Background In complete atrioventricular block (AVB) with underlying sinus rhythm, it is recommended to implant a dual-chamber pacemaker rather than a single-chamber pacemaker. However, no large-scale study has been able to demonstrate the superiority of this choice on hard clinical criteria such as morbimortality. Methods This retrospective observational study included all patients who received a primary pacemaker implantation in the indication of complete AVB with underlying sinus rhythm in France, based on the national administrative database between January 2013 and December 2022. Results After propensity score matching, we obtained two groups containing 19,219 patients each. The incidence of all-cause mortality was 9.22%/year for the dual-chamber pacemaker group, compared with 11.48%/year for the single-chamber pacemaker group (HR 0.807, p<0.0001). Similarly, there was a lower incidence of cardiovascular mortality (HR 0.766, p<0.0001), heart failure (HR 0.908, p<0.0001), atrial fibrillation (HR 0.778, p<0.0001) and ischemic stroke (HR 0.873, p=0.008) in the dual-chamber pacemaker group than in the single-chamber pacemaker group. Regarding reinterventions and complications, there were fewer upgrades (addition of atrial lead or left ventricular lead) in the dual chamber group (HR 0.210, p<0.0001), but more hematomas (HR 1.179, p=0.006) and lead repositioning (HR 1.123, p=0.04). Conclusion In the indication of complete AVB with underlying sinus rhythm, our results are consistent with current recommendations to prefer implantation of a dual-chamber pacemaker rather than a single-chamber pacemaker for these patients. Implantation of a dual-chamber pacemaker is associated with a lower risks of mortality, heart failure, atrial fibrillation, and stroke during follow-up.
{"title":"Dual chamber versus single chamber pacemaker in patients in sinus rhythm with an atrioventricular block: a nationwide cohort study","authors":"Alexandre Bodin, Ivann Texier, Arnaud Bisson, Bertrand Pierre, Julien Herbert, Mathieu Jacobs, Mathieu Nasarre, Anne Bernard, Laurent Fauchier","doi":"10.1093/europace/euae238","DOIUrl":"https://doi.org/10.1093/europace/euae238","url":null,"abstract":"Background In complete atrioventricular block (AVB) with underlying sinus rhythm, it is recommended to implant a dual-chamber pacemaker rather than a single-chamber pacemaker. However, no large-scale study has been able to demonstrate the superiority of this choice on hard clinical criteria such as morbimortality. Methods This retrospective observational study included all patients who received a primary pacemaker implantation in the indication of complete AVB with underlying sinus rhythm in France, based on the national administrative database between January 2013 and December 2022. Results After propensity score matching, we obtained two groups containing 19,219 patients each. The incidence of all-cause mortality was 9.22%/year for the dual-chamber pacemaker group, compared with 11.48%/year for the single-chamber pacemaker group (HR 0.807, p&lt;0.0001). Similarly, there was a lower incidence of cardiovascular mortality (HR 0.766, p&lt;0.0001), heart failure (HR 0.908, p&lt;0.0001), atrial fibrillation (HR 0.778, p&lt;0.0001) and ischemic stroke (HR 0.873, p=0.008) in the dual-chamber pacemaker group than in the single-chamber pacemaker group. Regarding reinterventions and complications, there were fewer upgrades (addition of atrial lead or left ventricular lead) in the dual chamber group (HR 0.210, p&lt;0.0001), but more hematomas (HR 1.179, p=0.006) and lead repositioning (HR 1.123, p=0.04). Conclusion In the indication of complete AVB with underlying sinus rhythm, our results are consistent with current recommendations to prefer implantation of a dual-chamber pacemaker rather than a single-chamber pacemaker for these patients. Implantation of a dual-chamber pacemaker is associated with a lower risks of mortality, heart failure, atrial fibrillation, and stroke during follow-up.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"19 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248041","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-13DOI: 10.1093/europace/euae235
Bulent Gorenek, Adrianus P Wijnmaalen, Andreas Goette, Gurbet Ozge Mert, Bradley Porter, Finn Gustafsson, Gheorghe Andrei Dan, Joris Ector, Markus Stuehlinger, Michael Spartalis, Nils Gosau, Offer Amir, Ovidiu Chioncel
Patients presenting with or alerting emergency networks due to acute heart failure (AHF) form a diverse group with a plethora of symptoms, risks, comorbidities, and aetiologies. During AHF, there is an increased risk of destabilizing the functional substrate and modulatory adding to the risk of ventricular arrhythmias (VAs) already created by the structural substrate. New VAs during AHF have previously identified patients with higher intra-hospital and 60-day morbidity and mortality. Risk stratification and criteria/best time point for coronary intervention and implantable cardioverter defibrillator (ICD) implantation, however, are still controversial topics in this difficult clinical setting. The characteristics and logistics of prehospital emergency medicine, as well as the density of centers capable of treating AHF and VAs, differ massively throughout Europe. Scientific guidelines provide clear recommendations for the management of arrhythmias in chronic HF patients. However, the incidence, significance, and management of arrhythmias in patients with AHF have been less studied. This consensus paper aimed to address the identification and treatment of VAs that complicate the course of patients who have AHF, including cardiogenic shock.
