higher proportion of power delivered to the myocardium and lower baseline impedance leading to slightly larger RFCA lesions (0.6 mm deeper and 0.8 mm wider).<br /><b>Conclusions</b><br />An anterior vs. posterior DP location will not meaningfully affect RFCA for posterior left atrial ablation, and the slightly larger lesions predicted with anterior DP location for anterior RV ablation are of unclear clinical significance.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Irastorza RM, Maher T, Barkagan M, Liubasuskas R, Berjano E, d'Avila A
Europace: 13 Jan 2023; epub ahead of print | PMID: 36635956
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<div><h4>Reduction in long-term mortality using remote device monitoring in a large real-world population of patients with implantable defibrillators.</h4><i>Kolk MZH, Narayan SM, Clopton P, Wilde AAM, Knops RE, Tjong FVY</i><br /><b>Aims</b><br />Remote monitoring (RM) for implantable cardioverter-defibrillators (ICDs) is advocated for the potential of early detection of disease progression and device dysfunction. While studies have examined the effect of RM on clinical outcomes in carefully selected populations of heart failure patients implanted with ICDs from a single vendor, there is a paucity of data in real-world patients. We aimed to assess the long-term effect of RM in a representative ICD population using real-world data.<br /><b>Methods and results</b><br />This is an observational retrospective longitudinal study of 1004 patients implanted with an ICD or cardiac resynchronization therapy device (CRT-D) from all device vendors between 2010 and 2021. Patients started on RM (N = 403) within 90 days following de novo device implantation and yearly in-office visits were compared with patients with only bi-yearly in-office follow-up (non-RM, N = 601). In a propensity score matched cohort of 430 patients (mean age 61.4 ± 14.3 years, 26.7% female), all-cause mortality at 4-year was 12.6% in the RM and 27.7% in the non-RM group [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.32-0.82; P = 0.005]. No difference in inappropriate ICD-therapy (HR 1.90, 95% CI 0.86-4.21; P = 0.122) was observed. The risk of appropriate ICD-therapy (HR 1.71, 95% CI 1.07-2.74; P = 0.026) was higher in the RM group.<br /><b>Conclusion</b><br />Remote monitoring was associated with a reduction in long-term all-cause and cardiac mortality compared with traditional office visits in a real-world ICD population.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Kolk MZH, Narayan SM, Clopton P, Wilde AAM, Knops RE, Tjong FVY
Europace: 13 Jan 2023; epub ahead of print | PMID: 36636951
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<div><h4>Outcome and safety of intraoperative defibrillation testing during device replacement: the Simpler trial.</h4><i>Milman A, Nof E, Rav Acha M, Beinart R, ... Klempfner R, Glikson M</i><br /><b>Aims</b><br />Intraoperative defibrillation testing (DT) during implant or replacement of implantable cardioverter-defibrillators (ICDs) has been a matter of debate for many years. This debate was put to rest by the Simple and Nordic ICD trials, and the practice of testing during new implantations has essentially been almost abandoned. Old registries demonstrated an increased incidence of significant findings in DT during replacements. The aim of the present study was to evaluate frequency of significant findings and safety of DT in subjects undergoing device replacement.<br /><b>Methods and results</b><br />A prospective observational multi-centre study included consecutive patients undergoing ICD generator replacement. The primary outcome was a failure to terminate induced ventricular fibrillation (VF) with a single shock 10 J below the maximal capacity of the device. Secondary outcomes included complications of DT. Patients were followed-up at 1- and 6-months post-procedure.  A total of 92 patients were eligible, and consented to the study, of which 84 underwent DT during battery replacement. The median age was 68 years and 79.8% were males. Induction of VF was successful in 84 patients as was a successful conversion on the first attempt in all. There were no procedure-related complications. During follow up one patient had two appropriate ICD shock events. In four patients, ICD programming was changed. None suffered inappropriate shock. There was no evidence of lead malfunction. Two deaths occurred, none of which was related to arrhythmia.<br /><b>Conclusion</b><br />The present study found DT was not associated with complications in patients undergoing ICD generator replacement but produced no clinically important information.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
