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Aims: Cardiac conduction disorders are common in haemodialysis patients, with a relatively high rate of pacemaker implantations. Pacemaker-related complications, especially lead infections and central venous stenosis, pose significant challenges in this population. This study aims to compare single-chamber leadless pacemaker to single-chamber transvenous pacemakers in terms of survival and related complications in haemodialysis patients.

Methods and results: This retrospective study included adult haemodialysis patients who received a first single-chamber transvenous or leadless pacemaker between January 2017 and December 2020. Data were obtained from the French national REIN registry matched to the national health databases (Système National des Données de Santé). Propensity score matching was used to balance baseline characteristics. Survival and complications were compared between groups by Cox regression and by competitive risk models, respectively. One hundred and seventy-eight patients were included after propensity score matching, with 89 patients in each group. The median follow-up time was 24 (range 7-37) months. Leadless pacemakers were associated with significantly lower all-cause mortality rates compared to transvenous pacemakers [hazard ratio (HR) = 0.68, 95% confidence interval (CI) (0.47-0.99)]. Device-related infections are significantly lower with leadless pacemakers throughout the follow-up period (HR 0.43, 95% CI 0.21-0.86). Leadless pacemaker recipients also required fewer vascular access interventions [odds ratio 0.53, 95% CI (0.33-0.68)] on arteriovenous fistula.

Conclusion: With the limitations of its observational design, this study suggests that leadless pacemakers are associated with a lower rate of complications and better survival as compared with transvenous VVI pacemakers in haemodialysis patients, supporting to consider their preferential use in this population.

Aims: Rotational re-entries and ectopic foci, or 'drivers', are proposed mechanisms for persistent atrial fibrillation (persAF), but driver-based interventions have had mixed success in clinical trials. Selective targeting of drivers with multi-month stability may improve these interventions, but no prior work has investigated whether drivers can be stable on such a long timescale.

Objective: We hypothesized that drivers could recur even several months after initial observation.

Methods and results: We performed serial electrophysiology studies on paced canines (n = 18, 27-35 kg) at 1-, 3-, and 6 months post-initiation of continual persAF. Using a high-density 64-electrode catheter, we captured endocardial electrograms in the left atrium (LA) and right atrium (RA) to determine the presence of drivers at each major anatomical site. We defined drivers that were repeatedly observed across consecutive studies to be recurrent. The mean probability that any driver would recur was 66% (LA: 73%, RA: 41%). We also found evidence of 'multi-recurring' drivers, i.e. those seen in all three studies. Multi-recurring drivers constituted 53% of initially observed drivers with at least one found in 92% of animals, and we found more multi-recurring drivers per animal than predicted by random chance (2.6 ± 1.5 vs. 1.2 ± 1.1, P < 0.001). Driver sites showed more enhancement than non-drivers during late gadolinium enhancement-magnetic resonance imaging (P = 0.04), but we observed no relationship between enhancement and driver recurrence type.

Conclusion: We observed recurring drivers over a 6-month period at fixed locations, confirming our hypothesis. We also found drivers to be associated with fibrosis, implying a structural basis.

Aims: The CHA2DS2VASc score is recommended for stroke risk stratification in patients with atrial fibrillation (AF). This score assigns one extra point to female sex based on evidence from the early 2000s, suggesting higher thromboembolic risk in women. This incremental risk of thromboembolism in women has decreased over time between 2007 and 2018, becoming non-significant in recent years. The objective of this study was to assess the impact of removing the sex category (Sc) from the CHA2DS2VASc score, thus validating a non-sex CHA2DS2VASc (i.e. CHA2DS2VA) score.

Methods and results: We analysed UK primary and secondary care data comprising 195 719 patients with AF followed between 1998 and 2016 (mean age: 75.9 ± 12.3 years; 49.2% women). Among 126 428 non-anticoagulated patients, we compared the CHA2DS2VASc vs. CHA2DS2VA scores every calendar year. Throughout 413 007 patient-years, a total of 8742 events of ischaemic stroke or systemic embolism were recorded. Sex differences in thromboembolic risk were not observed in the lower-risk population, but higher stroke rates were consistently seen in female patients in the higher-risk category (i.e. CHA2DS2VA ≥2). C-statistics for both CHA2DS2VA and CHA2DS2VASc scores were similar over the years (ranging from 0.62 to 0.71). With CHA2DS2VA, no relevant differences were observed in integrated discrimination improvement, and net reclassification improvement (NRI) resulted in improved reclassification (11%) in lower thromboembolic risk groups. The NRI suggested misclassification in higher thromboembolic risk patients (-7%), but this did not affect their indication for anticoagulation (i.e. patients retained their high-risk status).

