Circulation. Arrhythmia and electrophysiology最新文献

Background: Catheter ablation of scar-dependent ventricular tachycardia (VT) is frequently hampered by hemodynamic instability, long procedure duration, and high recurrence rates. Magnetic resonance imaging-based personalized heart digital twins may overcome these challenges by noninvasively predicting VT circuits and optimum ablation lesion sites. In this combined clinical and digital twin study, we investigated the relationship between digital twin-predicted VTs and optimum ablation lesion sets with their invasively mapped counterparts during clinical VT ablation.

Methods: A total of 18 patients with scar-dependent VT underwent digital twin creation based on preprocedural, contrast-enhanced cardiac magnetic resonance imaging. Using rapid pacing protocols, VT was simulated and ablation targets were derived that would terminate all possible VTs in the models. Patients subsequently underwent invasive VT ablation, including targeting of diastolic activity and optimum entrainment sites. Digital twin-predicted VT circuits and ablation lesions were compared with their invasive clinical counterparts.

Results: Forty-three clinical VTs and 92 digital twin VTs were induced. Diastolic activity was seen in 16 of 43 (37.2%) clinical VTs. Sensitivity, specificity, positive predictive, and negative predictive values for the detection of critical VT sites by digital twins were 81.3%, 83.8%, 21.7%, and 98.8%, respectively. At an American Heart Association-segment level, agreement between clinical VT critical sites and digital twin primary predicted sites was moderate, with a κ coefficient of 0.46 (±0.32; P≤0.001). Termination of VT with ablation was achieved at a digital twin-predicted site in 4 of 5 (80%) cases where attempted. A total of 426 of 709 (60.1%) lesions were within 5 mm of a predicted target site. In total, 54.0% (±28.9%) of the digital twin-predicted area was ablated per patient based on conventional mapping criteria.

Conclusions: Heart digital twin VT circuits and ablation targets accurately predict many features of their respective clinical counterparts but have some limitations in spatial resolution. Our findings demonstrate the significant potential of digital twin technology in guiding catheter ablation for scar-dependent VT.

Background: Inflammation is a common mechanism for atrial fibrillation (AF). 2-Hydroxybenzylamine (2-HOBA) is a novel therapeutic that scavenges isolevuglandins-a downstream mediator of inflammation and oxidative stress. 2-HOBA is safe and reduces AF in mice, prompting a first-in-human pilot clinical trial.

Methods: Participants were enrolled and randomized 1:1 to placebo or 2-HOBA (750 mg p.o. TID) 3 days before a planned AF ablation. Participants were monitored for 28 days after their ablation for recurrence of AF as detected by smartwatch single-lead ECG recordings. Blood was collected at the time of ablation for measurement of isolevuglandin levels. The study drug was stopped at 28 days. A 12-month extended follow-up period was used to monitor for any residual effect of the study drug on AF recurrence.

Results: 2-HOBA increased the risk of AF recurrence in the postablation population (odds ratio, 3.65 [95% CI, 1.31-10.16]; P=0.013) after prespecified adjustment for potential confounders. This increased risk of recurrence remained despite post hoc adjustment for other clinical risk factors. There was no difference in isolevuglandin levels between the 2-HOBA and placebo groups. After the study drug was stopped, there was no difference in AF recurrence between the 2-HOBA and placebo groups during the 12-month extended follow-up.

Conclusions: 2-HOBA was associated with a higher risk of AF recurrence when tested early after AF ablation. This result was unexpected based on preclinical data, but paradoxical associations with AF have been previously reported for other drugs that target inflammation and oxidative stress pathways, such as omega-3 fatty acids. The mechanisms for AF immediately following ablation may be different from AF that occurs under other conditions, and the generalizability of these results to all forms of AF remains unknown.

Background: In patients with nonischemic cardiomyopathy and no late gadolinium enhancement (LGE) on cardiac magnetic resonance, risk prediction for the occurrence of sustained ventricular arrhythmias (VA) is challenging. Global and regional sympathetic denervation has been associated with VA in patients with ischemic cardiomyopathy. Its prognostic relevance in nonischemic cardiomyopathy is unknown.

Methods: Consecutive patients from the Leiden Nonischemic Cardiomyopathy Study who underwent programmed electrical stimulation, LGE-cardiac magnetic resonance, and 123-iodine meta-iodobenzylguanidine imaging between 2011 and 2019 were included. The presence of LGE and global and regional sympathetic denervation on 123-iodine meta-iodobenzylguanidine were evaluated, and patients were followed for the occurrence of VA. Global denervation was assessed using the heart-to-mediastinum ratio. Regional denervation was evaluated by calculating the number of denervated segments (DS), the ratio of DS, the summed defect score, and the weighted denervation size.

