Journal: Circ Arrhythm Electrophysiol

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Abstract

Impact of Bariatric Surgery on Atrial Fibrillation Type.

Donnellan E, Wazni O, Elshazly M, Kanj M, ... Jaber W, Saliba W

- Obesity is an independent risk factor for atrial fibrillation (AF) and is associated with a higher AF burden. Recently, weight loss has been found to be associated with a significant reversal in AF type. Bariatric surgery (BS) is associated with reductions in inflammation, left atrial and ventricular remodeling, sleep apnea, blood pressure and improved glycemic control, all of which may reduce AF burden. In this study we sought to determine the impact of BS on AF type.- We studied AF type prior to and following BS in 220 morbidly obese patients (BMI Ȧ5; 40 kg/m). All patients underwent extended outpatient cardiac rhythm monitoring within 12 months of BS and at least 1 year after BS.- There was a significant reduction in BMI following BS from 49.7±9 to 37.2±9 kg/m. Weight loss was greatest in the gastric bypass group with a mean % weight loss of 25% compared to 19% in patients who underwent sleeve gastrectomy and 16% following gastric banding (p<0.0001). Significant reductions in CRP, NT-proBNP, HbA1C and systolic blood pressure were observed in all 3 groups. Reversal of AF type occurred in 71% of patients following gastric bypass, 56% of patients who underwent sleeve gastrectomy and 50% of patients following gastric banding (p=0.004). On Cox proportional hazards analyses, % weight loss was significantly associated with AF reversal (p=0.0002).- Bariatric surgery is associated with significant reductions in weight, inflammatory markers, blood pressure and AF type and the beneficial effects appear to be greatest in those undergoing gastric bypass surgery. This study further exemplifies the importance of weight loss and risk factor modification in AF management.



Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print
Donnellan E, Wazni O, Elshazly M, Kanj M, ... Jaber W, Saliba W
Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print | PMID: 31940441
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Abstract

Protein Biomarkers and Risk of Atrial Fibrillation: The Framingham Heart Study.

Staerk L, Preis SR, Lin H, Lubitz SA, ... Benjamin EJ, Trinquart L

- Identification of protein biomarkers associated with incident atrial fibrillation (AF) may improve the understanding of the pathophysiology, risk prediction, and development of new therapeutics for AF. We examined the associations between 85 protein biomarkers and incident AF.- We included participants Ȧ5;50 years of age from the Framingham Heart Study Offspring and Third Generation cohorts, who had 85 fasting plasma proteins measured using Luminex xMAP platform. Hazard ratios (per 1 standard deviation increment of rank normalized biomarker [HR]) and 95% confidence intervals (CI) for incident AF were calculated using Cox regression models adjusted for age, sex, height, weight, current smoking, systolic blood pressure, diastolic blood pressure, hypertension treatment, diabetes, valvular heart disease, prevalent myocardial infarction, and prevalent heart failure. We used the False Discovery Rate to account for multiple testing.- The study sample comprised 3378 participants (54% women), with mean (SD) age of 61.5 (8.4) years. In total, 401 developed AF over a mean follow-up of 12.3±3.8 years. We observed lower hazard of incident AF associated with higher mean levels of insulin-like growth factor 1 (IGF1) (HR per 1 standard deviation increment in protein level = 0.84; 95% CI, 0.76-0.93), and higher hazard of incident AF associated with higher mean levels of both insulin-like growth factor-binding protein 1 (IGFBP1) (HR = 1.24; 95% CI, 1.1-1.39) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) (HR = 1.73; 95% CI, 1.52-1.96).- Decreased levels of IGF1 and increased levels of IGFBP1 and NT-proBNP were associated with higher risk of incident AF.



Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print
Staerk L, Preis SR, Lin H, Lubitz SA, ... Benjamin EJ, Trinquart L
Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print | PMID: 31941368
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Abstract

Physiological Left Bundle Branch Pacing Validated by Ultra-high Density Ventricular Mapping in a Swine Model.

Qian Z, Hou X, Wang Y, Jiang H, ... Wang B, Zou J

Left bundle branch (LBB) pacing was first reported by Huang et al in 2017 and following studies demonstrated that LBB pacing could provide favorable left ventricular (LV) electrical and mechanical synchrony. However, the mechanism of LV activation during LBB pacing is not fully understood. This study aimed to elucidate the detailed LV endocardial activation during LBB pacing in a swine model using an ultra-high density electroanatomic mapping system.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Qian Z, Hou X, Wang Y, Jiang H, ... Wang B, Zou J
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31935122
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Abstract

Association of Left Atrial High-Resolution Late Gadolinium Enhancement on Cardiac Magnetic Resonance with Electrogram Abnormalities Beyond Voltage in Patients with Atrial Fibrillation.

Kuo L, Zado E, Frankel D, Santangeli P, ... Nazarian S, Desjardins B

- Conflicting data have been reported on the association of left atrial (LA) late gadolinium enhancement (LGE) with atrial voltage in patients with atrial fibrillation. The association of LGE with electrogram (EGM) fractionation and delay remains to be examined. We sought to examine the association between LA LGE on cardiac magnetic resonance (CMR) and EGM abnormalities in patients with atrial fibrillation (AF).- High-resolution LGE CMR was performed prior to EGM mapping and ablation in AF patients. CMR features were quantified using LA myocardial signal intensity z-score (SI-Z), a continuous normalized variable, as well as a dichotomous LGE variable based upon previously validated methodology. EGM mapping was performed pre-ablation during sinus rhythm or LA pacing, and EGM locations were co-registered with CMR images. Analyses were performed using multi-level patient-clustered mixed effects regression models.- In the 40 AF patients (age 63.2 ± 9.2 years, 1312.3 ± 767.3 EGM points per patient), lower bipolar voltage was associated with higher SI-Z in patients who had undergone previous ablation (coefficient=-0.049, p<0.001), but not in ablation-naïve patients (coefficient=-0.004, p=0.7). LA EGM activation delay was associated with SI-Z in patients with previous ablation (SI-Z: coefficient=0.004, p<0.001; LGE: coefficient=0.04, p<0.001) but not in ablation-naïve patients. In contrast, increased LA EGM fractionation was associated with SI-Z (coefficient=0.012, p=0.03) and LGE (coefficient=0.035, P<0.001) only in ablation-naïve patients.- The association of LA LGE with voltage is modified by ablation. Importantly, in ablation naïve patients, atrial LGE is associated with EGM fractionation even in the absence of voltage abnormalities.



Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print
Kuo L, Zado E, Frankel D, Santangeli P, ... Nazarian S, Desjardins B
Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print | PMID: 31940244
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Abstract

Evaluation of ECG Imaging to Map Haemodynamically Stable and Unstable Ventricular Arrhythmias.

Graham AJ, Orini M, Zacur E, Dhillon G, ... Schilling RJ, Lambiase PD

- ECG Imaging (ECGI) has been used to guide treatment of ventricular ectopy and arrhythmias. However, the accuracy of ECGI in localizing the origin of arrhythmias during catheter ablation of ventricular tachycardia (VT) in structurally abnormal hearts remains to be fully validated.- During catheter ablation of VT, simultaneous mapping was performed using electro-anatomical mapping (EAM) (CARTO, Biosense-Webster) and ECGI (CardioInsight™, Medtronic) in 18 patients. Sites of entrainment, pace-mapping and termination during ablation were used to define the VT site of origin (SoO). Distance between SoO and the site of earliest activation on ECGI were measured using co-registered geometries from both systems. The accuracy of ECGI vs a 12-lead surface ECG algorithm was compared.- A total of 29 VTs were available for comparison. Distance between SoO and sites of earliest activation in ECGI was 22.6, 13.9-36.2 mm (median, first-third quartile). ECGI mapped VT sites of origin onto the correct AHA segment with higher accuracy than a validated 12-lead ECG algorithm (83.3% vs 38.9%, P=0.015).- This simultaneous assessment demonstrates that CardioInsight™ localizes VT circuits with sufficient accuracy to provide a region of interest for targeting mapping for ablation. Resolution is not sufficient to guide discrete radiofrequency lesion delivery via catheter ablation without concomitant use of an electro-anatomical mapping system, but may be sufficient for segmental ablation with radiotherapy.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Graham AJ, Orini M, Zacur E, Dhillon G, ... Schilling RJ, Lambiase PD
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31934784
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Abstract

Epicardial Connections Involving Pulmonary Veins: The Prevalence, Predic-tors and Implications for Ablation Outcome.

Barrio-López MT, Sanchez-Quintana D, Garcia Martinez J, Betancur A, ... Garcia F, Almendral J

- The presence of epicardial connections (ECs) between pulmonary veins (PVs) and other anatomical structures may hinder PV isolation. In this study we analyzed their prevalence, location, associated factors and clinical implications.- Five hundred and thirty-four consecutive patients with atrial fibrillation (AF) undergoing radiofrequency ablation were included. We considered that an EC was present if: 1) the first pass around the PV antrum did not produce PV isolation and 2) subsequent atrial activation during PV pacing showed that the earliest site was located away from the ablation line and later activation sites were observed near the ablation line. Clinical, and electrophysological variables were collected from all patients. Patients were followed during 12.9±9.4 months and any documented atrial tachyarrhythmia after the 3-month blanking period was classified as a recurrence.- Out of the 534 patients included, 72 (13.5%) were found to have 81 ECs. There was a significant association between the presence ECs and structural heart disease (SHD) (15.3% in patients without ECs vs. 36.5% in patient with ECs; p<0.001) and patent foramen ovale (PFO) (4.6% vs. 13.5%; p=0.002). The presence of a left common trunk was significantly associated with the absence of ECs (29.6% in patients without ECs vs 16.2% in patients with ECs; p=0.014). Patients with ECs had lower acute success in PV isolation compared with patients without ECs (99.1% vs. 86.1%; p<0.001). After adjusting for age, sex, type of AF, LA area, hypertension, SHD, presence of left common trunk, patent foramen ovale and time for AF diagnosis to the ablation we found a significantly higher risk of atrial tachyarrhythmia recurrences in patients with ECs compared with patients without ECs (hazard ratio: 1.7; 95% confidence inter-val: 1.1-2.9; p=0.04).- ECs between PVs and other adjacent structures are frequent in patient with AF (prevalence: 13.5%). SHD and a PFO are strongly associated with the presence of ECs. ECs reduce the acute and chronic success of PV isolation.



Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print
Barrio-López MT, Sanchez-Quintana D, Garcia Martinez J, Betancur A, ... Garcia F, Almendral J
Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print | PMID: 31940223
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Abstract

Differences by Race/Ethnicity in the Prevalence of Clinically-detected and Monitor-detected Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis.

Heckbert SR, Austin TR, Jensen PN, Chen LY, ... Kronmal RA, Psaty BM

- African Americans are consistently found to have a lower prevalence of clinically-detected atrial fibrillation (AF) than whites, despite a higher prevalence of major AF risk factors and higher risk of ischemic stroke. Long-term ambulatory electrocardiographic (ECG) monitors provide the opportunity for unbiased AF detection. We determined differences by race/ethnicity in the prevalence of clinically-detected AF and in the proportion with monitor-detected AF.- We conducted a cross-sectional analysis in the Multi-Ethnic Study of Atherosclerosis (MESA), a community-based cohort study that enrolled 6814 Americans free of clinically-recognized cardiovascular disease in 2000-2002. At the 2016-2018 examination, 1556 individuals participated in an ancillary study involving ambulatory ECG monitoring and had follow-up for clinically-detected AF since cohort entry.- Among 1556 participants, 41% were white, 25% African American, 21% Hispanic, and 14% Chinese; 51% were women; and the mean age was 74 years. The prevalence of clinically-detected AF after 14.4 years\' follow-up was 11.3% in whites, 6.6% in African Americans, 7.8% in Hispanics, and 9.9% in Chinese, and was significantly lower in African Americans than in whites, in both unadjusted and risk factor-adjusted analyses (adjusted rate difference, -6.6%, 95% CI -10.1, -3.1%, P < 0.001). By contrast, in the same individuals, the proportion with monitor-detected AF using a 14-day ambulatory ECG monitor was similar in the four race/ethnic groups: 7.1%, 6.4%, 6.9%, and 5.2%, respectively (compared with whites, all P > 0.5).- The prevalence of clinically-detected AF was substantially lower in African American than in white participants, without or with adjustment for AF risk factors. However, unbiased AF detection by ambulatory monitoring in the same individuals revealed little difference in the proportion with AF by race/ethnicity. These findings provide support for the hypothesis of differential detection by race/ethnicity in the clinical recognition of AF, which may have important implications for stroke prevention.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Heckbert SR, Austin TR, Jensen PN, Chen LY, ... Kronmal RA, Psaty BM
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31934795
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Abstract

Mechanism of Recurrence of AT: Comparison between First Vs. Redo Procedures in a High-resolution Mapping System.

Takigawa M, Derval N, Martin CA, Vlachos K, ... Haïssaguerre M, Jaïs P

- Atrial fibrillation (AF) ablation related atrial tachycardia (AFA-rAT) is complex, and may demonstrate several forms: anatomical macroreenrant AT (AMAT), Non-AMAT, and focal AT. We aimed to elucidate the recurrence rate and mechanisms of AFA-rAT recurrence.- Among 147 patients with ATs treated with the Rhythmia™-system, 68 (46.3%) had recurrence at mean 4.2[2.9-11.6] months and 44 patients received a redo procedure. AT circuits in the first procedure were compared to those in the redo procedure.- Although mappable ATs were not observed in 7 patients, 68 ATs were observed in 37 patients during the first procedure: peri-mitral flutter (PMF) in 26 patients, roof-dependent macroreentrant-AT (RMAT) in 18, peri-tricuspid flutter (PTF) in 10, Non-AMAT in 14, and focal AT in 3. During the redo AT ablation procedure, 54 ATs were observed in 41 patients: PMF in 24, RMAT in 14, PTF in 1, Non-AMAT in 14, and focal AT in 1. Recurrence of PMF and RMAT was observed in 15/26 (57.7%) and 8/18 (44.4%) respectively, while PTF did not recur. Neither the same focal AT nor the same Non-AMAT were observed except in one case with septal scar related biatrial-AT. Epicardial structure-related ATs were involved in 18/24 (75.0%) in PMF, 4/14 (28.6%) in RMAT, and 4/14 (28.6%) in Non-AMAT. Out of 21 patients with a circuit including epicardial structures, 6 patients treated with ethanol-infusion in the vein of Marshall (VOM) did not show any AT-recurrence, though 8/15 (53.3%) treated with RF showed AT-recurrence (P=0.04).- Although high-resolution mapping may lead to correct diagnosis and appropriate ablation in the first procedure, the recurrence rate is still high. The main mechanism of AFA-rAT is the recurrence of PMF and RMAT, or Non-AMAT different from the first procedure. Epicardial structures (e.g. coronary sinus/VOM system) are often involved, and ethanol-infusion in the VOM may be an additional treatment.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Takigawa M, Derval N, Martin CA, Vlachos K, ... Haïssaguerre M, Jaïs P
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31937120
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Abstract

Importance of Diastolic Function for the Prediction of Arrhythmic Death: A Prospective, Observer Blinded, Long-term Study.

Pezawas T, Burger AL, Binder T, Diedrich A

- Patients with ischemic or dilated cardiomyopathy and reduced left ventricular ejection fraction (LVEF) face a high risk for ventricular arrhythmias. Exact grading of diastolic function might improve risk stratification for arrhythmic death.- We prospectively enrolled 120 patients with ischemic, 60 patients with dilated cardiomyopathy and 30 patients with normal LVEF. Diastolic function was graded normal (N) or dysfunction grade I-III. Primary outcome parameter was arrhythmic death (AD) or resuscitated cardiac arrest (RCA).- Normal diastolic function was found in 23 (11%) patients, dysfunction grade I in 107 (51%), grade II in 31 (14.8%) and grade III in 49 (23.3%) patients, respectively. After an average follow-up of 7.0±2.6 years, AD or RCA was observed in 28 (13.3%) and 33 (15.7%) patients, respectively. Non-arrhythmic death was found in 41 (19.5%) patients. On Kaplan-Meier analysis, patients with dysfunction grade III had the highest risk for AD or RCA (p<0.001). This finding was independent from the degree of LVEF dysfunction and was observed in patients with LVEFȦ4;35% (p=0.001) and with LVEF>35% (p=0.014). Non-arrhythmic mortality was highest in patients with dysfunction grade III. This was true for patients with LVEFȦ4;35% (p=0.009) or >35% (p<0.001). In an adjusted model for relevant confounding factors, grade III dysfunction was associated with a 3.5-fold increased risk for AD or RCA in the overall study population (HR=3.52, p<0.001).- Diastolic dysfunction is associated with a high risk for AD or RCA regardless if LVEF is Ȧ4;35% or >35%. Diastolic function grading might improve risk stratification for AD.



Circ Arrhythm Electrophysiol: 15 Jan 2020; epub ahead of print
Pezawas T, Burger AL, Binder T, Diedrich A
Circ Arrhythm Electrophysiol: 15 Jan 2020; epub ahead of print | PMID: 31944144
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Abstract

Differentiating Atrioventricular Reentry Tachycardia and AV Node Reentry Tachycardia Using Premature His Bundle Complexes.

Padanilam BJ, Ahmed AS, Clark BA, Gilge JL, ... Prystowsky EN, Steinberg LA

- Current maneuvers for differentiation of AV node reentry tachycardia (AVNRT) and atrioventricular reentry tachycardia (AVRT) lack sensitivity and specificity for AVRT circuits located away from the site of pacing. We hypothesized that a premature His complex (PHC) will always perturb AVRT because the His bundle is obligatory to the circuit. Further, AVNRT could not be perturbed by a late PHC (Ȧ4; 20 ms ahead of the His) due to the retrograde His conduction time. Earlier PHCs can advance the AVNRT circuit but only by a quantity less than the prematurity of the PHC.- High output pacing at the distal His location delivered PHCs. AVRT was predicted when late PHCs perturbed tachycardia or when earlier PHCs led to atrial advancement by an amount equal or greater than the degree of PHC prematurity.- Among the 73 SVTs, the test accurately predicted AVRT (n=29) and AVNRT (n=44) in all cases. Late PHC advanced the circuit in all 29 AVRTs and none of the AVNRTs (sensitivity and specificity 100%). With earlier PHCs, the degree of atrial advancement was equal or greater than the PHC prematurity in 26/29 AVRTs and none of the AVNRTs (90% sensitivity and 100% specificity). The mean prematurity of the PHC required to perturb AVNRT was 48 ms (range 28-70 ms) and the advancement less than the prematurity of the PHC (mean 32 ms; range 18-54 ms).- The responses to PHCs distinguished AVRT and AVNRT with 100% specificity and sensitivity.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Padanilam BJ, Ahmed AS, Clark BA, Gilge JL, ... Prystowsky EN, Steinberg LA
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31934781
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Abstract

Higher Incidence of Asymptomatic Cerebral Emboli after Atrial Fibrillation Ablation Found with High-resolution Diffusion-weighted MRI.