{"title":"Ventricular Arrhythmias in Acute Heart Failure. A Clinical Consensus Statement of the Association for Acute CardioVascular Care Association (ACVC), the European Heart Rhythm Association (EHRA) and the Heart Failure Association (HFA) of the ESC","authors":"Bulent Gorenek, Adrianus P Wijnmaalen, Andreas Goette, Gurbet Ozge Mert, Bradley Porter, Finn Gustafsson, Gheorghe Andrei Dan, Joris Ector, Markus Stuehlinger, Michael Spartalis, Nils Gosau, Offer Amir, Ovidiu Chioncel","doi":"10.1093/europace/euae235","DOIUrl":"https://doi.org/10.1093/europace/euae235","url":null,"abstract":"Patients presenting with or alerting emergency networks due to acute heart failure (AHF) form a diverse group with a plethora of symptoms, risks, comorbidities, and aetiologies. During AHF, there is an increased risk of destabilizing the functional substrate and modulatory adding to the risk of ventricular arrhythmias (VAs) already created by the structural substrate. New VAs during AHF have previously identified patients with higher intra-hospital and 60-day morbidity and mortality. Risk stratification and criteria/best time point for coronary intervention and implantable cardioverter defibrillator (ICD) implantation, however, are still controversial topics in this difficult clinical setting. The characteristics and logistics of prehospital emergency medicine, as well as the density of centers capable of treating AHF and VAs, differ massively throughout Europe. Scientific guidelines provide clear recommendations for the management of arrhythmias in chronic HF patients. However, the incidence, significance, and management of arrhythmias in patients with AHF have been less studied. This consensus paper aimed to address the identification and treatment of VAs that complicate the course of patients who have AHF, including cardiogenic shock.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"525 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248042","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1093/europace/euae240
Kazutaka Nakasone, Makoto Nishimori, Masakazu Shinohara, Mitsuru Takami, Kimitake Imamura, Taku Nishida, Akira Shimane, Yasushi Oginosawa, Yuki Nakamura, Yasuteru Yamauchi, Ryudo Fujiwara, Hiroyuki Asada, Akihiro Yoshida, Kaoru Takami, Tomomi Akita, Takayuki Nagai, Philipp Sommer, Mustapha El Hamriti, Hiroshi Imada, Luigi Pannone, Andrea Sarkozy, Gian Battista Chierchia, Carlo de Asmundis, Kunihiko Kiuchi, Ken-ichi Hirata, Koji Fukuzawa
Background Several algorithms can differentiate inferior axis premature ventricular contractions (PVCs) originating from the right side and left side on 12-lead electrocardiograms (ECGs). However, it is unclear whether distinguishing the origin should rely solely on PVC or incorporate sinus rhythm (SR). Aims We compared the Dual-Rhythm model (incorporating both SR and PVC) to the PVC model (using PVC alone), and quantified the contribution of each ECG lead in predicting the PVC origin for each cardiac rotation. Methods This multicenter study enrolled 593 patients from 11 centers—493 from Japan and Germany, and 100 from Belgium, which used as the external validation dataset. Using a hybrid approach combining a Resnet50-based convolutional neural network and a Transformer model, we developed two variants—the PVC and Dual-Rhythm models—to predict PVC origin. Results In the external validation dataset, the Dual-Rhythm model outperformed the PVC model in accuracy (0.84 vs. 0.74, respectively; p < 0.01), precision (0.73 vs. 0.55, respectively; p < 0.01), specificity (0.87 vs. 0.68, respectively; p < 0.01), area under the receiver operating characteristic curve (0.91 vs. 0.86, respectively; p = 0.03), and F1-Score (0.77 vs. 0.68, respectively; p = 0.03). The contributions to PVC origin prediction were 77.3% for PVC and 22.7% for the SR. However, in patients with counterclockwise rotation, SR had a greater contribution in predicting the origin of right-sided PVC. Conclusions Our deep learning-based model, incorporating both PVC and SR morphologies, resulted in a higher prediction accuracy for PVC origin. Considering SR is particularly important for predicting right-sided origin in patients with counterclockwise rotation.
背景 有几种算法可以区分 12 导联心电图（ECG）上源于右侧和左侧的下轴型室性早搏（PVC）。然而，目前还不清楚区分起源是仅依靠 PVC 还是结合窦性心律（SR）。目的 我们比较了双节律模型（同时包含 SR 和 PVC）和 PVC 模型（仅使用 PVC），并量化了每个心电图导联在预测每个心脏旋转的 PVC 起因方面的贡献。方法 这项多中心研究从 11 个中心招募了 593 名患者，其中 493 名来自日本和德国，100 名来自比利时，作为外部验证数据集。我们采用基于 Resnet50 的卷积神经网络和 Transformer 模型相结合的混合方法，开发了两个变体--PVC 模型和双节律模型--来预测 PVC 起源。01）、特异性（分别为 0.87 vs. 0.68；pamp &;lt;0.01）、接收者操作特征曲线下面积（分别为 0.91 vs. 0.86；p = 0.03）和 F1-Score （分别为 0.77 vs. 0.68；p = 0.03）。预测 PVC 起始点的贡献率为 77.3%，预测 SR 的贡献率为 22.7%。然而，在逆时针旋转的患者中，SR 对预测右侧 PVC 起因的贡献更大。结论 我们基于深度学习的模型结合了 PVC 和 SR 形态，对 PVC 起源的预测准确率更高。考虑 SR 对预测逆时针旋转患者的右侧起源尤为重要。