Milman A, Nof E, Rav Acha M, Beinart R, ... Klempfner R, Glikson M
Europace: 13 Jan 2023; epub ahead of print | PMID: 36636968
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<div><h4>Premature atrial contractions promote local directional heterogeneities in conduction velocity vectors.</h4><i>van Schie MS, Misier NLR, Razavi Ebrahimi P, Heida A, ... Taverne YJHJ, de Groot NMS</i><br /><b>Aims</b><br />Loss of cell-to-cell communication results in local conduction disorders and directional heterogeneity (LDH) in conduction velocity (CV) vectors, which may be unmasked by premature atrial contractions (PACs). We quantified LDH and examined differences between sinus rhythm (SR) and spontaneous PACs in patients with and without atrial fibrillation (AF).<br /><b>Methods and results</b><br />Intra-operative epicardial mapping of the right and left atrium (RA, LA), Bachmann\'s bundle (BB) and pulmonary vein area (PVA) was performed in 228 patients (54 with AF). Conduction velocity vectors were computed at each electrode using discrete velocity vectors. Directions and magnitudes of individual vectors were compared with surrounding vectors to identify LDH. Five hundred and three PACs [2 (1-3) per patient; prematurity index of 45 ± 12%] were included. During SR, most LDH were found at BB and LA [11.9 (8.3-14.9) % and 11.3 (8.0-15.2) %] and CV was lowest at BB [83.5 (72.4-94.3) cm/s, all P < 0.05]. Compared with SR, the largest increase in LDH during PAC was found at BB and PVA [+13.0 (7.7, 18.3) % and +12.5 (10.8, 14.2) %, P < 0.001]; CV decreased particularly at BB, PVA and LA [-10.0 (-13.2, -6.9) cm/s, -9.3 (-12.5, -6.2) cm/s and -9.1 (-11.7, -6.6) cm/s, P < 0.001]. Comparing patients with and without AF, more LDH were found during SR in AF patients at PVA and BB, although the increase in LDH during PACs was similar for all sites.<br /><b>Conclusion</b><br />Local directional heterogeneity is a novel methodology to quantify local heterogeneity in CV as a possible indicator of electropathology. Intra-operative high-resolution mapping indeed revealed that LDH increased during PACs particularly at BB and PVA. Also, patients with AF already have more LDH during SR, which becomes more pronounced during PACs.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Europace: 13 Jan 2023; epub ahead of print</small></div>
van Schie MS, Misier NLR, Razavi Ebrahimi P, Heida A, ... Taverne YJHJ, de Groot NMS
Europace: 13 Jan 2023; epub ahead of print | PMID: 36637110
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<div><h4>Impact of Residual Functional Mitral Regurgitation After Atrial Fibrillation Ablation on Clinical Outcomes in Patients With Left Ventricular Systolic Dysfunction.</h4><i>Okada M, Tanaka N, Onishi T, Tanaka K, ... Sakata Y, Inoue K</i><br /><AbstractText>Functional mitral regurgitation (FMR) negatively impacts the prognosis in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although structural reverse remodeling after AF ablation can reduce FMR severity, the prognostic impact of FMR and its evolution remain unclear. Of 491 patients with baseline LVEF <50% who underwent first-time AF ablation, 134 patients (27%) had grade 2 to 4 FMR at baseline. Among them, 88 patients (66%) exhibited FMR improvement to grade 0 to 1 FMR 6 months after AF ablation. Conversely, among 357 with baseline grade 0 to 1 FMR, 13 patients (3.6%) exhibited FMR worsening to grade 2 to 4 FMR despite AF ablation. Assessment with multidetector computed tomography revealed that an increase in