Yu Y, Wang X, Li X, Zhou X, ... Yang B, Chen M

- Asymptomatic cerebral emboli (ACE) are commonly seen on cerebral MRI after atrial fibrillation (AF) ablation, but the incidence in previous studies varies widely. No data exists to compare the effects of different diffusion-weighted imaging (DWI) settings on detecting ablation-related ACE. This self-control study sought to compare the incidence and characteristics of ablation-related ACE between high-resolution DWI (hDWI) and conventional DWI (cDWI).- A total of 55 consecutive patients referred for AF ablation between December 2017 and September 2018 were enrolled. Patients underwent hDWI one day prior to ablation and repeated hDWI and cDWI within 48 hours post-ablation. The incidence, number, size, and location of ACE were compared between two DWI settings in the same patients.The hDWI revealed a higher incidence of acute ACE compared to cDWI (67.3% vs. 41.8% of patients, P <0.001) and significantly more ACE (106 vs. 45 lesions, P = 0.001). For ACE seen on both scans, the size measured by hDWI was larger (5.42 vs. 4.21 mm, P <0.001). No patients had any impaired neurocognitive performance during follow-up. Impaired left ventricular ejection fraction (LVEF) (P = 0.012) and low intraoperative activated clotting time (ACT) (P = 0.009) level were associated with the occurrence of ACE in a multivariate analysis.- High-resolution DWI revealed a higher incidence and greater details of post-ablation ACE in AF patients. MRI settings significantly impact the detection of ACE and should be considered when comparing incidence rates of ACE amongst different studies.- ClinicalTrials.gov; Unique Identifier: NCT01761188.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Yu Y, Wang X, Li X, Zhou X, ... Yang B, Chen M
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31937118
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Abstract

Can the Durability of Pulmonary Vein Isolation be Predicted by the Time-to-Isolation in Second-generation Cryoballoon Ablation? Insight from the Results of Repeat Procedures.

Miyazaki S, Kajiyama T, Watanabe T, Nakamura H, ... Tada H, Iesaka Y

Second-generation cryoballoons (2-CBs) are widely used in atrial fibrillation (AF) ablation, however, the optimal freeze dose is still under debate. Recently, the time-to-isolation (TTI), which is the time until an acute pulmonary vein isolation (PVI), is noted based on clinical and experimental studies, and a TTI-guided strategy has been proposed. However, in real-world human CB procedures, the direct association between the TTI and PVI durability has not been well examined. We sought to investigate whether the TTI plus >120 second freezes, when the TTI is <60 seconds, accurately predicts a durable 2-CB ablation PVI.



Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print
Miyazaki S, Kajiyama T, Watanabe T, Nakamura H, ... Tada H, Iesaka Y
Circ Arrhythm Electrophysiol: 13 Jan 2020; epub ahead of print | PMID: 31935121
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Abstract

Major Adverse Cardiovascular Events Associated with Post-Operative Atrial Fibrillation after Non-Cardiac Surgery: A Systematic Review and Meta-analysis.

AlTurki A, Marafi M, Proietti R, Cardinale D, ... Healey JS, Huynh T

- Post-operative atrial fibrillation (POAF) is a frequent occurrence after non-cardiac surgery. It remains unclear whether POAF is associated with an increased risk of major adverse events. We aimed to elucidate the risk of stroke, myocardial infarction and death associated with POAF following non-cardiac surgery by a meta-analysis of randomized controlled studies and observational studies.- We searched electronic databases from inception up to August 1st, 2019 for all studies that reported stroke or myocardial infarction in adult patients who developed POAF following non-cardiac surgery. We used random-effects models to summarize the studies.- The final analyses included 28 studies enrolling 2,612,816 patients. At one-month (ten studies), POAF was associated with an approximately three-fold increase in the risk of stroke (weighted mean 2.1% vs 0.7%) [odds ratio (OR) 2.82 (95% Confidence intervals (CI): 2.15-3.70); p< 0.001]. POAF was associated with approximately four-fold increase in the long-term risk of stroke with (weighted mean 2.0% vs 0.6%) (OR 4.12, 95% CI: 3.32-5.11; pȦ4;0.001) in eight studies with Ȧ5;12-month follow-up. There was a significant overall increase in the risk of stroke and myocardial infarction associated with POAF (weighted mean 2.5% vs 0.9%) (OR 3.44,95% CI: 2.38-4.98; p<0.001) and (weighted mean 12.6% vs 2.7%) (OR 4.02, 95% CI: 3.08-5.24; p<0.001) respectively. Furthermore, POAF was associated with a three-fold increase in all-cause mortality at 30 days (weighted mean 15.0% vs 5.4%) (OR: 3.36; 95% CI: 2.13-5.31; p<0.001).- POAF was associated with markedly higher risk of stroke, myocardial infarction and all-cause mortality following non-cardiac surgery. Future studies are needed to evaluate the impact of optimal cardiovascular pharmacotherapies to prevent POAF and to decrease the risk of major adverse events in these high-risk patients.



Circ Arrhythm Electrophysiol: 15 Jan 2020; epub ahead of print
AlTurki A, Marafi M, Proietti R, Cardinale D, ... Healey JS, Huynh T
Circ Arrhythm Electrophysiol: 15 Jan 2020; epub ahead of print | PMID: 31944855
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Abstract

Pulsed Field Ablation vs Radiofrequency Ablation: Esophageal Injury in a Novel Model.

Koruth JS, Kuroki K, Kawamura I, Brose R, ... Dukkipati SR, Reddy VY

- Pulsed field ablation (PFA) can be myocardium-selective, potentially sparing the esophagus during left atrial ablation. In an in vivo porcine esophageal injury model, we compared the effects of newer biphasic PFA with radiofrequency ablation (RFA).- In 10 animals, under general anesthesia, the lower esophagus was deflected towards the inferior vena cava (IVC) using an esophageal deviation balloon, and ablation was performed from within the IVC at areas of esophageal contact. Four discrete esophageal sites were targeted in each animal: 6 animals received 8 PFA applications/site (2 kV, multispline catheter), and 4 animals received 6 clusters of irrigated RFA applications (30W x 30 seconds, 3.5mm catheter). All animals were survived to 25 days, sacrificed and the esophagus submitted for pathological examination, including 10 discrete histological sections/esophagus.- The animals weight increased by 13.7±6.2 and 6.8±6.3 % (p=0.343) in the PFA and RFA cohorts, respectively. No PFA animals (0 of 6, 0%) developed abnormal in-life observations, but 1 of 4 RFA animals (25%) developed fever and dyspnea. On necropsy, no PFA animals (0 of 6, 0%) demonstrated esophageal lesions. In contrast, esophageal injury occurred in all RFA animals (4 of 4, 100%; p=0.005): a mean of 1.5 mucosal lesions/animal (length - 21.8±8.9 mm, width - 4.9±1.4 mm) were observed, including one esophago-pulmonary fistula, and deep esophageal ulcers in the other animals. Histological examination demonstrated tissue necrosis surrounded by acute and chronic inflammation and fibrosis. The necrotic RFA lesions involved multiple esophageal tissue layers with evidence of arteriolar medial thickening and fibrosis of peri-esophageal nerves. Abscess formation and full-thickness esophageal wall disruptions were seen in areas of perforation/fistula.- In this novel porcine model of esophageal injury, biphasic PFA induced no chronic histopathological esophageal changes, while RFA demonstrated a spectrum of esophageal lesions including fistula and deep esophageal ulcers and abscesses.



Circ Arrhythm Electrophysiol: 23 Jan 2020; epub ahead of print
Koruth JS, Kuroki K, Kawamura I, Brose R, ... Dukkipati SR, Reddy VY
Circ Arrhythm Electrophysiol: 23 Jan 2020; epub ahead of print | PMID: 31977250
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Abstract

When Sinus Tachycardia Becomes Too Much: Negative Effects of Excessive Upright Tachycardia on Cardiac Output in Vasovagal Syncope, Postural Tachycardia Syndrome, and Inappropriate Sinus Tachycardia.

Stewart JM, Medow MS, Visintainer P, Sutton R

- Upright posture reduces venous return, stroke volume and cardiac output (CO) while causing reflex sinus rate (HR) increase. Yet, in inappropriate sinus tachycardia (IST), postural tachycardia syndrome (POTS), and vasovagal syncope (VVS) symptomatic excessive HR occurs. We hypothesized CO reaches maximum as function of HR in all.- We recruited 12 healthy controls, 9 IST, 30 VVS and 30 POTS patients (13-23years) selected randomly by disorder not by HR, each fulfilled appropriate diagnostic criteria. Subjects were instrumented for electrocardiography, beat-to-beat blood pressure, respiratory rate, CO-Modelflow algorithm, and central blood volume (CBV) from impedance cardiography; 10min data was collected supine; subjects were tilted head-up for =/<10min. We computed phase differences, ΔΦ, between fluctuations of HR (ΔHR) and CO (ΔCO) tabulating data when phases were synchronized, determined by a squared nonlinear phase synchronization index (PhSI) >0.5, describing extent/validity of CO/HR coupling. We graphed results supine, 1min-post-tilt-up, mid-tilt, and pre-tilt-down using polar coordinates (HR - radius, ΔΦ - angle) plotting cos(ΔΦ) vs HR to determine if transition HR exists at which in-phase shifts to anti-phase above which CO decreases when HR further increases.- At baseline HR, diastolic and mean arterial pressure in IST and POTS were higher vs controls. Upright HR increased most in POTS then IST and VVS, with diverse changes in CO, SVR, and CBV. Each patient grouping was separately and collectively analyzed for HR change showing transition from in-phase to anti-phase (ΔΦ) as HR increased: HR =115±6(IST),123±8(POTS),124±7(VVS), p=ns. Controls never reached transitional HR.- Excessive HR independently and equivalently reduces upright CO, in IST, POTS and VVS.



Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print
Stewart JM, Medow MS, Visintainer P, Sutton R
Circ Arrhythm Electrophysiol: 14 Jan 2020; epub ahead of print | PMID: 31941353
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Abstract

Real-time Electrogram Analysis for Drivers of AtRial Fibrillation (RADAR): A Multi-Center FDA-IDE Clinical Trial of Persistent AF.

Choudry S, Mansour M, Sundaram S, Nguyen DT, ... Kessman P, Reddy VY

- Pulmonary vein isolation (PVI) is insufficient to treat all patients with persistent atrial fibrillation (AF), and effective adjunctive ablation strategies are needed. Ablation of AF drivers holds promise, but current technologies to identify drivers are limited by spatial resolution. In a single-arm, first-in-human, investigator-initiated FDA IDE study, we employed a novel system for real-time, high-resolution identification of AF drivers in persistent AF.- Persistent or longstanding persistent AF patients underwent ablation using the RADAR system in conjunction with a standard electroanatomical mapping system. After PVI, electrogram and spatial information was streamed and analyzed to identify driver domains to target for ablation.- Across 4 centers, 64 subjects were enrolled: 73% male, age 64.7±9.5 years, BMI 31.7±6.0 kg/m, LA size 54±10 mm, with persistent/longstanding persistent AF in 53 (83%) / 11 (17%), prior AF ablation (re-do group) in 26 (41%). After 12.6 ±} 0.8 months follow-up, 68% remained AF-free off all antiarrhythmics; 74% remained AF-free and 66% remained AF/AT/AFL-free on or off antiarrhythmic drugs. AF terminated with ablation in 35 patients (55%) overall and in 23/38 (61%) of de novo ablation patients. For patients with AF termination during ablation, 82% remained AF-free and 74% AF/AT/AFL free during follow-up on or off antiarrhythmic drugs. Patients undergoing first-time ablation generally had higher rates of freedom from AF than the re-do group.- This novel technology for panoramic mapping of AF drivers showed promising results in a persistent/long-standing persistent AF population. These data provide the scientific basis for a randomized trial.- clinicaltrials.org; Unique Identifier: NCT03263702; IDE#G170049.



Circ Arrhythm Electrophysiol: 15 Jan 2020; epub ahead of print
Choudry S, Mansour M, Sundaram S, Nguyen DT, ... Kessman P, Reddy VY
Circ Arrhythm Electrophysiol: 15 Jan 2020; epub ahead of print | PMID: 31944826
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Abstract

Characterization of Structural Changes in Arrhythmogenic Right Ventricular Cardiomyopathy with Recurrent Ventricular Tachycardia after Ablation: Insights from Repeat Electroanatomic Voltage Mapping.

Briceño DF, Liang JJ, Shirai Y, Markman TM, ... Callans DJ, Marchlinski FE

Background - Data characterizing structural changes of arrhythmogenic right ventricular cardiomyopathy (ARVC) are limited.
Methods - Patients presenting with left bundle branch block ventricular tachycardia (VT) in the setting of ARVC with procedures separated by at least 9 months were included.
Results - Nineteen consecutive patients (84% males; mean age 39{plus minus}15 years [range, 20 to 76 years]) were included. All 19 patients underwent two detailed sinus rhythm electroanatomic endocardial voltage maps (average 385{plus minus}177 points per map; range, 93 to 847 points). Time interval between the initial and repeat ablation procedures was mean 50 {plus minus} 37 months (range 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [IQR 25, 54] vs. 53 cm2 [IQR 25, 65], p=0.09; unipolar: 116 cm2 [IQR 61, 209] vs. 159 cm2 [IQR 73, 204], p=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase = 28%; 206 ml [IQR 170, 253] vs. 263 ml [IQR 204, 294], p<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman\'s rho, 0.6965, p=0.006; unipolar: Spearman\'s rho, 0.5743, p=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure.
Conclusions - In patients with ARVC presenting with recurrent VT, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent VTs are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size, and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with ARVC who have progressive RV dilation.



Circ Arrhythm Electrophysiol: 09 Jan 2020; epub ahead of print
Briceño DF, Liang JJ, Shirai Y, Markman TM, ... Callans DJ, Marchlinski FE
Circ Arrhythm Electrophysiol: 09 Jan 2020; epub ahead of print | PMID: 31922914
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Abstract

Impedance in the Diagnosis of Lead Malfunction.

Swerdlow CD, Koneru JN, Gunderson B, Kroll MW, Ploux S, Ellenbogen KA

Impedance is the ratio of voltage to current in an electrical circuit. Cardiac implantable electronic devices measure impedance to assess the structural integrity electrical performance of leads, typically using subthreshold pulses. We review determinants of impedance, how it is measured, variation in clinically-measured pacing and high-voltage impedance, and impedance trends as a diagnostic for lead failure and lead-device connection problems. We consider the differential diagnosis of abnormal impedance and the approach to the challenging problem of a single, abnormal impedance measurement. Present impedance provides a specific but insensitive diagnostic. For pacing circuits, we review the complementary roles of impedance and more sensitive oversensing diagnostics. Shock circuits lack a sensitive diagnostic. This deficiency is particularly important for insulation breaches, which may go undetected and present with short circuits during therapeutic shocks. We consider new methods for measuring impedance that may increase sensitivity for insulation breaches.



Circ Arrhythm Electrophysiol: 26 Jan 2020; epub ahead of print
Swerdlow CD, Koneru JN, Gunderson B, Kroll MW, Ploux S, Ellenbogen KA
Circ Arrhythm Electrophysiol: 26 Jan 2020; epub ahead of print | PMID: 31985260
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Abstract

The Left Atrial Appendage Morphology Improves Prediction of Stagnant Flow and Stroke Risk in Atrial Fibrillation.

Yaghi S, Chang A, Ignacio G, Scher E, ... Atalay M, Song C

The left atrial appendage (LAA) is the most common site of thrombus formation in patients with atrial fibrillation. Therefore, better knowledge of the morphology, physiology, and function of the LAA may provide a better estimate of stroke risk. The LAA morphology is currently classified into 4 categories: chicken-wing (CW), windsock, cauliflower, and cactus. Chicken-wing is the most common and carries lower risk. This classification system, however, lacks consistent inter-rater reliability and correlation with stroke risk.



Circ Arrhythm Electrophysiol: 26 Jan 2020; epub ahead of print
Yaghi S, Chang A, Ignacio G, Scher E, ... Atalay M, Song C
Circ Arrhythm Electrophysiol: 26 Jan 2020; epub ahead of print | PMID: 31986073
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Abstract

Persistent Asthma is Associated with Increased Risk for Incident Atrial Fibrillation in the Multi-Ethnic Study of Atherosclerosis (MESA).

Tattersall MC, Dasiewicz AS, McClelland RL, Gepner AD, ... Hamdan MH, Stein JH

- Asthma and atrial fibrillation (AF) share an underlying inflammatory pathophysiology. We hypothesized that persistent asthmatics are at higher risk for developing AF and that this association would be attenuated by adjustment for baseline markers of systemic inflammation.- The Multi-Ethnic Study of Atherosclerosis is a prospective longitudinal study of adults free of cardiovascular disease at baseline. Presence of asthma was determined at exam 1. Persistent asthma was defined as asthma requiring use of controller medications. Intermittent asthma was defined as asthma without use of controller medications. Participants were followed for a median of 12.9 (interquartile range 10-13.6) years for incident AF. Multivariable Cox regression models were used to assess associations of asthma subtype and AF.- The 6,615 participants were a mean (standard deviation) 62.0 (10.2) years old, (47% male, 27% African-American, 12% Chinese, 22% Hispanic). AF incidence rates were 0.11 [95% CI 0.01, 0.12] events/10 person-years for non-asthmatics, 0.11 [95% CI 0.08, 0.14] events/10 person-years for intermittent asthmatics, and 0.19 [95% CI 0.12, 0.49] events/10 person-years for persistent asthmatics (log-rank p=0.008). In risk-factor adjusted models, persistent asthmatics had a greater risk of incident AF (hazard ratio [HR] 1.49 [95% CI 1.03-2.14], p=0.03). Interleukin 6 (IL-6, HR 1.26 [95% CI 1.13-1.42]), tumor necrosis factor-α receptor 1 (TNF-α R1, HR 1.09 [95% CI 1.08-1.11]) and D-Dimer (HR 1.10 [95% CI 1.02-1.20]) predicted incident AF, but the relationship between asthma and incident AF was not attenuated by adjustment for any inflammation marker (IL-6, C-reactive protein, TNF-α R1, D-dimer, fibrinogen).- In a large multiethnic cohort with nearly 13 years follow-up, persistent asthma was associated with increased risk for incident AF. This association was not attenuated by adjustment for baseline inflammatory biomarkers.