{"title":"Enhancing Origin Prediction: Deep Learning Model for Diagnosing Premature Ventricular Contractions with Dual-Rhythm Analysis Focused on Cardiac Rotation","authors":"Kazutaka Nakasone, Makoto Nishimori, Masakazu Shinohara, Mitsuru Takami, Kimitake Imamura, Taku Nishida, Akira Shimane, Yasushi Oginosawa, Yuki Nakamura, Yasuteru Yamauchi, Ryudo Fujiwara, Hiroyuki Asada, Akihiro Yoshida, Kaoru Takami, Tomomi Akita, Takayuki Nagai, Philipp Sommer, Mustapha El Hamriti, Hiroshi Imada, Luigi Pannone, Andrea Sarkozy, Gian Battista Chierchia, Carlo de Asmundis, Kunihiko Kiuchi, Ken-ichi Hirata, Koji Fukuzawa","doi":"10.1093/europace/euae240","DOIUrl":"https://doi.org/10.1093/europace/euae240","url":null,"abstract":"Background Several algorithms can differentiate inferior axis premature ventricular contractions (PVCs) originating from the right side and left side on 12-lead electrocardiograms (ECGs). However, it is unclear whether distinguishing the origin should rely solely on PVC or incorporate sinus rhythm (SR). Aims We compared the Dual-Rhythm model (incorporating both SR and PVC) to the PVC model (using PVC alone), and quantified the contribution of each ECG lead in predicting the PVC origin for each cardiac rotation. Methods This multicenter study enrolled 593 patients from 11 centers—493 from Japan and Germany, and 100 from Belgium, which used as the external validation dataset. Using a hybrid approach combining a Resnet50-based convolutional neural network and a Transformer model, we developed two variants—the PVC and Dual-Rhythm models—to predict PVC origin. Results In the external validation dataset, the Dual-Rhythm model outperformed the PVC model in accuracy (0.84 vs. 0.74, respectively; p &lt; 0.01), precision (0.73 vs. 0.55, respectively; p &lt; 0.01), specificity (0.87 vs. 0.68, respectively; p &lt; 0.01), area under the receiver operating characteristic curve (0.91 vs. 0.86, respectively; p = 0.03), and F1-Score (0.77 vs. 0.68, respectively; p = 0.03). The contributions to PVC origin prediction were 77.3% for PVC and 22.7% for the SR. However, in patients with counterclockwise rotation, SR had a greater contribution in predicting the origin of right-sided PVC. Conclusions Our deep learning-based model, incorporating both PVC and SR morphologies, resulted in a higher prediction accuracy for PVC origin. Considering SR is particularly important for predicting right-sided origin in patients with counterclockwise rotation.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"36 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-11DOI: 10.1093/europace/euae223
Karli Gillette, Benjamin Winkler, Stefan Kurath-Koller, Daniel Scherr, Edward J Vigmond, Markus Bär, Gernot Plank
Wolff-Parkinson-White syndrome is a cardiovascular disease characterized by abnormal atrio-ventricular conduction facilitated by accessory pathways (APs). Invasive catheter ablation of the AP represents the primary treatment modality. Accurate localization of APs is crucial for successful ablation outcomes, but current diagnostic algorithms based on the 12 lead electrocardiogram (ECG) often struggle with precise determination of AP locations. In order to gain insight into the mechanisms underlying localization failures observed in current diagnostic algorithms, we employ a virtual cardiac model to elucidate the relationship between AP location and ECG morphology. We first introduce a cardiac model of electrophysiology that was specifically tailored to represent antegrade APs in the form of a short atrio-ventricular bypass tract. Locations of antegrade APs were then automatically swept across both ventricles in the virtual model to generate a synthetic ECG database consisting of 9271 signals. Regional grouping of antegrade APs revealed overarching morphological patterns originating from diverse cardiac regions. We then applied variance-based sensitivity analysis relying on polynomial chaos expansion on the ECG database to mathematically quantify how variation in AP location and timing relates to morphological variation in the 12 lead ECG. We utilized our mechanistic virtual model to showcase limitations of AP localization using standard ECG-based algorithms and provide mechanistic explanations through exemplary simulations. Our findings highlight the potential of virtual models of cardiac electrophysiology not only to deepen our understanding of the underlying mechanisms of Wolff-Parkinson-White syndrome but also to potentially enhance the diagnostic accuracy of ECG-based algorithms and facilitate personalized treatment planning.