Conclusion: Removing Sc from the CHA2DS2VASc score does not affect its ability to discriminate thromboembolic events in the population with AF. The use of CHA2DS2VA may simplify initial decision-making for thromboprophylaxis.

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common with a prevalence of 20-50% at one year after LVAD implantation. Arrhythmias predispose these patients to additional risk and are associated with considerable morbidity from recurrent implantable cardioverter-defibrillator (ICD) shocks, progressive failure of the unsupported right ventricle, and herald an increased risk of mortality. Management of patients with arrhythmias and LVAD differs in many aspects from the general population heart failure patients. These include ruling out the reversible causes of arrhythmias that in LVAD patients may include mechanical irritation from the inflow cannula and suction events. For patients with symptomatic arrhythmias refractory to medical treatment, catheter ablation might be relevant. There are specific technical and procedural challenges perceived to be unique to LVAD-related ventricular tachycardia ablation such as vascular and LV access, signal filtering, catheter manoeuvrability within decompressed chambers, and electroanatomic mapping system interference. In some patients, the arrhythmogenic substrate might not be readily accessible by catheter ablation after LVAD implantation. In this regard, the peri-implantation period offers a unique opportunity to surgically address arrhythmogenic substrate and suppress future ventricular tachycardia recurrences. This document aims to address specific aspects of the management of arrhythmias in LVAD patients focusing on anti-arrhythmic drug therapy and ablations.

Alterations in repolarisation gradients and increased heterogeneity are key electrophysiological determinants of ventricular arrhythmogenesis across a variety of aetiologies with and without structural heart disease. High-density repolarisation mapping to localise these repolarisation abnormalities could improve characterisation of the individual arrhythmogenic substrate and inform more targeted ablation. Yet, due to challenges posed by intrinsic features of human cardiac repolarisation itself as well as technical and practical limitations, they are not routinely assessed, and traditional substrate mapping techniques remain strictly limited to determining conduction abnormalities. Here, we provide an overview of the mechanistic role of repolarisation alterations in ventricular re-entry arrhythmias followed by a description of a clinical workflow that enables high-density repolarisation mapping during VT ablations using existing clinical tools. We describe step-by-step guidance of how-to set-up and generate repolarisation maps illustrating the approach in case examples of structural normal and abnormal hearts. Furthermore, we discuss how repolarisation mapping could be combined with existing substrate mapping approaches, including isochronal late activation mapping, to delineate sites of increased re-entry vulnerability, that may represent targets for ablation without the requirement for VT induction. Finally, we review challenges and pitfalls and ongoing controversies in relation to repolarisation mapping and discuss the need for future technical and analytical improvements in repolarisation mapping to integrate into ventricular substrate mapping strategies. Repolarisation mapping remains investigational and future research efforts need to be focused on prospective trials to establish the additional diagnostic value and its role in clinical ablation procedures.

Background: Catheter ablation is an effective treatment method for recurrent ventricular tachycardias (VT). However, at least in part, procedural and clinical outcomes are limited by challenges in generating an adequate lesion size in the ventricular myocardium.

Objective: We investigated procedural and clinical outcomes of VT ablation using a novel "large-footprint" catheter that allows the creation of larger lesions either by radiofrequency (RF) or by pulsed field (PF) energy.

Methods: In prospectively collected case series, we describe our initial experience with VT ablation using a lattice-tip, dual-energy catheter (Sphere-9, Medtronic), and a compatible proprietary electroanatomical mapping system (Affera, Medtronic).