Circ Arrhythm Electrophysiol: 03 Feb 2020; epub ahead of print
Tattersall MC, Dasiewicz AS, McClelland RL, Gepner AD, ... Hamdan MH, Stein JH
Circ Arrhythm Electrophysiol: 03 Feb 2020; epub ahead of print | PMID: 32013555
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Abstract

Heart Rate Reduction after Exercise Is Associated with Arrhythmic Events in Patients with Catecholaminergic Polymorphic Ventricular Tachycardia.

Lieve KVV, Dusi V, van der Werf C, Bos JM, ... Ackerman MJ, Wilde AAM

- Risk stratification in catecholaminergic polymorphic ventricular tachycardia (CPVT) remains ill defined. Heart rate reduction (HRR) immediately after exercise is regulated by autonomic reflexes, particularly vagal tone, and may be associated with symptoms and ventricular arrhythmias (VAs) in patients with CPVT. Our objective was to evaluate whether HRR after maximal exercise on the exercise stress test (EST) is associated with symptoms and VAs.- In this retrospective observational study, we included patients ≤ 65 years with an EST without antiarrhythmic drugs (AAD) who attained at least 80% of their age- and gender-predicted maximal HR. HRR in the recovery phase was calculated as the difference in heart rate (HR) at maximal exercise and at one minute in the recovery phase (ΔHRR1\').- We included 187 patients (median age 36 years, 68 [36%] symptomatic before diagnosis). Pre-EST HR and maximal HR were equal among symptomatic and asymptomatic patients. Patients that were symptomatic prior to diagnosis had a greater ΔHRR1\' after maximal exercise (43 [IQR, 25-58] vs. 25 [IQR, 19-34] beats/minute, p<0.001). Corrected for age, gender and relatedness, patients in the upper tertile for ΔHRR1\' had an odds ratio of 3.4 (95% confidence interval, 1.6-7.4) of being symptomatic before diagnosis (p<0.001). In addition, ΔHRR1\' was higher in patients with complex VAs at EST off AADs (33 [IQR, 22-48] beats/minute vs. 27 [IQR, 20-36], p=0.01. After diagnosis, patients with a ΔHRR1\' in the upper tertile of its distribution had significantly more arrhythmic events as compared to patients in the other tertiles (p=0.045).- CPVT patients with a larger HRR following exercise are more likely to be symptomatic and have complex VAs during first EST off AAD.



Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print
Lieve KVV, Dusi V, van der Werf C, Bos JM, ... Ackerman MJ, Wilde AAM
Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print | PMID: 32063070
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Abstract

Granger Causality-based Analysis for Classification of Fibrillation Mechanisms and Localisation of Rotational Drivers.

Handa BS, Li X, Aras KK, Qureshi NA, ... Peters NS, Ng FS

- The mechanisms sustaining myocardial fibrillation remain disputed, partly due to a lack of mapping tools that can accurately identify the mechanism with low spatial resolution clinical recordings. Granger causality (GC) analysis, an econometric tool for quantifying causal relationships between complex time-series, was developed as a novel fibrillation mapping tool and adapted to low spatial resolution sequentially-acquired data.- VF optical mapping was performed in Langendorff-perfused Sprague-Dawley rat hearts (n=18), where novel algorithms were developed using GC-based analysis to: a) quantify causal dependence of neighbouring signals and plot GC-vectors, b) quantify global organisation with the causality pairing index (CPI), a measure of neighbouring causal signal pairs and c) localise rotational drivers (RDs) by quantifying the circular interdependence of neighbouring signals with the circular interdependence value (CIV). GC-based mapping tools were optimised for low spatial resolution from down-sampled optical mapping data, validated against high-resolution phase analysis and further tested in previous VF optical mapping recordings of coronary perfused donor heart LV wedge preparations (n=12), and adapted for sequentially-acquired intracardiac-electrograms during human persistent atrial fibrillation (PsAF) mapping (n=16).- Global VF organisation quantified by CPI showed a negative correlation at progressively lower resolutions (50% resolution: p=0.006, R=0.38, 12.5% resolution, p=0.004, R=0.41) with a phase analysis derived measure of disorganisation, lps. In organised VF with high CPI values, GC-vector mapping characterised dominant propagating patterns and localised stable RDs, with the CIV showing a significant difference in driver versus non-driver regions (0.91±0.05 vs 0.35±0.06, p=0.0002). These findings were further confirmed in human VF. In PsAF, a positive correlation was found between the CPI and presence of stable RDs (p=0.0005,R =0.56). 50% of patients had RDs, with a low incidence of 0.9±0.3 RDs/patient.- GC-based fibrillation analysis can measure global fibrillation organisation, characterise dominant propagating patterns and map RDs using low spatial resolution sequentially-acquired data.



Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print
Handa BS, Li X, Aras KK, Qureshi NA, ... Peters NS, Ng FS
Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print | PMID: 32064900
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Abstract

Assessing and Mitigating Bias in Medical Artificial Intelligence: The Effects of Race and Ethnicity on a Deep Learning Model for ECG Analysis.

Noseworthy PA, Attia ZI, Brewer LC, Hayes SN, ... Friedman PA, Lopez-Jimenez F

- Deep learning algorithms derived in homogeneous populations may be poorly generalizable and have the potential to reflect, perpetuate, and even exacerbate racial/ethnic disparities in health and healthcare. In this study we aimed to (1) assess if the performance of a deep learning algorithm designed to detect low left ventricular ejection fraction (LVEF) using the 12-lead electrocardiogram (ECG) varies by race/ethnicity, and to (2) determine whether its performance is determined by the derivation population, or by racial variation in the ECG.- We performed a retrospective cohort analysis that included 97,829 patients with paired ECGs and echocardiograms. We tested the model performance by race/ethnicity for convolutional neural network (CNN) designed to identify patients with a LVEF ≤35% from the 12-lead ECG.- The CNN which was previously derived in a homogeneous population (derivation cohort N=44,959; 96.2% non-Hispanic White) demonstrated consistent performance to detect low LVEF across a range of racial/ethnic subgroups in a separate testing cohort (N=52,870): Non-Hispanic white (N= 44,524, AUC 0.931), Asian (N=557, AUC 0.961), black/African American (N=651, AUC 0.937), Hispanic/Latino (N=331, AUC 0.937), and American Indian/Native Alaskan (N=223, AUC 0.938). In secondary analyses, a separate neural network was able to discern racial subgroup category (Black/African-American [AUC of 0.84], and white, non-Hispanic [AUC 0.76] in a five-class classifier), and a network trained only in non-Hispanic whites from the original derivation cohort performed similarly well across a range of racial/ethnic subgroups in the testing cohort with an AUC of at least 0.930 in all racial/ethnic subgroups.- Our study demonstrates that while ECG characteristics vary by race, this did not impact the ability of a CNN to predict low LVEF from the ECG. We recommend reporting of performance amongst diverse ethnic, racial, age and gender groups for all new AI tools to ensure responsible use of AI in medicine.



Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print
Noseworthy PA, Attia ZI, Brewer LC, Hayes SN, ... Friedman PA, Lopez-Jimenez F
Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print | PMID: 32064914
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Abstract

Bipolar Radiofrequency Ablation of Ventricular Arrhythmias Originating in the Vicinity of His Bundle.

Futyma P, Ciąpała K, Sander J, Głuszczyk R, Futyma M, Kułakowski P

When arrhythmia originates from the His bundle (HB) area conventional radiofrequency catheter ablation (RFCA) is associated with increased risk of atrioventricular block (AVB). Biophysics of bipolar RFCA (Bi-RFCA) suggest more selective lesion formation. It has been shown that Bi-RFCA can be an alternative in case of premature ventricular complex (PVC) or ventricular tachycardia (VT) refractory to standard RF. Whether Bi-RFCA can result in safe and effective ablation of PVC/VT originating from the close proximity of HB has not yet been investigated.



Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print
Futyma P, Ciąpała K, Sander J, Głuszczyk R, Futyma M, Kułakowski P
Circ Arrhythm Electrophysiol: 15 Feb 2020; epub ahead of print | PMID: 32063033
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Abstract

Non-Invasive Assessment of Complexity of Atrial Fibrillation: Correlation with Contact Mapping and Impact of Ablation.

Rodrigo M, Climent AM, Hernández-Romero I, Liberos A, ... Narayan SM, Atienza F

- It is difficult to non-invasively phenotype atrial fibrillation (AF) in a way that reflects clinical endpoints such as response to therapy. We set out to map electrical patterns of disorganization and regions of reentrant activity in AF from the body surface using electrocardiographic imaging (ECGI), calibrated to panoramic intracardiac recordings and referenced to AF termination by ablation.- Bi-atrial intracardiac electrograms of 47 AF patients at ablation (30 persistent, 29 male, 63±9 years) were recorded with 64-pole basket catheters and simultaneous 57-lead body surface ECGs. Atrial epicardial electrical activity was reconstructed and organized sites were invasively and non-invasively tracked in 3D using phase singularity (PS). In a subset of 17 patients, sites of AF organization were targeted for ablation.- Body surface mapping showed greater AF organization near intracardially-detected drivers than elsewhere, both in PS density (2.3±2.1 vs 1.9±1.6, p=0.02) and number of drivers (3.2±2.3 vs 2.7±1.7, p=0.02). Complexity, defined as the number of stable AF reentrant sites, was concordant between non-invasive and invasive methods (r =0.5, CC=0.71). In the subset receiving targeted ablation, AF complexity showed lower values in those in whom AF terminated than those in whom AF did not terminate (p<0.01).- AF complexity tracked non-invasively correlates well with organized and disorganized regions detected by panoramic intracardiac mapping, and correlates with the acute outcome by ablation. This approach may assist in bedside monitoring of therapy or in improving the efficacy of ongoing ablation procedures.