the left atrial emptying fraction (odds ratio 3.55 per 10% increase; 95% confidence interval 2.12 to 5.95) and a reduction in the LV end-diastolic volume index (1.35 per 10-ml/m<sup>2</sup> decrease; 1.04 to 1.76) were identified as contributors to the FMR improvement. During a follow-up of 43 months, patients with postprocedural grade 2 to 4 FMR more frequently experienced hospitalizations for heart failure or cardiovascular death than those with grade 0 to 1 FMR (30.5% vs 4.6%, log-rank p <0.001). An age-adjusted multivariate Cox regression analysis including baseline and postprocedural FMR revealed that postprocedural grade 2 to 4 FMR (hazard ratio, 3.24; 95% confidence interval 1.43 to 7.35) was significantly associated with unfavorable events. In conclusion, AF ablation was modified and often improved FMR severity in patients with reduced LVEF. Residual grade 2 to 4 FMR 6 months after AF ablation was associated with a poor prognosis.</AbstractText><br /><br />Copyright © 2022 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 13 Jan 2023; 191:66-75</small></div>
Okada M, Tanaka N, Onishi T, Tanaka K, ... Sakata Y, Inoue K
Am J Cardiol: 13 Jan 2023; 191:66-75 | PMID: 36641982
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<div><h4>Evaluation of the Association Between Circulating IL-1β and Other Inflammatory Cytokines and Incident Atrial Fibrillation in a Cohort of Postmenopausal Women.</h4><i>Gomez SE, Parizo J, Ermakov S, Larson J, ... Stefanick M, Perez MV</i><br /><b>Background</b><br />Inflammatory cytokines play a role in atrial fibrillation (AF). Interleukin (IL)-1β, which is targeted in the treatment of ischemic heart disease, has not been well-studied in relation to AF.<br /><b>Methods</b><br />Postmenopausal women from the Women\'s Health Initiative were included. Cox proportional hazards regression models were used to evaluate the association between log-transformed baseline cytokine levels and future AF incidence. Models were adjusted for body mass index, age, race, education, hypertension, diabetes, hyperlipidemia, current smoking, and history of coronary heart disease, congestive heart failure, or peripheral artery disease.<br /><b>Results</b><br />Of 16,729 women, 3,943 developed AF over an average of 8.5 years. Racial and ethnic groups included White (77.4%), Black/African-American (16.1%), Asian (2.7%), American Indian/Alaska Native (1.0%), and Hispanic (5.5%). Baseline IL-1β log continuous levels were not significantly associated with incident AF (HR 0.86 per 1 log (pg/mL) increase, p=0.24), similar to those of other inflammatory cytokines, IL-7, IL-8, IL-10, IGF-1, and TNF-α. There were significant associations between C-reactive protein (CRP) and IL-6 with incident AF.<br /><b>Conclusions</b><br />In this large cohort of postmenopausal women, there was no significant association between IL-1β and incident AF, although downstream effectors, CRP and IL-6, were associated with incident AF.<br /><br />Copyright © 2023 Elsevier Ltd. All rights reserved.<br /><br /><small>Am Heart J: 13 Jan 2023; epub ahead of print</small></div>
Gomez SE, Parizo J, Ermakov S, Larson J, ... Stefanick M, Perez MV
Am Heart J: 13 Jan 2023; epub ahead of print | PMID: 36646198
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<div><h4>Incidence and Management of Atrio-Ventricular Conduction Disorders in New-Onset Left Bundle Branch Block After TAVI A Prospective Multicenter Study.</h4><i>Massoullié G, Ploux S, Souteyrand G, Mondoly P, ... Bordachar P, Eschalier R</i><br /><b>Background</b><br />New-onset left bundle branch block (LBBB) is one of the most frequent complications after transcatheter aortic valve implantation (TAVI) and is associated with delayed high degree atrio-ventricular block (AVB).<br /><b>Objective</b><br />The objective of this study was to determine the incidence of AVB in such a population and to assess the performance and safety of a risk stratification algorithm based on electrophysiological study (EPS) followed by implantation of pacemaker or implantable loop recorder (ILR).