Results: Of 75 included patients (median age 63 years [25th-75th interquartile range (IQR) 54-68], 79% male, left ventricular ejection fraction 36% [IQR, 27-44], 37% inducible for VA), 35 had no LGE. During 4.5±1.6 years of mean follow-up, VA occurred in 8 of 35 (23%) patients without LGE and in 18 of 40 (45%) patients with LGE. Among patients without LGE, those with VA had greater regional sympathetic denervation (median number of DS 8 [IQR, 7-10] versus 2 [IQR, 1-5], P=0.004; median ratio of DS 0.5 [IQR, 0.5-0.7] versus 0.2 [IQR, 0.1-0.4], P=0.007; median defect score 36 [IQR, 30-41] versus 18 [IQR, 14-24], P=0.01; median weighted denervation size 47 [IQR, 38-54] versus 22 [IQR, 14-30]; P=0.01). In bivariate analysis, the number of DS (hazard ratio, 1.25 [95% CI, 1.06-1.46]; P=0.006) was associated with the occurrence of VA in patients without LGE. Denervation of ≥7 segments identified patients without LGE at risk for VA (area under the curve, 0.83; sensitivity, 88%; specificity, 89%). Among patients with LGE, the innervation state was not associated with VA during follow-up.

Conclusions: In patients with nonischemic cardiomyopathy without LGE the extent of regional denervation may contribute to risk stratification for VA.

Background: Frequent nonphysiological ventricular pacing and resultant pacing-induced cardiomyopathy are well characterized in transvenous pacemakers (TVP). The incidence of pacing-induced cardiomyopathy in leadless pacemakers (LP) is less understood, particularly compared with TVP.

Methods: We utilized the TriNetX Analytics Network database to identify 2594 propensity score-matched patients who underwent implantation of LP and TVP between January 1, 2016, and January 1, 2023. The primary outcome was the incidence of pacing-induced cardiomyopathy, defined as a new diagnosis of systolic heart failure or a left ventricular ejection fraction <50%, occurring from the index hospitalization through December 2024, after excluding other etiologies of heart failure.

Results: The median age of the study population was 73.8 years (±15). Baseline left ventricular ejection fraction was similar between groups (LP: 63±7 versus TVP: 64±8). During a median follow-up period of 2.4 years, 422 incident cases of PCM occurred. Incidence rates of pacing-induced cardiomyopathy were comparable (LP: 7.6% versus TVP: 8.6%; P=0.187), including in patients with pacing indications of complete heart block or atrioventricular nodal ablation (LP: 10.3% versus TVP: 10.4%; P=0.948). The mean drop in left ventricular ejection fraction was comparable between both groups; however, patients with LP were less likely to undergo cardiac resynchronization therapy upgrade compared with those with TVP (LP: 9.7% versus TVP: 17.5%; P=0.014).

Conclusions: The incidence and characteristics of pacing-induced cardiomyopathy are similar between LP and TVP. However, patients with LP are less likely to undergo cardiac resynchronization therapy upgrade.

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia. Its detection rates vary significantly across ethnic groups, impacting epidemiological and clinical outcomes. We aim to explore ethnic differences in self-reported versus hospital-reported AF using the MESA (Multi-Ethnic Study of Atherosclerosis).

Methods: Six thousand seven hundred seventy-five adults aged 45 to 84 years, free from baseline AF and major cardiovascular events, were monitored over 8.4 years (2000-2012) across 6 US locations. AF incidence was measured via hospital discharge International Classification of Diseases codes and self-reported data, validated by follow-up questionnaires. AF incidence per 1000 person-years was assessed by ethnic group and reporting method. Incidence rate ratios and adjusted hazard ratios were calculated with White participants as the referent group.

Results: The study comprised 2611 White, 800 Chinese, 1485 Hispanic, and 1879 Black participants, with a mean age of 62.15 (10.24) years; 47.1% were male. Chinese had significantly lower incidence rate ratio (0.40 [95% CI, 0.19-0.75]; P=0.009) for AF reported only during hospitalization, whereas Hispanic group had significantly lower incidence rate ratio (0.29 [95% CI, 0.15-0.51]; P<0.001) for AF only via self-reporting. The combined overall reported AF incidence was 6.4%, or 7.72 per 1000 person-years, highest in the White group (10.69 per 1000 person-years) and lower in in Chinese (6.43 [95% CI, 4.61-8.71]; P=0.003), Hispanics (4.79 [95% CI, 3.61-6.24]; P<0.001), and Blacks (6.39 [95% CI, 5.16-7.84]; P<0.001).

Conclusions: The reported incidence of AF varies with the inclusion of self-reported data and across ethnic and racial groups. The inclusion of self-reported data increased the reported incidence of AF the most among Chinese individuals and the least among Hispanic participants. In the MESA study, the inclusion of self-reported data reveals heterogeneous changes across ethnic and racial groups, which may be due to differences in true incidence, methods of ascertainment, symptom perception, or health care access, and deserves further exploration.