沃尔夫-帕金森-怀特综合征是一种心血管疾病，其特征是由附属通路（AP）引起的房室传导异常。有创导管消融 AP 是主要的治疗方式。AP 的准确定位对成功消融至关重要，但目前基于 12 导联心电图（ECG）的诊断算法往往难以精确确定 AP 的位置。为了深入了解当前诊断算法中观察到的定位失败的内在机制，我们采用了一个虚拟心脏模型来阐明 AP 位置与心电图形态之间的关系。我们首先引入了一个心脏电生理学模型，该模型是专门为表示短的房室旁路束形式的逆行 AP 而定制的。然后，在虚拟模型中自动扫描两个心室的逆行 AP 位置，生成由 9271 个信号组成的合成心电图数据库。对前向 APs 进行区域分组显示了源自不同心脏区域的总体形态模式。然后，我们利用多项式混沌扩展对心电图数据库进行了基于方差的敏感性分析，从数学角度量化了 AP 位置和时间的变化与 12 导联心电图形态变化的关系。我们利用机理虚拟模型展示了使用基于心电图的标准算法进行 AP 定位的局限性，并通过示例模拟提供了机理解释。我们的研究结果凸显了心脏电生理学虚拟模型的潜力，它不仅能加深我们对沃尔夫-帕金森-怀特综合征内在机制的理解，还能潜在地提高基于心电图算法的诊断准确性，促进个性化治疗计划的制定。
{"title":"A computational study on the influence of antegrade accessory pathway location on the 12-lead electrocardiogram in Wolff-Parkinson-White syndrome","authors":"Karli Gillette, Benjamin Winkler, Stefan Kurath-Koller, Daniel Scherr, Edward J Vigmond, Markus Bär, Gernot Plank","doi":"10.1093/europace/euae223","DOIUrl":"https://doi.org/10.1093/europace/euae223","url":null,"abstract":"Wolff-Parkinson-White syndrome is a cardiovascular disease characterized by abnormal atrio-ventricular conduction facilitated by accessory pathways (APs). Invasive catheter ablation of the AP represents the primary treatment modality. Accurate localization of APs is crucial for successful ablation outcomes, but current diagnostic algorithms based on the 12 lead electrocardiogram (ECG) often struggle with precise determination of AP locations. In order to gain insight into the mechanisms underlying localization failures observed in current diagnostic algorithms, we employ a virtual cardiac model to elucidate the relationship between AP location and ECG morphology. We first introduce a cardiac model of electrophysiology that was specifically tailored to represent antegrade APs in the form of a short atrio-ventricular bypass tract. Locations of antegrade APs were then automatically swept across both ventricles in the virtual model to generate a synthetic ECG database consisting of 9271 signals. Regional grouping of antegrade APs revealed overarching morphological patterns originating from diverse cardiac regions. We then applied variance-based sensitivity analysis relying on polynomial chaos expansion on the ECG database to mathematically quantify how variation in AP location and timing relates to morphological variation in the 12 lead ECG. We utilized our mechanistic virtual model to showcase limitations of AP localization using standard ECG-based algorithms and provide mechanistic explanations through exemplary simulations. Our findings highlight the potential of virtual models of cardiac electrophysiology not only to deepen our understanding of the underlying mechanisms of Wolff-Parkinson-White syndrome but also to potentially enhance the diagnostic accuracy of ECG-based algorithms and facilitate personalized treatment planning.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142222804","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-09DOI: 10.1093/europace/euae229
Jorio Mascheroni, Martin Stockburger, Ashish Patwala, Lluís Mont, Archana Rao, Hartwig Retzlaff, Christophe Garweg, Anthony G Gallagher, Tom Verbelen
Aims In cardiac device implantation, having both surgical skills and ability to manipulate catheter/lead/wire is crucial. Few cardiologists, however, receive formal surgical training prior to implanting. Skills are mostly acquired directly on-the-job and surgical technique varies across institutions; suboptimal approaches may increase complications. We investigated how novel proficiency-based progression (PBP) simulation training impacts the surgical quality of implantations, compared to traditional simulation (SIM) training. Methods In this international prospective study, novice implanters were randomized (blinded) 1:1 to participate in a simulation-based procedure training curriculum, with proficiency demonstration requirements for advancing (PBP approach) or without (SIM). Ultimately, trainees performed the surgical tasks of an implant on a porcine tissue which was video-recorded and then scored by two independent assessors (blinded to group), using previously validated performance metrics. Primary outcomes were the number of procedural Steps Completed, Critical Errors, Errors (non-critical) and All Errors Combined. Results Thirty novice implanters from 10 countries participated. Baseline experiences were similar between groups. Compared to SIM-trained, the PBP-trained group completed on average 11% more procedural Steps (p<0.001) and made 61.2% fewer Critical Errors (p<0.001), 57.1% fewer Errors (p=0.140), 60.7% fewer All Errors Combined (p=0.001); 11/15 (73%) PBP-trainees demonstrated the predefined target performance level vs 3/15 SIM-trainees (20%) in the video-recorded performance. Conclusions PBP training produces superior objectively assessed novice operators’ surgical performance in device implantation compared with traditional (simulation) training. Systematic PBP incorporation into formal academic surgical skills training is recommended before in-vivo device practice. Future studies will quantify PBP training’s effect on surgery-related device complications.
