Circulation. Arrhythmia and electrophysiology最新文献

Background: Pulsed field ablation (PFA) has been available in Europe since 2021. In the United States, PFA became commercially available in 2024, and practice patterns are expected to differ from those in Europe. The objective of this study was to describe acute procedural efficiency and safety outcomes, clinical workflow patterns, and the physician learning curve associated with PFA for paroxysmal and nonparoxysmal atrial fibrillation in the first US real-world registry.

Methods: DISRUPT-AF (A Registry Based Collaborative to Measure Efficiency, Effectiveness, and Safety of Farapulse PFA Technology for AF) is a prospective, multicenter registry capturing patient-level data on first-time PFA procedures for paroxysmal atrial fibrillation and nonparoxysmal atrial fibrillation using the pentaspline catheter. Patient baseline characteristics and acute procedural efficiency and safety outcomes were collected. Physicians' learning curve analyses were assessed by categorizing experience levels as 1 to 3, 4 to 10, and >11 procedures.

Results: A total of 1076 patients were included; 80.9% of the cases involved ablation beyond the pulmonary veins. Most procedures were performed under general anesthesia (90.2%) using electroanatomic mapping (94.8%). The mean procedural time was 66.64±28.36 minutes. The median fluoroscopy time was 6.17 (0-11.6) minutes, with 25.3% of cases performed using a zero-fluoroscopy approach and 31% utilizing a low-fluoroscopy approach (<2 minutes). The overall procedure-related complication rate was low (1.7%), driven primarily by vascular access complications requiring intervention or transfusion. Procedural efficiency improved with operator experience, evidenced by a reduction in both procedural and fluoroscopy times.

Conclusions: Initial US experience with the pentaspline PFA catheter demonstrated key differences from previously reported European workflows, including higher use of general anesthesia and electroanatomic mapping. Physician learning curve analysis indicated rapid adoption, with improvements in procedural efficiency and consistent safety with operator experience.

Background: Despite advances in endocardial catheter ablation (ECA) for persistent atrial fibrillation (PersAF), undertreatment persists, especially in ECA nonresponders and in longstanding PersAF (LSPersAF), with disappointing ablation results. These patients need effective clinical treatment options.

Methods: The DEEP (Dual Epicardial and Endocardial Procedure) was a prospective, multicenter, single-arm, investigational device exemption trial to establish the safety and effectiveness of a combined epicardial/endocardial ablation procedure with left atrial appendage exclusion for PersAF/LSPersAF. Eligibility included age 18 to 75 years; symptomatic PersAF/LSPersAF refractory to ≥1 Class I/III antiarrhythmic drug; and ≤2 previous failed ECAs. Two-stage hybrid ablation included ECA performed at 91 to 121 days after the epicardial first stage (including left atrial appendage exclusion), followed by a 90-day blanking and 90-day antiarrhythmic drug optimization period. Primary effectiveness was defined as freedom from documented atrial fibrillation/atrial flutter/atrial tachycardia episodes >30 seconds through the 12-month follow-up, absent Class I/III antiarrhythmic drugs, except previously failed antiarrhythmic drugs at doses not exceeding those previously failed. Primary safety was defined as a composite of device/procedure-related serious adverse events within 30 days of epicardial ablation and 7 days of ECA.

Results: Ninety patients enrolled from February 2015 to December 2020; 83.3% (75/90) were male and mean±SD age was 63.4±7.7 years. AF classification was 83.3% (75/90) PersAF/16.7% (15/90) LSPersAF, and 47.8% (43/90) had prior ECA. The composite serious adverse events rate was 6.7% (6/90 [95% CI, 2.5%-13.9%]; P<0.001 versus safety goal), including 3 patients experiencing serious adverse events within 30 days of the epicardial procedure and 3 patients within 7 days of the endocardial procedure, all of whom were anticoagulated at the time of the event. Primary effectiveness through 12 months was 71.8% (61/85 [95% CI, 62.2%-81.3%]; P=0.0134 versus performance goal) and was 62.4% (53/85 [95% CI, 52.1%-72.7%]) through 2 years.

Conclusions: A collaborative hybrid ablation approach to treating PersAF/LSPersAF is safe and effective.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02393885.

Background: Multiple extrastimulus (ES) pacing protocols exist for ventricular substrate mapping. Despite being increasingly adopted in clinical practice, direct protocol comparisons have been limited. This study aims to compare the substrate delineation and mapping efficiency of right ventricular pacing+ES (RVp+ES) and sensed ES pacing strategies in a large animal ischemia-reperfusion injury model.

Methods: Four swine underwent 90-minute balloon occlusion of the mid-left anterior descending artery, followed by late gadolinium-enhanced cardiac magnetic resonance between days 30 and 58 and invasive electroanatomic mapping. Late gadolinium-enhanced cardiac magnetic resonances were segmented for scar topography and border zone channel geometry.

Results: Sensed ES substrate maps had greater point density (12.90±4.20 pts/cm² versus 5.75±0.52 pts/cm²; P=0.032) and faster acquisition (113.71±22.38 s/pt per cm² versus 228.57±77.30 s/pt per cm²; P=0.027) than RVp+ES. Despite this, RVp+ES substrate maps had greater uncovering of split potentials within border zone channels (76.5% [15.4%-95.5%] versus 16.7% [0%-52.9%]; P=0.028), higher sensitivity (53% versus 30%), and similarly high specificity (91% versus 93%) than sensed ES, as well as better visual correlation on decrement-evoked potential maps. Bipolar voltage in sinus rhythm and RVp did not reliably predict tissue response to ES, with 46% to 57% of split potentials within border zone channels arising from seemingly normal voltage (≥1.5 mV).