Pulsed field ablation (PFA) has been developed as a largely nonthermal ablation technology with a unique biophysical profile to treat atrial fibrillation. Existing evidence has shown that PFA offers a safe and efficient atrial fibrillation ablation procedure. Among different PFA technologies, the pentaspline FARAPULSE system has been the most extensively used and investigated; however, notable variability exists in workflow, fluoroscopy time, and lesion durability. While innovations such as 3-dimensional electroanatomic mapping systems and intracardiac echocardiography can enhance procedural precision in catheter ablation, fluoroscopy remains the primary imaging modality for guiding pentaspline PFA in many electrophysiology labs worldwide. This is particularly true in centers where limitations in cost, infrastructure, or training may preclude the routine use of advanced imaging technologies. This article summarizes general practical considerations and presents a primarily fluoroscopy-based, refined workflow developed by a group of experts. The goal is to provide a procedural foundation and practical guide for using the pentaspline FARAPULSE PFA system in atrial fibrillation ablation procedures. Developing a fluoroscopy-based practical guide would: (1) Democratize access to PFA technology, enabling safe and effective implementation across a broader range of clinical settings, including those without intracardiac echocardiography or 3-dimensional mapping support; (2) Reduce procedural heterogeneity by offering reproducible best practices; (3) Facilitate meaningful intercenter comparisons of procedural efficacy and safety, aiding in the identification of optimal approaches and improving the quality of clinical data for ongoing research, registries, and real-world performance monitoring of PFA technologies; and (4) Ultimately improve patient outcomes through standardized, accessible, and evidence-based practices.

Background: Cryoballoon pulmonary vein isolation has become an established treatment for atrial fibrillation (AF). However, data on long-term outcomes beyond 5 years are scarce. This prospective analysis aimed to evaluate the long-term outcome after cryoballoon pulmonary vein isolation.

Methods: Data from consecutive patients treated with cryoballoon pulmonary vein isolation for symptomatic AF between 2012 and 2018 in 13 institutions were analyzed. Patients with ≥5-year follow-up after the index procedure were included. Arrhythmia recurrence was defined as AF or atrial tachycardia lasting >30 seconds beyond a 3-month blanking period.

Results: A total of 1330 patients were enrolled (28.4% female patients, mean age was 60.1±10.5 years). Patients with paroxysmal AF accounted for 73.1%; the median history of AF was 36.0 (13.0-75.0) months. The rate of AF/atrial tachycardia recurrences progressively increased over time (event rate: 52.5% [49.4%-55.8%] at 8-year follow-up). A low incidence of progression to permanent AF was seen in the entire cohort (7.0%). Importantly, 15.7% of patients underwent a redo ablation for AF during follow-up; in 45.9% of these cases, all PVs were isolated at the redo procedure, with a median number of PVs isolated after the index procedure being 3 (1-4) veins. Independent predictors of arrhythmia recurrences were AF type (persistent AF: hazard ratio, 1.36 [95% CI, 1.14-1.62]; P<0.001) and chronic kidney disease (hazard ratio, 1.77 [95% CI, 1.12-2.81]; P=0.016) in multivariate analysis.

Conclusions: Cryoballoon pulmonary vein isolation as the index procedure for AF ablation resulted in a favorable long-term outcome in patients with symptomatic AF, with limited progression towards permanent AF during follow-up. Persistent AF was the strongest predictor of recurrences at long-term follow-up.

Background: Blocking a line depends not only on the ablation but also on the validation technique. We sought to compare the performance of different pacing modes for roof line validation.

Methods: Fifty consecutive patients underwent atrial fibrillation ablation, which included a roof line and a floor line. Floor line block was mandatory for clear evaluation of the roof line, the block of which was demonstrated by a box isolation of the dome. Before floor line creation, first-pass roof line evaluation was based on high-density mapping while pacing from either: (1) the left appendage; (2) just above the line; or (3) with an overlapping multispline catheter.

Results: Roof line mapping was feasible in all patients (100%) during left appendage and nearby pacing, and in 45 (90%) patients during overlap pacing. Left appendage pacing sensitivity for true gaps was significantly lower than nearby (48% versus 97%; P<0.001) and overlap (48% versus 93%; P<0.001) pacing. Left appendage pacing negative predictive value for true block was significantly lower than nearby (50% versus 94%; P=0.001) and overlap (50% versus 89%; P=0.004) pacing. Double potentials during left appendage pacing were shorter than during nearby pacing (63±20 ms versus 103±22 ms; P<0.001). In 1 patient, a slow conduction gap was unmasked only after floor line block. Final box isolation of the dome was achieved in 47 (94%) patients.

Conclusions: The longer the activation delay from one side of a line to the other, the greater the chance to unmask a slow conduction gap across the line. Nearby pacing thus better identifies roof line gaps than left appendage pacing. Overlap pacing offers a simple and fast alternative with similar performance.