{"title":"Surgical Skill Simulation Training to Proficiency Reduces Procedural Errors among Novice Cardiac Device Implanters. A Randomized Study","authors":"Jorio Mascheroni, Martin Stockburger, Ashish Patwala, Lluís Mont, Archana Rao, Hartwig Retzlaff, Christophe Garweg, Anthony G Gallagher, Tom Verbelen","doi":"10.1093/europace/euae229","DOIUrl":"https://doi.org/10.1093/europace/euae229","url":null,"abstract":"Aims In cardiac device implantation, having both surgical skills and ability to manipulate catheter/lead/wire is crucial. Few cardiologists, however, receive formal surgical training prior to implanting. Skills are mostly acquired directly on-the-job and surgical technique varies across institutions; suboptimal approaches may increase complications. We investigated how novel proficiency-based progression (PBP) simulation training impacts the surgical quality of implantations, compared to traditional simulation (SIM) training. Methods In this international prospective study, novice implanters were randomized (blinded) 1:1 to participate in a simulation-based procedure training curriculum, with proficiency demonstration requirements for advancing (PBP approach) or without (SIM). Ultimately, trainees performed the surgical tasks of an implant on a porcine tissue which was video-recorded and then scored by two independent assessors (blinded to group), using previously validated performance metrics. Primary outcomes were the number of procedural Steps Completed, Critical Errors, Errors (non-critical) and All Errors Combined. Results Thirty novice implanters from 10 countries participated. Baseline experiences were similar between groups. Compared to SIM-trained, the PBP-trained group completed on average 11% more procedural Steps (p&lt;0.001) and made 61.2% fewer Critical Errors (p&lt;0.001), 57.1% fewer Errors (p=0.140), 60.7% fewer All Errors Combined (p=0.001); 11/15 (73%) PBP-trainees demonstrated the predefined target performance level vs 3/15 SIM-trainees (20%) in the video-recorded performance. Conclusions PBP training produces superior objectively assessed novice operators’ surgical performance in device implantation compared with traditional (simulation) training. Systematic PBP incorporation into formal academic surgical skills training is recommended before in-vivo device practice. Future studies will quantify PBP training’s effect on surgery-related device complications.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"2 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142227861","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-08DOI: 10.1093/europace/euae232
Luca Aerts, Michal J Kawczynski, Elham Bidar, Justin Luermans, Marisevi Chaldoupi, Mark La Meir, Mariusz Kowaleski, Jos G Maessen, Samuel Heuts, Bart Maesen
Background and aims Both isolated thoracoscopic and hybrid thoracoscopic atrial fibrillation (AF) ablation techniques have demonstrated favorable outcomes in the management of patients with (long-standing) persistent AF, as compared to catheter ablation. However, it is currently unknown whether there is a difference in short- and long-term outcomes when comparing these two minimally invasive surgical AF ablation procedures. Therefore, a systematic review and meta-analysis were performed to investigate these two techniques, with a specific emphasis on long-term freedom from atrial tachyarrhythmias (ATA) Methods A systematic search through PubMed, EMBASE, and the Cochrane Library databases was performed. All studies reporting on short-term outcomes were included in the meta-analysis. A pooled analysis of long-term freedom from ATA was performed based on Kaplan-Meier (KM) curve-derived individual patient data (IPD). Reconstructed individual time-to-event data were analyzed in a multivariable Cox frailty model with adjustments for age, sex, type of AF, duration of AF history, and study variable (frailty term in the frailty Cox model). Results In total, 53 studies were included in the meta-analysis, encompassing 4950 patients. There were no differences in major short-term outcomes (mortality or stroke) between isolated thoracoscopic and hybrid thoracoscopic ablation. A total of 18 studies reported KM curves for long-term freedom from ATA, comprising 2038 patients. Adjusted analysis revealed that hybrid ablation was significantly associated with greater freedom from ATA (Adjusted Hazard Ratio [aHR]=0.59, 95%CI: 0.43-0.83, p<0.001) compared to isolated thoracoscopic ablation. Additionally, older age (aHR=1.07, 95%CI: 1.03-1.12, p=0.002) and a higher percentage of male patients (aHR=1.02, 95% CI: 1.01-1.03, p<0.001) were significantly associated with lower long-term freedom from ATA recurrence. Conclusion Hybrid thoracoscopic AF-ablation is associated with a greater long-term freedom from ATA when compared to isolated thoracoscopic ablation, without differences in complications.
背景和目的 与导管消融术相比，孤立胸腔镜和混合胸腔镜心房颤动（房颤）消融技术在治疗（长期）持续性房颤患者方面都取得了良好的疗效。然而，目前尚不清楚这两种微创手术房颤消融术的短期和长期疗效是否存在差异。因此，我们对这两种技术进行了系统性回顾和荟萃分析，特别强调了长期免于房性快速性心律失常（ATA）的情况。所有报告短期结果的研究都纳入了荟萃分析。根据 Kaplan-Meier (KM) 曲线得出的单个患者数据 (IPD) 对长期免于 ATA 进行了汇总分析。在多变量 Cox 衰弱模型中分析了重建的个体事件时间数据，并对年龄、性别、房颤类型、房颤病史持续时间和研究变量（衰弱 Cox 模型中的衰弱项）进行了调整。结果 本次荟萃分析共纳入 53 项研究，涵盖 4950 名患者。孤立胸腔镜消融术和混合胸腔镜消融术在主要短期结果（死亡率或中风）方面没有差异。共有18项研究报告了长期免于ATA的KM曲线，其中包括2038名患者。调整后的分析显示，与孤立胸腔镜消融术相比，混合消融术与更大的 ATA 自由度显著相关（调整后危险比 [aHR]=0.59, 95%CI: 0.43-0.83，p<0.001）。此外，年龄越大（aHR=1.07，95%CI：1.03-1.12，p=0.002）、男性患者比例越高（aHR=1.02，95%CI：1.01-1.03，p<0.001），ATA 长期复发率越低。结论 与孤立的胸腔镜消融术相比，混合胸腔镜房颤消融术与更高的 ATA 长期免复发率相关，但并发症方面无差异。