Conclusions: RVp+ES is more sensitive than sensed ES and highly specific for the detection of late gadolinium-enhanced cardiac magnetic resonance border zone channels postmyocardial infarct.

Background: In the randomized controlled SUPPRESS-AF trial (Efficacy and Safety of Left Atrial Low-voltage Area Guided Ablation for Recurrence Prevention Compared to Pulmonary Vein Isolation Alone in Patients with Persistent Atrial Fibrillation), the efficacy of low-voltage-area (LVA) ablation was highly dependent on the degree of atrial remodeling, while the efficacy was not statistically significant in total patients. This subanalysis of the SUPPRESS-AF trial aimed to compare the efficacy of LVA ablation in patient groups classified by left atrial diameter (LAD), which is a commonly used atrial remodeling index.

Methods: The SUPPRESS-AF trial included patients with persistent AF and left atrial LVAs, and compared rhythm outcomes between patients randomized to undergo pulmonary vein isolation (PVI) followed by left atrial LVA ablation group (n=170) or PVI-alone group (n=172). In this post hoc subanalysis, patients in each of the 2 randomly allocated groups were further divided into 2 groups using a median LAD of 44 mm.

Results: Atrial fibrillation or atrial tachycardia recurrence-free rates did not differ between patients with LAD>44 mm and ≤44 mm (60.1% versus 53.7%; P=0.261). Among patients with a LAD>44 mm, the LVA ablation group demonstrated a higher atrial fibrillation or atrial tachycardia-recurrence-free rate than the PVI-alone group (62.5% versus 43.4%; P=0.016). In contrast, no difference in atrial fibrillation or atrial tachycardia recurrence-free rate was found between the 2 groups of patients with a LAD≤44 mm (60.8% versus 59.6%; P=0.986).

Conclusions: The efficacy of LVA ablation in addition to PVI for the treatment of persistent AF was more pronounced in patients with a large left atrium.

Registration: URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000035940.

Background: Hyperactivity of sympathetic neurons in the stellate ganglia (SG) contributes to ventricular arrhythmias and remodeling postmyocardial infarction (MI). However, the role of satellite glial cells (SGCs) surrounding the neurons in this process remains unknown.

Methods: SGC-specific chemogenetic manipulation was locally applied to modulate SG-SGC activity dual-directionally in the rats with naïve or infarcted hearts. Subsequently, cardiac sympathetic neural activity and ventricular electrophysiological stability in response to stimulation were evaluated, as well as cardiac neural and structural remodeling post-MI. SG bulk RNA sequencing and the interaction between SGCs and sympathetic neurons isolated from SG were used to explore the underpinning mechanisms.

Results: SG-SGC excitation increased SG neural activity and ventricular electrophysiological instability in rats with naïve hearts, whereas its inhibition influenced none of the above under physiological conditions. Of note, 2-hour-MI provoked SG-SGC activation that positively correlated with cardiac sympathetic neurotransmitter (norepinephrine) release. Accordingly, SGC activation in the SG enhanced cardiac sympathetic hyperactivity 2 hours post-MI, whereas SG-SGC inhibition suppressed MI-induced cardiac sympathetic hyperexcitability. Moreover, the persistent inhibition of SG-SGCs improved ventricular remodeling and dysfunction, alleviated SG and ventricular sympathetic nerve sprouting 7 days post-MI. In addition, the bulk RNA sequencing with SG and pharmacological purinergic P2Y1R (P2Y1 receptor) blockage indicated that P2Y1R/IGFBP2 (insulin-like growth factor-binding protein 2) signaling mediated the effects of SG-SGC activation on cardiac sympathetic hyperexcitability post-MI, and IGFBP2 bridged the interaction between the neurons and surrounding SGCs.

Conclusions: SGC inhibition in SG rectifies cardiac sympathetic hyperactivity, stabilizes ventricular electrophysiological properties, and alleviates cardiac structural and neural remodeling post-MI, thereby preventing ventricular arrhythmias and cardiac dysfunction. Neuromodulation targeting SG-SGCs exhibits a safe and fruitful strategy for the treatment of MI.

Background: The incidence of postural orthostatic tachycardia syndrome (POTS) in long COVID has been a growing concern since the first cases were reported in 2021. The aim of this study was to assess the prevalence and clinical impact of POTS in a series of well-characterized patients with long COVID.

Methods: We prospectively analyzed 467 nonhospitalized, highly symptomatic (sick leave ≥50%) patients with long COVID, and studied differences in demographics and clinical assessment outcomes between those diagnosed with POTS and the remaining long COVID patients. Examinations were performed at a median of 12 months after acute COVID-19, followed by a cardiologist evaluation with 48-hour ECG, head-up tilt test, and Active Stand Test for those with clinically suspected POTS.

Results: Of all long COVID patients, 143 (31%) were diagnosed with POTS, 128 (27%) did not fulfill POTS criteria, while 196 (42%) had no clinical signs of POTS. Patients with POTS were younger (mean age, 40.0 versus 44.0 versus 47.0 years, respectively; P≤0.001) and predominantly female (91%). They had significantly lower physical activity compared with the other 2 groups, as measured with the Frändin-Grimby scale (P=0.001). Heart rates during the 6-minute walk test were significantly higher in the POTS group, both during walking and at rest afterward, with a significantly shorter walking distance (448 m versus 472 m versus 509 m, respectively; P≤0.001). However, the distribution of symptoms showed no significant differences between the groups.

Conclusions: In this cohort of predominantly younger women with highly symptomatic long COVID, POTS is common and presents with overlapping symptoms between POTS and non-POTS patients. Long COVID POTS confers lower physical activity and capacity compared with non-POTS long COVID and should be systematically assessed in this condition.