<br /><b>Methods</b><br />Prospective, open-label study with 12 months follow-up. From June 2015 to November 2018, 183 TAVI recipients (mean age 82.3±5.9 years) were included at 10 centers. New-onset LBBB after TAVI persisting for more than 24 hours was assessed by EPS during initial hospitalisation. High-risk patients (His-ventricle interval≥70 ms) were implanted with a dual-chamber pacemaker recording AV conduction disturbance episodes. Patients at lower risk were implanted with an ILR with automatic remote monitoring.<br /><b>Results</b><br />High-grade AV conduction disorder was identified in 56 subjects (30.6%) at 12 months. Four subjects were symptomatic, all in the ILR group. No complications were associated with the stratification procedure. Patients with His-ventricle interval ≥70 ms displayed more high-grade AV conduction disorders [53.2%(25/47) vs. 22.8%(31/136), p<0.001]. In a multivariate analysis, His-ventricle interval ≥70 ms was independently associated with the occurrence of a high-grade conduction disorder: subdistribution hazard ratio 2.4(95%CI 1.2-4.8), p=0.010.<br /><b>Conclusion</b><br />New-onset LBBB after TAVI were associated with high rates of high-grade AV conduction disturbances. The stratification algorithm provided safe and valuable aid to management decisions and reliable guidance on pacemaker implantation.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 13 Jan 2023; epub ahead of print</small></div>
Massoullié G, Ploux S, Souteyrand G, Mondoly P, ... Bordachar P, Eschalier R
Heart Rhythm: 13 Jan 2023; epub ahead of print | PMID: 36646235
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Abstract
<div><h4>Elevated Uric Acid Is Associated With New-Onset Atrial Fibrillation: Results From the Swedish AMORIS Cohort.</h4><i>Ding M, Viet NN, Gigante B, Lind V, Hammar N, Modig K</i><br /><AbstractText><br /><b>Background:</b><br/>The role of uric acid is gaining increasing importance in the evaluation of cardiovascular disease, but its relationship with atrial fibrillation (AF) is unclear. This study aims to investigate the association between uric acid levels and risk of new-onset AF. Methods and Results A total of 339 604 individuals 30 to 60 years of age and free from cardiovascular disease at baseline (1985-1996) in the Swedish AMORIS (Apolipoprotein-Mortality Risk) cohort were followed until December 31, 2019 for incident AF. Cox regression models were used to examine the association between uric acid and AF, adjusting for potential confounders and stratifying by incident cardiovascular disease. Over a mean follow-up of 25.9 years, 46 516 incident AF cases occurred. Compared with the lowest uric acid quartile, each of the upper 3 quartiles were associated with an increased risk of AF in a dose-response manner. Adjusted hazard ratios were 1.09 (95% CI, 1.06-1.12) for second quartile, 1.19 (95% CI, 1.16-1.23) for third quartile, and 1.45 (95% CI, 1.41-1.49) for fourth quartile. The association was similar among individuals with and without incident hypertension, diabetes, heart failure, or coronary heart disease. The dose-response pattern was further supported in a subsample of individuals with repeated measurements of uric acid. <br /><b>Conclusions:</b><br/>Elevated uric acid was associated with an increased risk of AF, not only among people with cardiovascular disease and cardiovascular risk factors but also among those without. Future investigations are needed to examine whether lowering uric acid is relevant for AF prevention.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 12 Jan 2023:e027089; epub ahead of print</small></div>
Ding M, Viet NN, Gigante B, Lind V, Hammar N, Modig K
J Am Heart Assoc: 12 Jan 2023:e027089; epub ahead of print | PMID: 36633024
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Abstract