{"title":"Short- and long-term outcomes in thoracoscopic versus hybrid thoracoscopic ablation in patients with atrial fibrillation: a systematic review and reconstructed individual patient data meta-analysis.","authors":"Luca Aerts, Michal J Kawczynski, Elham Bidar, Justin Luermans, Marisevi Chaldoupi, Mark La Meir, Mariusz Kowaleski, Jos G Maessen, Samuel Heuts, Bart Maesen","doi":"10.1093/europace/euae232","DOIUrl":"https://doi.org/10.1093/europace/euae232","url":null,"abstract":"Background and aims Both isolated thoracoscopic and hybrid thoracoscopic atrial fibrillation (AF) ablation techniques have demonstrated favorable outcomes in the management of patients with (long-standing) persistent AF, as compared to catheter ablation. However, it is currently unknown whether there is a difference in short- and long-term outcomes when comparing these two minimally invasive surgical AF ablation procedures. Therefore, a systematic review and meta-analysis were performed to investigate these two techniques, with a specific emphasis on long-term freedom from atrial tachyarrhythmias (ATA) Methods A systematic search through PubMed, EMBASE, and the Cochrane Library databases was performed. All studies reporting on short-term outcomes were included in the meta-analysis. A pooled analysis of long-term freedom from ATA was performed based on Kaplan-Meier (KM) curve-derived individual patient data (IPD). Reconstructed individual time-to-event data were analyzed in a multivariable Cox frailty model with adjustments for age, sex, type of AF, duration of AF history, and study variable (frailty term in the frailty Cox model). Results In total, 53 studies were included in the meta-analysis, encompassing 4950 patients. There were no differences in major short-term outcomes (mortality or stroke) between isolated thoracoscopic and hybrid thoracoscopic ablation. A total of 18 studies reported KM curves for long-term freedom from ATA, comprising 2038 patients. Adjusted analysis revealed that hybrid ablation was significantly associated with greater freedom from ATA (Adjusted Hazard Ratio [aHR]=0.59, 95%CI: 0.43-0.83, p&lt;0.001) compared to isolated thoracoscopic ablation. Additionally, older age (aHR=1.07, 95%CI: 1.03-1.12, p=0.002) and a higher percentage of male patients (aHR=1.02, 95% CI: 1.01-1.03, p&lt;0.001) were significantly associated with lower long-term freedom from ATA recurrence. Conclusion Hybrid thoracoscopic AF-ablation is associated with a greater long-term freedom from ATA when compared to isolated thoracoscopic ablation, without differences in complications.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"95 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142227498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-24DOI: 10.1093/europace/euae102.036
C Guenancia, K Benali, L Garnier, G Duloquin, R Didier, T Pommier, G Laurent, C Vergely, Y Bejot
Background Detection of atrial fibrillation (AF) is critical after ischemic stroke, providing information regarding the mechanism of the event and leading to modification in the antithrombotic strategy. While most guidelines recommend screening patients for AF with 12-lead ECG, telemetry, long-duration Holter monitoring and implantable cardiac monitor (ICM), the optimal timing and combination of such screening tools remain unclear. Objective This study aimed at investigating the suitability of a sequential combination of screening techniques (12-lead ECG, telemetry, in hospital long-lasting Holter monitoring, and ICM in the detection of AF after stroke. Methods Patients without previously known AF admitted to the Dijon University Hospital stroke unit for acute ischemic stroke were prospectively enrolled. After a stepwise screening approach for AF based on admission ECG, telemetry monitoring during the stroke unit stay and long-duration Holter monitoring during hospital stay, cryptogenic stroke patients were implanted of an ICM. Primary endpoint was the presence of AF detected during the 3-year period after stroke based on this sequential screening approach. Results A total of 240 patients were included. Among them, 104 (43.3%) patients had a documented cause of stroke non-related to AF. Among the remaining 136 patients (53.7% male, 70.8±13.7 yo), AF was detected in 82 (60%) patients over the acute screening phase or the 3-year follow-up with ICM. AF was diagnosed using 12-lead ECG, in-hospital telemetry, and in hospital long-lasting Holter monitoring in 17 (13%), 25 (18%), and 18 (13%) patients, respectively. AF was detected after the first 24 hours on the long-lasting Holter monitoring in 66% of patients. Among the 76 (56%) patients classified as cryptogenic after the complete stroke work-up and implanted from an ICM, AF was detected in 22 (29%) patients. AF occurred during the first, second, and third years of implantable monitoring in 14 (18.4%), 5 (6.6%), and 3 (3.9%) patients, respectively (Figure 1). Mean time from ICM implantation to AF diagnosis was 308+/-279 days. Finally, among all AF detected, 72% (60/83) were found during the initial intensive in-hospital screening. Conclusion A stepwise approach for AF screening after ischemic stroke allows the early detection of AF in a substantial number of patients during hospital stay. Even with such proactive initial monitoring strategy, invasive monitoring remains complementary to non-invasive screening tools not to overlook more distant AF episodes. Studies focusing on the relative risk of ischemic stroke recurrence according to AF timing and burden are needed.Figure 1
{"title":"Effectiveness of a stepwise approach for screening of atrial fibrillation after stroke: insights from the SAFAS study","authors":"C Guenancia, K Benali, L Garnier, G Duloquin, R Didier, T Pommier, G Laurent, C Vergely, Y Bejot","doi":"10.1093/europace/euae102.036","DOIUrl":"https://doi.org/10.1093/europace/euae102.036","url":null,"abstract":"Background Detection of atrial fibrillation (AF) is critical after ischemic stroke, providing information regarding the mechanism of the event and leading to modification in the antithrombotic strategy. While most guidelines recommend screening patients for AF with 12-lead ECG, telemetry, long-duration Holter monitoring and implantable cardiac monitor (ICM), the optimal timing and combination of such screening tools remain unclear. Objective This study aimed at investigating the suitability of a sequential combination of screening techniques (12-lead ECG, telemetry, in hospital long-lasting Holter monitoring, and ICM in the detection of AF after stroke. Methods Patients without previously known AF admitted to the Dijon University Hospital stroke unit for acute ischemic stroke were prospectively