Circ Arrhythm Electrophysiol: 12 Feb 2020; epub ahead of print
Rodrigo M, Climent AM, Hernández-Romero I, Liberos A, ... Narayan SM, Atienza F
Circ Arrhythm Electrophysiol: 12 Feb 2020; epub ahead of print | PMID: 32078374
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Abstract

Accurate Conduction Velocity Maps and their Association with Scar Distribution on Magnetic Resonance Imaging in Patients with Post-Infarction Ventricular Tachycardias.

Aronis KN, Ali RL, Prakosa A, Ashikaga H, ... Chrispin J, Trayanova NA

- Characterizing myocardial conduction velocity (CV) in patients with ischemic cardiomyopathy (ICM) and ventricular tachycardia (VT) is important for understanding the patient-specific pro-arrhythmic substrate of VTs and therapeutic planning. The objective of this study is to accurately assess the relation between CV and myocardial fibrosis density on late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) imaging in patients with ICM.- We enrolled 6 patients with ICM undergoing VT ablation and 5 with structurally normal left ventricles (controls) undergoing PVC or VT ablation. All patients underwent LGE-CMR and electro-anatomical mapping (EAM) in sinus rhythm (2,960 EAM points analyzed). We estimated CV from EAM local activation time using the triangulation method, that provides an accurate estimate of CV as it accounts for the direction of wavefront propagation. We evaluated for the association between LGE-CMR intensity and CV with multi-level linear mixed models.- Median CV in ICM patients and controls was 0.41 m/s and 0.65 m/s respectively. In ICM patients, CV in areas with no visible fibrosis was 0.81 m/s (95%CI: 0.59-1.12 m/s). For each 25% increase in normalized LGE intensity CV decreased by 1.34-fold (95%CI: 1.25-1.43). Dense scar areas have on average 1.97-2.66-fold slower CV compared to areas without dense scar. Ablation lesions that terminated VTs were localized in areas of slow conduction on CV maps.- CV is inversely associated with LGE-CMR fibrosis density in patients with ICM. Non-invasive derivation of CV maps from LGE-CMR is feasible. Integration of non-invasive CV maps with EAM during substrate mapping has the potential to improve procedural planning and outcomes.



Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print
Aronis KN, Ali RL, Prakosa A, Ashikaga H, ... Chrispin J, Trayanova NA
Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print | PMID: 32191131
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Abstract

Left Bundle Branch Block: Current and Future Perspectives.

Tan NY, Witt CM, Oh JK, Cha YM

Left bundle branch block (LBBB) may be due to conduction system degeneration or a reflection of myocardial pathology. LBBB may also develop following aortic valve disease or cardiac procedures. Patients with heart failure with reduced ejection fraction (HFrEF) and LBBB may respond positively to cardiac resynchronization therapy (CRT). Lead placement via the coronary sinus is the mainstay approach of CRT. However, other options including physiologic pacing are being explored. In this review, we summarize the salient pathophysiologic and clinical aspects of LBBB, as well as current and future strategies for management.



Circ Arrhythm Electrophysiol: 17 Mar 2020; epub ahead of print
Tan NY, Witt CM, Oh JK, Cha YM
Circ Arrhythm Electrophysiol: 17 Mar 2020; epub ahead of print | PMID: 32186936
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Abstract

Initial Precipitants and Recurrence of Atrial Fibrillation.

Wang EY, Hulme OL, Khurshid S, Weng LC, ... Trinquart L, Lubitz SA

- Atrial fibrillation (AF) may occur after an acute precipitant and subsequently resolve. Management guidelines for AF in these settings are unclear, since the risk of recurrent AF and related morbidity is poorly understood. We examined the relations between acute precipitants of AF and long-term recurrence of AF in a clinical setting.- From a multi-institutional longitudinal electronic medical record database, we identified patients with newly diagnosed AF between 2000-14. We developed algorithms to identify acute AF precipitants (surgery, sepsis, pneumonia, pneumothorax, respiratory failure, myocardial infarction, thyrotoxicosis, alcohol, pericarditis, pulmonary embolism, and myocarditis). We assessed risks of AF recurrence in individuals with and without a precipitant and the relations between AF recurrence and heart failure, stroke, and mortality.- Among 10,723 patients with newly diagnosed AF (67.9 ± 9.9 years, 41% women), 19% had an acute AF precipitant, the most common of which were cardiac surgery (22%), pneumonia (20%), and non-cardiothoracic surgery (15%). The cumulative incidence of AF recurrence at 5 years was 41% among individuals with a precipitant compared to 52% in those without a precipitant (adjusted hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.69-0.81, p<0.001). The lowest risk of recurrence among those with precipitants was postoperative AF (5-year incidence 32% in cardiac surgery and 39% in non-cardiothoracic surgery). Regardless of the presence of an initial precipitant, recurrent AF was associated with increased adjusted risks of heart failure (HR: 2.74, 95% CI: 2.39-3.15, p<0.001), stroke (HR: 1.57, 95% CI: 1.30-1.90, p<0.001) and mortality (HR: 2.96, 95% CI: 2.70-3.24, p<0.001).- AF after an acute precipitant frequently recurs, although the risk of recurrence is lower than among individuals without an acute precipitant. Recurrence is associated with substantial long-term morbidity and mortality. Future studies should address surveillance and management after newly diagnosed AF in the setting of an acute precipitant.



Circ Arrhythm Electrophysiol: 11 Feb 2020; epub ahead of print
Wang EY, Hulme OL, Khurshid S, Weng LC, ... Trinquart L, Lubitz SA
Circ Arrhythm Electrophysiol: 11 Feb 2020; epub ahead of print | PMID: 32078361
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Abstract

Genetic Susceptibility for Atrial Fibrillation in Patients Undergoing Atrial Fibrillation Ablation.

Shoemaker MB, Husser D, Roselli C, Al Jazairi M, ... Roden DM, Lubitz S

- Ablation is a widely used therapy for atrial fibrillation (AF); however, arrhythmia recurrence and repeat procedures are common. Studies examining surrogate markers of genetic susceptibility to AF such as family history and individual AF susceptibility alleles suggest these may be associated with recurrence outcomes. Accordingly, the aim of this study was to test the association between AF genetic susceptibility and recurrence after ablation using a comprehensive polygenic risk score for AF.- Ten centers from the AF Genetics Consortium identified patients who had undergone de novo AF ablation. AF genetic susceptibility was measured using a previously described polygenic risk score (N=929 SNPs) and tested for an association with clinical characteristics and time to recurrence with a 3 month blanking period. Recurrence was defined as >30 seconds of AF, atrial flutter, or atrial tachycardia. Multivariable analysis adjusted for age, sex, height, BMI, persistent AF, hypertension, coronary disease, LA size, LVEF, and year of ablation.- 4,276 patients were eligible for analysis of baseline characteristics and 3,259 for recurrence outcomes. The overall arrhythmia recurrence rate between 3-12 months was 44% (1,443/3,259). Patients with higher AF genetic susceptibility were younger (P<0.001) and had fewer clinical risk factors for AF (P=0.001). Persistent AF (HR 1.39, 95% CI: 1.22-1.58; P<0.001), LA size (per cm: HR 1.32, 95% CI: 1.19-1.46; P<0.001), and LVEF (per 10%: HR 0.88, 95% CI: 0.80-0.97; P=0.008) were associated with increased risk of recurrence. In univariate analysis, higher AF genetic susceptibility trended towards a higher risk of recurrence (HR 1.08, 95% CI: 0.99-1.18; P=0.07), which became less significant in multivariable analysis (HR 1.06, 95% CI: 0.98-1.15; P=0.13). - Higher AF genetic susceptibility was associated with younger age and fewer clinical risk factors, but not recurrence. Arrhythmia recurrence after AF ablation may represent a genetically different phenotype compared to AF susceptibility.



Circ Arrhythm Electrophysiol: 13 Feb 2020; epub ahead of print
Shoemaker MB, Husser D, Roselli C, Al Jazairi M, ... Roden DM, Lubitz S
Circ Arrhythm Electrophysiol: 13 Feb 2020; epub ahead of print | PMID: 32078373
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Impact:
Abstract

Substrate Spatial Complexity Analysis for the Prediction of Ventricular Arrhythmias in Patients with Ischemic Cardiomyopathy.