<div><h4>Does Early Detection of Atrial Fibrillation Reduce the Risk of Thromboembolic Events? Rationale and Design of the Heartline Study.</h4><i>Gibson CM, Steinhubl S, Lakkireddy D, Turakhia MP, ... Spertus JA, Heartline Steering Committee</i><br /><b>Background</b><br />The impact of using direct-to-consumer wearable devices as a means to timely detect atrial fibrillation (AF) and to improve clinical outcomes is unknown.<br /><b>Methods</b><br />Heartline is a pragmatic, randomized, and decentralized application-based trial of US participants aged ≥65 years. Two randomized cohorts include adults with possession of an iPhone and without a history of AF and those with a diagnosis of AF taking a direct oral anticoagulant (DOAC) for ≥30 days. Participants within each cohort are randomized (3:1) to either a core digital engagement program (CDEP) via iPhone application (Heartline application) and an Apple Watch (Apple Watch Group) or CDEP alone (iPhone-only Group). The Apple Watch Group has the watch Irregular Rhythm Notification (IRN) feature enabled and access to the ECG application on the Apple Watch. If an IRN notification is issued for suspected AF then the study application instructs participants in the Apple Watch Group to seek medical care. All participants were \"watch-naïve\" at time of enrollment and have an option to either buy or loan an Apple Watch as part of this study. The primary endpoint is time from randomization to clinical diagnosis of AF, with confirmation by healthcare claims. Key secondary endpoints are claims-based incidence of a 6-component composite cardiovascular/systemic embolism/mortality event, direct oral anticoagulant medication use and adherence, costs/health resource utilization, and frequency of hospitalizations for bleeding. All study assessments, including patient-reported outcomes, are conducted through the study application. The target study enrollment is approximately 28,000 participants in total; at time of manuscript submission, a total of 26,485 participants have been enrolled into the study.<br /><b>Conclusion</b><br />The Heartline Study will assess if an Apple Watch with the IRN and ECG application, along with application-facilitated digital health engagement modules, improves time to AF diagnosis and cardiovascular outcomes in a real-world environment.<br /><b>Trial registration</b><br />ClinicalTrials.gov Identifier: NCT04276441.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Am Heart J: 12 Jan 2023; epub ahead of print</small></div>
Gibson CM, Steinhubl S, Lakkireddy D, Turakhia MP, ... Spertus JA, Heartline Steering Committee
Am Heart J: 12 Jan 2023; epub ahead of print | PMID: 36642226
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<div><h4>Anterior mitral line in patients with persistent AF and anterior scar: a multicenter matched comparison. The MiLine Study.</h4><i>Bergonti M, Spera FR, Ferrero TG, Nsahlai M, ... Rodríguez-Mañero M, Sarkozy A</i><br /><b>Background</b><br />The benefit of an anterior mitral line (AML) in patients with persistent atrial fibrillation (AF) and anterior atrial scar undergoing ablation has never been investigated.<br /><b>Objective</b><br />To evaluate the outcomes of AML on top of standard treatment, compared to standard treatment alone (no-AML), in this subset of patients.<br /><b>Methods</b><br />Patients with persistent AF and anterior low voltage zone (LVZ) treated with AML in three Centers were retrospectively enrolled. These patients were matched in a 1:1 fashion with patients with persistent AF and anterior LVZ, who underwent conventional ablation, in the same centers. Matching parameters were: age, LVZ burden, and repeated ablation. Primary endpoint was AF/atrial tachycardia (AT) recurrence.<br /><b>Results</b><br />186 patients (66±9 years, 34% women) were selected and included into two matched groups. Bidirectional conduction block was achieved in 95% of AML. After a median follow-up of 2 years, AF/AT recurrence occurred in 29% of the patients in the AML-group, vs. 48% in the No-AML-group (log-Rank p=0.024). At Cox-regression multivariate-analysis left atrial volume (HR 1.03, p=0.006) and AML (HR 0.46, p=0.003) were significantly associated with the primary endpoint. At univariate logistic-regression, lower BMI, older age, extensive anterior LVZ and the position of the left atrial activation breakthrough away from the AML, were associated with first-pass AML block.<br /><b>Conclusion</b><br />In this retrospective matched analysis of patients with persistent AF and anterior scar, AML on top of standard treatment was associated with improved AF/AT-free survival compared with matched patients treated with standard treatment alone.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 11 Jan 2023; epub ahead of print</small></div>