enrolled. After a stepwise screening approach for AF based on admission ECG, telemetry monitoring during the stroke unit stay and long-duration Holter monitoring during hospital stay, cryptogenic stroke patients were implanted of an ICM. Primary endpoint was the presence of AF detected during the 3-year period after stroke based on this sequential screening approach. Results A total of 240 patients were included. Among them, 104 (43.3%) patients had a documented cause of stroke non-related to AF. Among the remaining 136 patients (53.7% male, 70.8±13.7 yo), AF was detected in 82 (60%) patients over the acute screening phase or the 3-year follow-up with ICM. AF was diagnosed using 12-lead ECG, in-hospital telemetry, and in hospital long-lasting Holter monitoring in 17 (13%), 25 (18%), and 18 (13%) patients, respectively. AF was detected after the first 24 hours on the long-lasting Holter monitoring in 66% of patients. Among the 76 (56%) patients classified as cryptogenic after the complete stroke work-up and implanted from an ICM, AF was detected in 22 (29%) patients. AF occurred during the first, second, and third years of implantable monitoring in 14 (18.4%), 5 (6.6%), and 3 (3.9%) patients, respectively (Figure 1). Mean time from ICM implantation to AF diagnosis was 308+/-279 days. Finally, among all AF detected, 72% (60/83) were found during the initial intensive in-hospital screening. Conclusion A stepwise approach for AF screening after ischemic stroke allows the early detection of AF in a substantial number of patients during hospital stay. Even with such proactive initial monitoring strategy, invasive monitoring remains complementary to non-invasive screening tools not to overlook more distant AF episodes. Studies focusing on the relative risk of ischemic stroke recurrence according to AF timing and burden are needed.Figure 1","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"43 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141148161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-24DOI: 10.1093/europace/euae102.272
E Gul
Aims Three-dimensional mapping systems have been utilized to reduce fluoroscopy and minimize complications in patients with AVNRT. Recently, voltage-gradient mapping has been introduced to visualize low-voltage bridges. However, there are some limitations of voltage assessment due to catheter contract. Therefore, new Slow pathway Late Activation Mapping (SLAM) has been recently used to reveal slow conduction zone in AVNRT patients. Method and materials Seven adult patients with diagnosis of typical AVNRT were included. Electro anatomical mapping systems was used in all patients. Voltage and late activation mapping were performed with high-definition multipolar catheter. His cloud was also tagged in all patients. Voltage of 0.20-0.50 mV was used to delineate voltage-bridges. Latest activation in the SP area along with voltage-guided bridges were targeted with either radiofrequency ablation (RFA) or focal cryoablation (Figure 1 and 2). Results Limited fluoroscopy was used in 4 patients. Acute success was achieved in all patients. Patients had no structural heart disease. Detailed clinical and procedural data was depicted in Table. Cryoablation was used in 2 patients due to very small Koch triangle. Each cryolesion applied for 240 secs and overall, 3-4 lesions were delivered. Ablation at late activation areas successfully eliminated slow pathway. In most of cases, one ablation lesion was adequate to see junctional beats and elimination of dual AV nodal physiology. Conclusion SLAM is effective in guiding catheter ablation of AVNRT, with a complete acute success rate and no recurrences at short-term follow-up.
{"title":"SLAM-guided catheter ablation of AVNRT: single-center experience","authors":"E Gul","doi":"10.1093/europace/euae102.272","DOIUrl":"https://doi.org/10.1093/europace/euae102.272","url":null,"abstract":"Aims Three-dimensional mapping systems have been utilized to reduce fluoroscopy and minimize complications in patients with AVNRT. Recently, voltage-gradient mapping has been introduced to visualize low-voltage bridges. However, there are some limitations of voltage assessment due to catheter contract. Therefore, new Slow pathway Late Activation Mapping (SLAM) has been recently used to reveal slow conduction zone in AVNRT patients. Method and materials Seven adult patients with diagnosis of typical AVNRT were included. Electro anatomical mapping systems was used in all patients. Voltage and late activation mapping were performed with high-definition multipolar catheter. His cloud was also tagged in all patients. Voltage of 0.20-0.50 mV was used to delineate voltage-bridges. Latest activation in the SP area along with voltage-guided bridges were targeted with either radiofrequency ablation (RFA) or focal cryoablation (Figure 1 and 2). Results Limited fluoroscopy was used in 4 patients. Acute success was achieved in all patients. Patients had no structural heart disease. Detailed clinical and procedural data was depicted in Table. Cryoablation was used in 2 patients due to very small Koch triangle. Each cryolesion applied for 240 secs and overall, 3-4 lesions were delivered. Ablation at late activation areas successfully eliminated slow pathway. In most of cases, one ablation lesion was adequate to see junctional beats and elimination of dual AV nodal physiology. Conclusion SLAM is effective in guiding catheter ablation of AVNRT, with a complete acute success rate and no recurrences at short-term follow-up.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"13 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141148114","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-24DOI: 10.1093/europace/euae102.215
S R Lee, K Y Lee, E K Choi, S Oh