Okada DR, Miller J, Chrispin J, Prakosa A, ... Maggioni M, Wu KC

- Transition zones between healthy myocardium and scar form a spatially complex substrate that may give rise to reentrant ventricular arrhythmias (VA). We sought to assess the utility of a novel machine learning (ML) approach for quantifying 3D spatial complexity of grayscale patterns on late gadolinium enhanced cardiac magnetic resonance images (LGE-CMR) to predict VA in patients with ischemic cardiomyopathy (ICM).- 122 consecutive ICM patients with left ventricular ejection fraction ≤35% without prior history of VA underwent LGE-CMR. From raw grayscale data, we generated graphs encoding the 3D geometry of the left ventricle (LV). A novel technique, adapted to these graphs, assessed global regularity of signal intensity patterns using Fourier-like analysis and generated a substrate spatial complexity (SSC) profile for each patient. An ML statistical algorithm was employed to discern which SSC profiles correlated with VA events (appropriate ICD firings and arrhythmic sudden cardiac death) at 5 years of follow-up. From the statistical ML results, a complexity score (CS) ranging from 0-1 was calculated for each patient and tested using multivariable Cox regression models.- At 5 years of follow-up, 40 patients had VA events. The ML algorithm classified with 81% overall accuracy and correctly classified 86% of those without VA. Overall negative predictive value was 91%. Average CS was significantly higher in patients with VA events versus those without (0.5 ± 0.5 vs 0.1 ± 0.2; p<0.0001) and was independently associated with VA events in a multivariable model (hazard ratio = 1.5 [1.2- 2.0]; p=0.002).- SSC analysis of LGE-CMR images may be helpful in refining VA risk in patients with ICM, particularly to identify low risk patients who may not benefit from prophylactic ICD therapy.



Circ Arrhythm Electrophysiol: 17 Mar 2020; epub ahead of print
Okada DR, Miller J, Chrispin J, Prakosa A, ... Maggioni M, Wu KC
Circ Arrhythm Electrophysiol: 17 Mar 2020; epub ahead of print | PMID: 32188287
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Impact:
Abstract

An Automated Non-Contact Ultrasound Imaging and Ablation System for the Treatment of Atrial Fibrillation: Outcomes of the First-in-Human Trial.

Turagam MK, Petru J, Neuzil P, Kakita K, ... Dukkipati SR, Reddy VY

- Catheter ablation for atrial fibrillation (AF) using point-by-point radiofrequency energy or single-application one-shot balloons is either technically challenging or have limited ability to accommodate variable patient anatomy, respectively. A novel ablation system employs low intensity collimated ultrasound (LICU)-guided anatomical mapping and robotic ablation to isolate pulmonary veins (PVs). In this first-in-human, single-center, multi-operator trial,in paroxysmal AF patients, this LICU system was evaluated to determine its safety, effectiveness in PV isolation (PVI), and freedom from recurrent atrial arrhythmias.- In the enrolled 52 paroxysmal AF patients, ultrasound M-mode-based left atrial anatomies were successfully created, and ablation was performed under robotic control along an operator-defined lesion path. The LICU system software advanced over the course of the study: the last 13 patients were ablated with enhanced software.- Acute PVI was achieved in 98% of PVs - using LICU-only in 77.3% (153/198) of PVs, and requiring touch-up with a standard radiofrequency ablation catheter in 22.7% (45/198) PVs. The touch-up rate decreased to 5.8% (3/52) in patients undergoing LICU-ablation with enhanced software. Freedom from atrial arrhythmia recurrence was 79.6% (39/49 patients) at 12-months, or 92.3% (12/13 patients) with the enhanced software. Major adverse events occurred in 3 patients (5.8%): one had transient diaphragmatic paralysis, one vascular access complication, and one had transient ST-segment elevation from air-embolism, without sequelae.- In this first-in-human study, low intensity collimated ultrasound-guided anatomical mapping and robotic ablation allows PVI with good chronic safety; PVI success is improving with device enhancements.- https://clinicaltrials.gov; Unique Identifier: NCT03639597.



Circ Arrhythm Electrophysiol: 11 Feb 2020; epub ahead of print
Turagam MK, Petru J, Neuzil P, Kakita K, ... Dukkipati SR, Reddy VY
Circ Arrhythm Electrophysiol: 11 Feb 2020; epub ahead of print | PMID: 32078362
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Abstract

Accumulation of Pericardial Fat Is Associated with Alterations in Heart Rate Variability Patterns in Hypercholesterolemic Pigs.

Uceda DE, Zhu XY, Woollard JR, Ferguson CM, ... Lerman A, Lerman LO

- Heart rate variability (HRV) or pulse rate variability are indices of autonomic cardiac modulation. Increased pericardial fat is associated with worse cardiovascular outcomes. We hypothesized that progressive increases in pericardial fat volume and inflammation prospectively dampen HRV in hypercholesterolemic pigs.- Wild-type (WT) or PCSK9 gain-of-function Ossabaw mini-pigs were studied in-vivo before and after 3- and 6-months of a normal-diet (WT-ND n=4, PCSK9-ND n=6) or high-fat diet (WT-HFD n=3, PCSK9-HFD n=6). The arterial pulse waveform was obtained from an arterial telemetry transmitter to analyze HRV indices, including standard deviation (SDNN), root-mean-square of successive differences (RMSSD), proportion >50 milliseconds (pNN50) of normal-to-normal RR-intervals, and the calculated ratio of low-to-high frequency distributions (LF/HF). Pericardial fat volumes were evaluated using multidetector computed-tomography, and its inflammation by gene expression of tumor necrosis-factor (TNF)-α. Plasma lipid panel and norepinephrine level were also measured.- At diet completion, hypercholesterolemic PCSK9-HFD had significantly (p<0.05 vs. baseline) depressed HRV (SDNN, RMSSD, pNN50, HF, LF), and both HFD groups had higher sympathovagal balance (SDNN/RMSSD, LF/HF) compared to ND. Pericardial fat volumes and LDL-C concentrations correlated inversely with HRV and directly with sympathovagal balance, while sympathovagal balance correlated directly with plasma norepinephrine. Pericardial fat TNF-α expression was upregulated in PCSK9-HFD, co-localized with nerve fibers, and correlated inversely with RMSSD and pNN50.- Progressive pericardial fat expansion and inflammation are associated with a fall in HRV in Ossabaw mini-pigs, implying aggravated autonomic imbalance. Hence, pericardial fat accumulation is associated with alterations in HRV and the autonomic nervous system.



Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print
Uceda DE, Zhu XY, Woollard JR, Ferguson CM, ... Lerman A, Lerman LO
Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print | PMID: 32189516
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Abstract

ICD-Cybersecurity.

Alexander B, Neira V, Campbell D, Crystal E, ... Redfearn D, Baranchuk A

Medical device cybersecurity has gained increasing attention in recent years. While many devices have been targeted, security vulnerabilities in cardiac implantable electronic devices (CIEDs) are of particular concern as implantation of these devices is invasive and patients can be reliant upon these devices for life-sustaining therapy. The first major incident with CIEDs that received wide-spread attention occurred in 2016, when Muddy Waters LLC, in conjunction with vulnerability research firm MedSec, issued a report identifying potential cybersecurity concerns in several models of St. Jude Medical\'s (now Abbott) pacemakers following demonstration of a \"crash attack\" and a \"battery drain attack\". Replication of these attacks under experimental conditions failed to produce any clinical harm. The publication of this report prompted Abbott, in conjunction with the United States Food and Drug Administration (FDA), to release a firmware upgrade with enhanced cybersecurity features. As part of this release, Abbott published estimated rates of complications extrapolated from similar circumstances, which included complete loss of device function, loss of programmed device settings, and failure of the update, among others. As there had been no instances of patient harm and a small but non-negligible risk involved in the firmware upgrade, clinicians were asked to utilize a shared decision-making model when deciding whether to pursue the upgrade and to take individual factors such as pacemaker dependence and age of the device into account. Since that time, additional data have been collected on complications rates and patient attitudes toward the upgrade. Saxon et al. analyzed a population of 10,854 patients who were offered the firmware upgrade in the United States. Of those, only 25% elected to proceed once the risks and benefits were explained.



Circ Arrhythm Electrophysiol: 10 Feb 2020; epub ahead of print
Alexander B, Neira V, Campbell D, Crystal E, ... Redfearn D, Baranchuk A
Circ Arrhythm Electrophysiol: 10 Feb 2020; epub ahead of print | PMID: 32078370
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Abstract

Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-analysis of Observational Studies.

Chew DS, Black-Maier E, Loring Z, Noseworthy PA, ... Mark DB, Piccini JP

- The optimal timing of catheter ablation for atrial fibrillation (AF) in reference to the time of diagnosis is unknown. We sought to assess the impact of the duration between first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), on AF recurrence following catheter ablation.- We conducted a systematic electronic search for observational studies reporting the outcomes associated with catheter ablation for atrial fibrillation stratified by diagnosis-to-ablation time. The primary meta-analysis using a random effects model assessed AF recurrence stratified by DAT ≤ 1 year versus = 1 year. A secondary analysis assessed outcomes stratified by DAT ≤ 3 years versus = 3 years.- Of the 632 screened studies, 6 studies met inclusion criteria for a total of 4,950 participants undergoing AF ablation for symptomatic AF. A shorter DAT ≤ 1 year was associated with a lower relative risk (RR) of AF recurrence compared to DAT = 1 year (RR 0.73; 95% confidence interval (CI) 0.65 to 0.82, p<0.001). Heterogeneity was moderate (I=51%). When excluding the one study consisting of only persistent AF patients, the heterogeneity improved substantially (I=0%, Cochran\'s Q p=0.55) with a similar estimate of effect (RR 0.78; 95% CI 0.71 to 0.85, p<0.001).- Duration between time of first AF diagnosis and AF ablation is associated with an increased likelihood of ablation procedural success. Additional study is required to confirm these results and to explore implementation of earlier catheter AF ablation and patient outcomes within the current AF care pathway.



Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print
Chew DS, Black-Maier E, Loring Z, Noseworthy PA, ... Mark DB, Piccini JP
Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print | PMID: 32191539
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Abstract

Relation of Fractionated Atrial Potentials with the Vagal Innervation Evaluated by Extracardiac Vagal Stimulation during Cardioneuroablation.