Bergonti M, Spera FR, Ferrero TG, Nsahlai M, ... Rodríguez-Mañero M, Sarkozy A
Heart Rhythm: 11 Jan 2023; epub ahead of print | PMID: 36640853
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Abstract
<div><h4>A systematic review of global autopsy rates in all-cause mortality and young sudden death.</h4><i>Paratz ED, Rowe SJ, Stub D, Pflaumer A, La Gerche A</i><br /><AbstractText>Autopsy is the gold-standard method for determining cause of death. Young sudden death (SD) is a prototype condition in which autopsy is universally recommended. The aim of this review was to quantify real-world global rates of autopsy in either all-cause death or young SD. A systematic review was conducted. Rates of autopsy in all-cause death and in young SD were determined in each country using scientific and commercial search engines. 59/195 countries (30.3%) reported autopsy rates in all-cause death, with rates varying from 0.01-83.9%. Almost all of these figures derived from academic publications rather than governmental statistics. Only 16/195 countries (8.2%) reported autopsy rates in the context of young SD, with reported rates ranging from 5-100%. The definition of \'young\' was heterogeneous. No governmental statistics reported autopsy rates in young SD. Risks of bias included inability to verify reported figures, heterogeneity in reporting of clinical vs medicolegal autopsies, and the small number of studies identified overall, resulting in the consistent exclusion of low and middle-income countries. In conclusion, most countries globally do not report autopsy rates in either all-cause death (69.7%) or in sudden death (92.8%). Without transparent reporting of autopsy rates, global burdens of disease and rates of sudden cardiac death cannot be reliably calculated.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Heart Rhythm: 11 Jan 2023; epub ahead of print</small></div>
Paratz ED, Rowe SJ, Stub D, Pflaumer A, La Gerche A
Heart Rhythm: 11 Jan 2023; epub ahead of print | PMID: 36640854
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<div><h4>Atrial Functional Tricuspid Regurgitation: Importance of Atrial Fibrillation and Right Atrial Remodeling and Prognostic Significance.</h4><i>Kwak S, Lim J, Yang S, Rhee TM, ... Cho GY, Park JB</i><br /><b>Background</b><br />Little is known about the determinants and outcomes of significant atrial functional tricuspid regurgitation (AFTR).<br /><b>Objectives</b><br />The authors aimed to identify risk factors for significant TR in relation to atrial fibrillation-flutter (AF-AFL) and assess its prognostic implications.<br /><b>Methods</b><br />The authors retrospectively studied patients with mild TR with follow-up echocardiography examinations. Significant TR was defined as greater than or equal to moderate TR. AFTR was defined as TR, attributed to right atrial (RA) remodeling or isolated tricuspid annular dilatation, without other primary or secondary etiology, except for AF-AFL. The Mantel-Byar test was used to compare clinical outcomes by progression of AFTR.<br /><b>Results</b><br />Of 833 patients with mild TR, 291 (34.9%) had AF-AFL. During the median 4.6 years, significant TR developed in 35 patients, including 33 AFTRs. Significant AFTR occurred in patients with AF-AFL more predominantly than in those patients without AF-AFL (10.3% vs 0.6%; P < 0.001). In Cox analysis, AF-AFL was a strong risk factor for AFTR (adjusted HR: 8.33 [95% CI: 2.34-29.69]; P = 0.001). Among patients with AF-AFL, those who developed significant AFTR had larger baseline RA areas (23.8 vs 19.4 cm<sup>2</sup>; P < 0.001) and RA area-to-right ventricle end-systolic area ratio (3.0 vs 2.3; P < 0.001) than those who did not. These parameters were independent predictors of AFTR progression. The 10-year major adverse cardiovascular event was significantly higher after progression of AFTR than before or without progression (79.8% vs 8.6%; Mantel-Byar P < 0.001).<br /><b>Conclusions</b><br />In patients with mild TR, significant AFTR developed predominantly in patients with AF-AFL, conferring poor prognosis. RA enlargement, especially with increased RA area-to-right ventricle end-systolic area ratio, was a strong risk factor for progression of AFTR.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Imaging: 11 Jan 2023; epub ahead of print</small></div>