Background In this study, we evaluated efficacy, efficiency, and safety of pulmonary vein isolation (PVI) applying vHPSD ablation strategy in patients with atrial fibrillation (AF) and explored the association between left atrial wall thickness (LAWT) and the residual potential after first-pass PVI. Methods Between April 2, 2023 and October 6, 2023, drug refractory symptomatic AF patients who underwent AF ablation using vHPSD ablation strategy with QDOT MICRO catheter were prospectively enrolled. All patients took cardiac computed tomography (CT) a day before procedure. Using CT image, LAWT map was created. PV segments were categorized into prespecified 14 segments, and LAWT of each segment, segments with residual potential (RP) after first-pass PVI and early reconnection after 20-minute waiting after PVI were evaluated. Total procedure time, ablation time for PVI, and occurrence of procedure-related complication were collected. Results A total of 40 patients were included (mean age 64 years, 45% of persistent AF). Additional ablation other than PV was performed in 48% of patients, total procedure time was 77 minutes, and total PVI time was 9.9 minutes. With vHPSD PVI, all PVs first pass isolation rate was 60%; in terms of per PV, RSPV first-pass isolation was 88%, followed by LSPV and LIPV 85%, RIPV showed lowest first-pass isolation rate, 75% (Figure A). Most common RP sites was right carina, followed by left carina (Figure A). Compared to historical comparator, vHPSD PVI showed shorter procedure time, shorter ablation time for PVI, with numerically lower but statistically comparable first-pass PVI rate (Figure B). In total 560 PV segments in 40 patients, RSPV anterior, left carina, and right carina showed higher prevalence to be thick PV segments (over 60% of patients), followed by RPSV posterior, LSPV posterior, and RIPV anterior (over 40% of patients). Looking into ablation parameter detail, mean contact force was 10g, mean temperature was 47°C, and mean impedance drop was 8.4Ω. Compared to segments without RP, segments with RP showed thicker mean left atrial wall thickness grades, lower minimum contact force, higher maximum temperature, and lower minimum impedance drop. According to the left atrial wall thickness, thick PV segments showed higher prevalence of RP after first-pass PVI with vHPSD ablation. In segments with LAWT grade 3 or more, the RP rate was 9.1%. This thickness means thicker than 1.5 to 2.0 mm of thickness (Figure C). In 10% of patients (n=4) had audible or tactile steam-pops, visible char was confirmed in 5% of patients (n=2). There were no clinical complications. Conclusion PVI using vHPSD achieved shorter procedure time, shorter ablation time for PVI, and comparable first-pass PVI rate compared to historical comparator using ablation-index guided conventional power ablation. Thick segments had higher chance to have residual potential after first-pass PVI with vHPSD.
{"title":"Association between left atrial wall thickness and residual potential after first-pass pulmonary vein isolation using very high-power short-duration ablation in patients with atrial fibrillation","authors":"S R Lee, K Y Lee, E K Choi, S Oh","doi":"10.1093/europace/euae102.215","DOIUrl":"https://doi.org/10.1093/europace/euae102.215","url":null,"abstract":"Background In this study, we evaluated efficacy, efficiency, and safety of pulmonary vein isolation (PVI) applying vHPSD ablation strategy in patients with atrial fibrillation (AF) and explored the association between left atrial wall thickness (LAWT) and the residual potential after first-pass PVI. Methods Between April 2, 2023 and October 6, 2023, drug refractory symptomatic AF patients who underwent AF ablation using vHPSD ablation strategy with QDOT MICRO catheter were prospectively enrolled. All patients took cardiac computed tomography (CT) a day before procedure. Using CT image, LAWT map was created. PV segments were categorized into prespecified 14 segments, and LAWT of each segment, segments with residual potential (RP) after first-pass PVI and early reconnection after 20-minute waiting after PVI were evaluated. Total procedure time, ablation time for PVI, and occurrence of procedure-related complication were collected. Results A total of 40 patients were included (mean age 64 years, 45% of persistent AF). Additional ablation other than PV was performed in 48% of patients, total procedure time was 77 minutes, and total PVI time was 9.9 minutes. With vHPSD PVI, all PVs first pass isolation rate was 60%; in terms of per PV, RSPV first-pass isolation was 88%, followed by LSPV and LIPV 85%, RIPV showed lowest first-pass isolation rate, 75% (Figure A). Most common RP sites was right carina, followed by left carina (Figure A). Compared to historical comparator, vHPSD PVI showed shorter procedure time, shorter ablation time for PVI, with numerically lower but statistically comparable first-pass PVI rate (Figure B). In total 560 PV segments in 40 patients, RSPV anterior, left carina, and right carina showed higher prevalence to be thick PV segments (over 60% of patients), followed by RPSV posterior, LSPV posterior, and RIPV anterior (over 40% of patients). Looking into ablation parameter detail, mean contact force was 10g, mean temperature was 47°C, and mean impedance drop was 8.4Ω. Compared to segments without RP, segments with RP showed thicker mean left atrial wall thickness grades, lower minimum contact force, higher maximum temperature, and lower minimum impedance drop. According to the left atrial wall thickness, thick PV segments showed higher prevalence of RP after first-pass PVI with vHPSD ablation. In segments with LAWT grade 3 or more, the RP rate was 9.1%. This thickness means thicker than 1.5 to 2.0 mm of thickness (Figure C). In 10% of patients (n=4) had audible or tactile steam-pops, visible char was confirmed in 5% of patients (n=2). There were no clinical complications. Conclusion PVI using vHPSD achieved shorter procedure time, shorter ablation time for PVI, and comparable first-pass PVI rate compared to historical comparator using ablation-index guided conventional power ablation. Thick segments had higher chance to have residual potential after first-pass PVI with vHPSD.","PeriodicalId":11720,"journal":{"name":"EP Europace","volume":"22 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141148117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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