Europace最新文献

Aims: The clinical spectrum of cardiac implantable electronic device (CIED) infections includes isolated pocket infection (IPI), pocket infection complicated by infective endocarditis (PIRIE), and lead-related infective endocarditis (LRIE). The aim of this study was to assess the risk factors, clinical course and outcomes in patients with CIED infections and to demonstrate differences between PIRIE and LRIE.

Methods and results: The retrospective analysis of data from 3847 patients undergoing transvenous lead extraction (TLE) for non-infectious (2640; 68.62%) and infectious (1207; 31.38%) indications including 361 (29.91%) IPI, 472 (39.11%) PIRIE and 374 (30.99%) LRIE showed some differences in risk factors, clinical course and outcomes between the subgroups. Unlike PIRIE, diabetes [HR=1.488; 95%CI(1.178÷1.879), P<0.001] and lead abrasion [HR=2.117 95%CI(1.665÷2.691), P<0.001] increased the risk of LRIE. The risk of pocket infection spread was greater with S. Aureus infection [HR=1.596; 95%CI(1.202-2.120), p<0.001). Compared to LRIE, patients with PIRIE had lower levels of inflammatory markers and lower prevalence of vegetations. Mortality in PIRIE compared to LRIE patients was lower (53.18% vs 62.30%; p<0.001) and comparable to IPI (50.69%; p=0.162) at long-term [median 1828 (815÷3139) days] follow-up.

Conclusion: CIED infections share common risk factors, however, diabetes and intracardiac lead abrasion predispose to LRIE, whereas multiple leads and Staphylococcus aureus in pocket culture are risk factors for pocket infection spread. Compared to LRIE, the clinical course of PIRIE was milder and short- and long-term mortalities were lower, but comparable to IPI after more than one year. This may be an argument in favour of categorization into primary LRIE and secondary endocarditis, i.e. PIRIE.

Background and aims: Advanced technologies such as charge density mapping (CDM) show promise in guiding adjuvant ablation in patients with persistent atrial fibrillation (AF); however, their limited availability restricts widespread adoption. We sought to determine whether regions of the left atrium containing CDM-identified pivoting and rotational propagation patterns during AF could also be reliably identified using more conventional contact mapping techniques.

Methods: Twenty-two patients undergoing de novo ablation of persistent AF underwent both CDM and electroanatomic voltage mapping during AF and sinus rhythm with multiple pacing protocols. Though the use of a left atrium statistical shape model, the location of distinctive propagation patterns identified by CDM were compared with low-voltage areas (LVAs) and regions of slow conduction velocity (CV).

Results: Neither LVA nor CV mapping during paced rhythms reliably identified regions containing CDM propagation patterns. CV mapping during AF did correlate with these regions (ρ = -0.63, p < 0.0001 for pivoting patterns; ρ = -0.54, p < 0.0001 for rotational patterns). These propagation patterns consistently occurred in two specific anatomical regions across patients: the anteroseptal and inferoposterior walls of the left atrium.

Conclusion: Mapping techniques during paced rhythms do not reliably correspond with regions of CDM-identified propagation patterns in persistent AF. However, these propagation patterns are consistently observed in two specific anatomical regions, suggesting a predisposition to abnormal electrophysiological properties. While further research is needed, these regions may serve as promising targets for empirical ablation, potentially reducing the reliance on complex mapping techniques.

Aims: Intercostal extravascular implantable cardioverter defibrillator (EV-ICD) leads may work better in contact with the pericardium thereby directing pacing and defibrillation energy towards excitable myocytes. We report 3-month safety and performance outcomes with a second-generation intercostal EV-ICD lead paired with standard, commercially available ICD pulse generators (PGs).

Methods and results: Subjects undergoing a transvenous ICD (TV-ICD) procedure received a concomitant intercostal EV-ICD lead system. The intercostal EV-ICD lead was connected sequentially to a PG in a left pectoral and then a left mid-axillary location. Extravascular ICD lead assessment included sensing and defibrillation of induced ventricular arrhythmias and pacing capture. The intercostal EV-ICD system was followed in a 'recording-only' mode and the control TV-ICD system in 'therapy delivery' mode to compare stored events. Devices were evaluated prior to hospital discharge, 2 weeks, 1 month, 2 months, and 3 months post-implant. Defibrillation testing was repeated prior to lead removal; 20/20 (100%) were successfully implanted (median implant time of 9 min). Two major lead complications were reported over a mean of 82 days: (i) lead movement and (ii) infection of both the TV-ICD and EV-ICD systems. Intraoperative pacing capture was achieved with the integrated bipolar configuration in 19 of 20 (95%) subjects. Pacing capture with the EV-ICD system was tolerated in all subjects, with over 90% feeling no pain after a 1-month recovery from the procedure. Induced VF episodes were sensed in all subjects and defibrillated successfully in 17 of 17 patients (100%) with a left mid-axillary PG and 19 of 20 patients (95%) with a left pectoral PG. Sensing and defibrillation were successful in 18 of 18 (100%) tested prior to lead removal.