Pachon-M EI, Pachon-Mateos JC, Higuti C, Santillana-P TG, ... Silva RF, Guimarães OT

- Vagal hyperactivity is directly related to several clinical conditions as reflex/functional bradyarrhythmias and vagal atrial fibrillation (AF). Cardioneuroablation provides therapeutic vagal denervation through endocardial RF ablation for these cases. Main challenges are neuro-myocardium interface identification and the denervation control and validation. The finding that the AF-Nest (AFN) ablation eliminates the atropine response and decreases RR variability suggests that they are related to the vagal innervation.- Prospective, controlled, longitudinal, non-randomized study enrolling 62 patients in two groups: AFN group (AFNG-32 patients) with functional or reflex bradyarrhythmias or vagal AF treated with AFN ablation, and a control group (CG-30 patients) with anomalous bundles, ventricular premature beats, atrial flutter, AV-nodal reentry and atrial tachycardia, treated with conventional ablation (non-AFN ablation). In AFNG, ablation delivered at AFN detected by fragmentation/fractionation of the endocardial electrograms and by 3D anatomical location of the ganglionated plexus. Vagal response was evaluated before, during, and post-ablation by 5s non-contact vagal stimulation at the jugular foramen, through the internal jugular veins (ECVS), analyzing 15s mean heart rate, longest RR, pauses, and AV block. All patients had current guidelines arrhythmia ablation indication.- Pre-ablation ECVS induced sinus pauses, asystole and transient AV block in both groups showing a strong vagal response (=0.96). Post-ablation ECVS in the AFNG showed complete abolishment of the cardiac vagal response in all cases (Pre/post-ablation ECVS=<0.0001), demonstrating robust vagal denervation. However, in the CG, vagal response remained practically unchanged post-ablation (=0.35) showing that non-AFN ablation promotes no significant denervation.- AF-Nest ablation causes significant vagal denervation. Non-AF-Nest ablation causes no significant vagal denervation. These results suggest that AF-Nests are intrinsically related to vagal innervation. ECVS was fundamental to stepwise vagal denervation validation during cardioneuroablation.



Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print
Pachon-M EI, Pachon-Mateos JC, Higuti C, Santillana-P TG, ... Silva RF, Guimarães OT
Circ Arrhythm Electrophysiol: 18 Mar 2020; epub ahead of print | PMID: 32188285
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Abstract

Impact of Cardiac Resynchronization Therapy on Heart Transplant-Free Survival in Pediatric and Congenital Heart Disease Patients.

Chubb H, Rosenthal DN, Almond CS, Ceresnak SR, ... McElhinney DB, Dubin AM

- Cardiac resynchronization therapy (CRT) studies in pediatric and/or congenital heart disease (CHD) patients have shown an improvement in ejection fraction and heart failure symptoms. However, a survival benefit of CRT in this population has not been established. This study aimed to evaluate the impact of CRT upon heart transplant-free survival in pediatric and CHD patients, using a propensity score-matched analysis.- This single-center study compared CRT patients (implant date 2004-2017) and controls, matched by 1:1 propensity-score matching (PSM) using 21 comprehensive baseline indices for risk stratification. CRT patients were <21 years or had CHD; had systemic ventricular ejection fraction <;45%; symptomatic heart failure; and had significant electrical dyssynchrony, all prior to CRT implant. Controls were screened from non-selective imaging and ECG databases. Controls were retrospectively enrolled when they achieved the same inclusion criteria at an outpatient clinical encounter, within the same time period.- Of 133 patients who received CRT during the study period, 84 met all study inclusion criteria. 133 controls met all criteria at an outpatient encounter. Following PSM, 63 matched CRT-control pairs were identified with no significant difference between groups across all baseline indices. Heart transplant or death occurred in 12 (19%) PSM-CRT subjects and 37 (59%) PSM-controls with a median follow-up of 2.7 years (quartiles 0.8-6.1 years). CRT was associated with markedly reduced risk of heart transplant or death (hazard ratio 0.24 [95% CI 0.12-0.46], p<0.001). There was no CRT procedural mortality and one system infection at 54 months post-implant.- In pediatric and CHD patients with symptomatic systolic heart failure and electrical dyssynchrony, CRT was associated with improved heart transplant-free survival.



Circ Arrhythm Electrophysiol: 21 Mar 2020; epub ahead of print
Chubb H, Rosenthal DN, Almond CS, Ceresnak SR, ... McElhinney DB, Dubin AM
Circ Arrhythm Electrophysiol: 21 Mar 2020; epub ahead of print | PMID: 32202126
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Abstract

Impact of Change in 2010 American Heart Association Cardiopulmonary Resuscitation Guidelines on Survival After Out-of-Hospital Cardiac Arrest in the United States: An Analysis From 2006 to 2015.

Pasupula DK, Bhat A, Siddappa Malleshappa SK, Munir MB, ... Saba S, Bhonsale A
Background
In October 2010, the American Heart Association/Emergency Cardiovascular Care updated cardiopulmonary resuscitation guidelines. Its impact on the survival rate among out-of-hospital cardiac arrest patients (OHCA) is not well studied. We sought to assess the survival trends in OHCA patients before and after the introduction of the 2010 American Heart Association cardiopulmonary resuscitation guidelines in the United States.
Methods
A retrospective observational study from the National Emergency Department (ED) Sample was designed to identify patients presenting to the ED primarily after an OHCA in the United States between January 1, 2006, and December 31, 2015. The main outcome studied was the change in trends of ED survival and survival-to-discharge rates before and after guideline modification.
Results
Among 1 282 520 patients presenting to the ED after OHCA (mean [SD] age, 65.8 [17.2] years; 62% men), ED survival rate (23%) and survival-to-discharge rate (16%) trends showed significant improvement after implementation of the 2010 American Heart Association cardiopulmonary resuscitation guidelines, 1.25% ([95% CI, 0.72%-1.78%] =0.001) and 0.89% ([95% CI, 0.35%-1.43%] =0.006), respectively. Notably, among patients with nonshockable rhythm (change in ED survival rate trend, 1.3% [95% CI, 0.89%-1.74%]; <0.001 and survival-to-discharge trend, 0.94% [95% CI, 0.42%-1.47%]; =0.004). Among patients admitted to the presenting hospital (n=145 592), 46% were discharged alive, of which 49% were discharged home. Significant decrease in discharge to home was noted (-1.7% [95% CI, -3.18% to -0.22%]; =0.03), while a significant increase in neurological complication (0.17% [95% CI, 0.06%-0.28%]; =0.007) was noted with the guideline modification.
Conclusions
The change in 2010 American Heart Association cardiopulmonary resuscitation guidelines was associated with only slight improvement in ED survival and survival-to-discharge trends among US OHCA patients and only 1 in 6 OHCA patients survival to discharge.



Circ Arrhythm Electrophysiol: 30 Jan 2020; 13:e007843
Pasupula DK, Bhat A, Siddappa Malleshappa SK, Munir MB, ... Saba S, Bhonsale A
Circ Arrhythm Electrophysiol: 30 Jan 2020; 13:e007843 | PMID: 32069089
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Abstract

Balance Between Rapid Delayed Rectifier K Current and Late Na Current on Ventricular Repolarization: An Effective Antiarrhythmic Target?

Hegyi B, Chen-Izu Y, Izu LT, Rajamani S, ... Bers DM, Bányász T

- Rapid delayed rectifier K current (I) and late Na current (I) significantly shape the cardiac action potential (AP). Changes in their magnitudes can cause either long or short QT syndromes (LQT, SQT) associated with malignant ventricular arrhythmias and sudden cardiac death.- Physiological self AP-clamp was used to measure I and I during the AP in rabbit and porcine ventricular cardiomyocytes in order to test our hypothesis that the balance between I and I affects repolarization stability in health and disease conditions.- We found comparable amount of net charge carried by I and I during the physiological AP suggesting that outward K current via I and inward Na current via I are in balance during physiological repolarization. Remarkably, I and I integrals in each control myocyte were highly correlated in both healthy rabbit and pig myocytes, despite high overall cell-to-cell variability. This close correlation was lost in heart failure myocytes from both species. Pretreatment with E-4031 to block I (mimicking LQT2) or with ATX-II to impair Na channel inactivation (mimicking LQT3) prolonged APD; however, using GS-967 to inhibit I sufficiently restored APD to control in both cases. Importantly, I inhibition significantly reduced the beat-to-beat and short-term variabilities of APD. Moreover, I inhibition also restored APD and repolarization stability in heart failure. Conversely, pretreatment with GS-967 shortened APD (mimicking SQT), and E-4031 reverted APD shortening. Furthermore, the amplitude of AP alternans occurring at high pacing frequency was decreased by I inhibition, increased by I inhibition, and restored by combined I and I inhibitions.- Our data demonstrate that I and I are counterbalancing currents during the physiological ventricular AP and their integrals co-vary in individual myocytes. Targeting these ionic currents to normalize their balance may have significant therapeutic potential in heart diseases with repolarization abnormalities.



Circ Arrhythm Electrophysiol: 22 Mar 2020; epub ahead of print
Hegyi B, Chen-Izu Y, Izu LT, Rajamani S, ... Bers DM, Bányász T
Circ Arrhythm Electrophysiol: 22 Mar 2020; epub ahead of print | PMID: 32202931
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This program is still in alpha version.