Kwak S, Lim J, Yang S, Rhee TM, ... Cho GY, Park JB
JACC Cardiovasc Imaging: 11 Jan 2023; epub ahead of print | PMID: 36669928
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<div><h4>Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial.</h4><i>Kistler PM, Chieng D, Sugumar H, Ling LH, ... Sanders P, Kalman JM</i><br /><b>Importance</b><br />Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.<br /><b>Objective</b><br />To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.<br /><b>Design, setting, and participants</b><br />Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.<br /><b>Interventions</b><br />The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.<br /><b>Main outcomes and measures</b><br />Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.<br /><b>Results</b><br />Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.<br /><br /><b>Conclusions:</b><br/>and relevance</b><br />In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.<br /><b>Trial registration</b><br />anzctr.org.au Identifier: ACTRN12616001436460.<br /><br /><br /><br /><small>JAMA: 10 Jan 2023; 329:127-135</small></div>
Abstract
<div><h4>Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation.</h4><i>Simon TG, Schneeweiss S, Singer DE, Sreedhara SK, Lin KJ</i><br /><AbstractText><br /><b>Background:</b><br/>Many patients with cirrhosis have concurrent nonvalvular atrial fibrillation (NVAF). Data are lacking regarding recent oral anticoagulant (OAC) usage trends among US patients with cirrhosis and NVAF. Methods and Results Using MarketScan claims data (2012-2019), we identified patients with cirrhosis and NVAF eligible for OACs (CHA<sub>2</sub>DS<sub>2</sub>-VASc score ≥2 [men] or ≥3 [women]). We calculated the yearly proportion of patients prescribed a direct OAC (DOAC), warfarin, or no OAC. We stratified by high-risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end-stage renal disease). Among 32 487 patients (mean age=71.6 years, 38.5% women, 15.1% with decompensated cirrhosis, mean CHA<sub>2</sub>DS<sub>2</sub>-VASc=4.2), 44.6% used OACs within 180 days of NVAF diagnosis, including DOACs (20.2%) or warfarin (24.4%). Compared with OAC nonusers, OAC users were less likely to have decompensated cirrhosis (18.6% versus 10.7%), thrombocytopenia (19.5% versus 12.5%), or chronic kidney disease/end-stage renal disease (15.5% versus 14.0%). Between 2012 and 2019, warfarin use decreased by 21.0% (32.0% to 11.0%), whereas DOAC use increased by 30.6% (7.4% to 38.0%), and among all DOACs between 2012 and 2019, apixaban was the most commonly prescribed (46.1%). Warfarin use decreased and DOAC use increased in all subgroups, including in compensated and decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease/end-stage renal disease, and across CHA<sub>2</sub>DS<sub>2</sub>-VASc categories. Among OAC users (2012-2019), DOAC use increased by 58.9% (18.7% to 77.6%). Among DOAC users, the greatest proportional increase was with apixaban (61.2%; <i>P</i><0.001). <br /><b>Conclusions:</b><br/>Among US patients with cirrhosis and NVAF, DOAC use has increased substantially and surpassed warfarin, including in decompensated cirrhosis. Nevertheless, >55% of patients remain untreated, underscoring the need for clearer treatment guidance.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 10 Jan 2023:e026863; epub ahead of print</small></div>
Simon TG, Schneeweiss S, Singer DE, Sreedhara SK, Lin KJ
J Am Heart Assoc: 10 Jan 2023:e026863; epub ahead of print | PMID: 36625307
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