Conclusion: In this pilot experience with a second-generation intercostal EV-ICD lead implantation, sensing and defibrillation of induced VF were successful when paired with a standard ICD PG from either a left mid-axillary or pectoral pocket.

Clinical trial registration: NCT number: NCT05791032; URL: https://clinicaltrials.gov/study/NCT05791032.

Aims: The natural history of congenital or childhood non-immune, isolated atrioventricular block (AVB) is poorly defined. We aimed at clarifying its long-term outcomes.

Methods and results: We retrospectively studied 385 children with isolated, non-immune AVB diagnosed from in utero or up to 18 years of age, at 29 French medical centres, between 1980 and 2022. Patients with structural heart disease, endomyocardial fibrosis, or maternal antibodies were excluded. Atrioventricular block was asymptomatic in 314 (81.6%) and complete in 263 (68.3%) patients at the time of diagnosis. There was progression to complete AVB in 84/122 (68.8%) patients with incomplete AVB over 12 years (7-17). A total of 286/385 patients (74.3%) received a permanent pacemaker, implanted in the first year of life in 39 (14%) and before 10 years of age in 172 (60%) children. The pacing indication was prophylactic in 203 children (71%). Genetic screening was performed in 133/385 patients (34.5%), leading to the identification of a clinically actionable variant in 11 (8.3%) patients. After a median follow-up of 10 years (5-17), no patient died or developed endomyocardial fibrosis or dilated cardiomyopathy.

Conclusion: In this large nationwide study, the long-term outcome of congenital or childhood non-immune, isolated AVB was excellent. Most children required pacemaker implantation over time, albeit often as a prophylactic measure.

Atrial fibrillation (AF) is one of the most common cardiac diseases and a complicating comorbidity for multiple associated diseases. Many clinical decisions regarding AF are currently based on the binary recognition of AF being present or absent with the categorical appraisal of AF as continued or intermittent. Assessment of AF in clinical trials is largely limited to the time to (first) detection of an AF episode. Substantial evidence shows, however, that the quantitative characteristic of intermittent AF has a relevant impact on symptoms, onset, and progression of AF and AF-related outcomes, including mortality. Atrial fibrillation burden is increasingly recognized as a suitable quantitative measure of intermittent AF that provides an estimate of risk attributable to AF, the efficacy of antiarrhythmic treatment, and the need for oral anticoagulation. However, the diversity of assessment methods and the lack of a consistent definition of AF burden prevent a wider clinical applicability and validation of actionable thresholds of AF burden. To facilitate progress in this field, the AF burden Consensus Group, an international and multidisciplinary collaboration, proposes a unified definition of AF burden. Based on current evidence and using a modified Delphi technique, consensus statements were attained on the four main areas describing AF burden: Defining the characteristics of AF burden, the recording principles, the clinical relevance in major clinical conditions, and implementation as an outcome in the clinic and in clinical trials. According to this consensus, AF burden is defined as the proportion of time spent in AF expressed as a percentage of the recording time, undertaken during a specified monitoring duration. A pivotal requirement for validity and comparability of AF burden assessment is a continuous or near-continuous duration of monitoring that needs to be reported together with the AF burden assessment. This proposed unified definition of AF burden applies independent of comorbidities and outcomes. However, the disease-specific actionable thresholds of AF burden need to be defined according to the targeted clinical outcomes in specific populations. The duration of the longest episode of uninterrupted AF expressed as a time duration should also be reported when appropriate. A unified definition of AF burden will allow for comparability of clinical study data to expand evidence and to establish actionable thresholds of AF burden in various clinical conditions. This proposed definition of AF burden will support risk evaluation and clinical treatment decisions in AF-related disease. It will further promote the development of clinical trials studying the clinical relevance of intermittent AF. A unified approach on AF burden will finally inform the technology development of heart rhythm monitoring towards validated technology to meet clinical needs.

Aims: Pulsed field ablation (PFA) is described as non-thermal, but data from oncology and cardiology show thermal effects occur. The specific waveform parameters influencing thermal energy development during PFA are unclear. The aim of this study is to numerically evaluate the thermal effects of PFA on myocardial and oesophageal tissue at various peak voltage conditions.

Methods and results: A three-dimensional computer model of the left atrium quantified thermal effects from PFA at peak voltages of 1, 1.5, and 2 kV. Energy was applied using a bipolar configuration with far-field and symmetry boundaries set as electrically insulating. A monophasic waveform with a 100 μs pulse width and a 1 s gap between pulses was applied for a total of 50 pulses, mimicking clinical conditions. Minimal temperature rise in the oesophagus was observed with 1 kV pulses (214.5 J). At 1.5 and 2 kV (570.3 and 1.23 kJ), temperatures reached 46.3°C and >62°C, respectively, after a single pulse train. These findings suggest that repeated applications could lead to even higher temperatures, especially if good tissue contact is obtained. These results align with data from other medical fields using pulsed field treatments.

Conclusion: Thermal effects from PFA depend on the total energy deposited, with peak voltage being a significant factor. Current commercially available PFA systems have the potential to induce collateral thermal injury with repeated applications of pulsed field energy. This highlights the need for careful monitoring and adjustment of PFA parameters in clinical settings.