Results: The study population consisted of 18 patients (aged 55±15 years, 1 woman, structural heart disease: 94%, ischemic heart disease: 56%, left ventricular ejection fraction: 34±10%, electrical storm: 22%) with recurrent sustained VTs and ≥1 previously failed endocardial RF ablation with conventional irrigated-tip catheter in 66% of patients. On average, 12±7 RF and 8±9 PF applications were delivered per patient. In 3/4 of patients undergoing percutaneous epicardial ablation, spasms in coronary angiography were observed after PF applications. All resolved after intracoronary administration of nitrates. No acute phrenic nerve palsy was noted. One patient suffered from a stroke that resolved without sequelae. Post-ablation non-inducibility of VT was achieved in 89% of patients. Ventricular-arrhythmia-free survival at three months was 78%.

Conclusion: VT ablation using a dual-energy lattice-tip catheter and a novel electroanatomical mapping system is feasible. It allows rapid mapping and effective substrate modification with good outcomes during short-term follow-up.

Background and aims: The use of ultrasound (US)-guided venous puncture for cardiac pacing/defibrillation lead placement may minimize the risk of peri-procedural complications and radiation exposure. However, none of the published studies have been sufficiently powered to recommend this approach as the standard of care. We compare the safety and efficacy of ultrasound-guided axillary venous puncture (US-AVP) versus fluoroscopy-guided access for cardiac implantable electronic devices (CIED) by performing an individual patient data meta-analysis based on previously published studies.

Methods: We conducted a thorough literature search encompassing longitudinal investigations (five randomized and one prospective studies) reporting data on Xray-guided and US-AVP for CIED procedures. The primary endpoint was to compare the safety of the two techniques. Secondary endpoints included the success rate of each technique, the necessity of switching to alternative methods, the time needed to obtain venous access, Xray exposure and the occurrence of peri-procedural complications.

Results: Six longitudinal eligible studies were identified including 700 patients (mean age 74.9 ±12.1 years, 68.4% males). The two approaches for venous cannulation showed a similar success rate. The use of a Xray guided approach significantly increased the risk of inadvertent arterial punctures (OR: 2.15, 95% CI: 2.10-2.21, p=0.003), after adjustment for potential confounders. Conversely, an US-AVP approach reduces time to vascular access, radiation exposure and the number of attempts to vascular access.

Conclusions: The US-AVP enhances safety by reducing radiation exposure and time to vascular access while maintaining a low rate of major complications compared to the x-ray-guided approach.

Aims: Atrial fibrillation (AF) patients frequently require active rhythm control therapy to maintain sinus rhythm and reduce symptom burden. Our study assessed whether antiarrhythmic therapies (AATs) are used disproportionately between men and women after new-onset AF.

Methods and results: The nationwide Finnish anticoagulation in AF registry-based linkage study covers all patients with new-onset AF in Finland during 2007-2018. Study outcomes included initiation of AATs in the form of antiarrhythmic drugs (AADs), cardioversion, or catheter ablation. The study population constituted of 229 565 patients (50% females). Women were older than men (76.6 ± 11.8 vs. 68.9 ± 13.4 years) and had higher prevalence of hypertension or hyperthyroidism, but lower prevalence of vascular disease, diabetes, renal disease, and cardiomyopathies than men. Overall, 17.6% of women and 25.1% of men were treated with any AAT. Women were treated with AADs more often than men in all age groups [adjusted subdistribution hazard ratio (aSHR) 1.223, 95% confidence interval (CI) 1.187-1.261]. Cardioversions were also performed less often on women than on men aged <65 years (aSHR 0.722, 95% CI 0.695-0.749), more often in patients ≥ 75 years (aSHR 1.166, 95% CI 1.108-1.227), while no difference between the sexes existed in patients aged 65-74 years. Ablations were performed less often in women aged <65 years (aSHR 0.908, 95% CI 0.826-0.998) and ≥75 years (aSHR 0.521, 95% CI 0.354-0.766), whereas there was no difference in patients aged 65-74 years.

Conclusion: Women used more AAD than men in all age groups but underwent fewer cardioversion and ablation procedures when aged <65 years.

Aims: Atrial fibrillation (AF) is a common arrhythmia, and many cases of AF may be undiagnosed. Whether screening for AF and subsequent treatment if AF is detected can improve long-term outcome remains an unsettled question. The primary aim of the NORwegian atrial fibrillation self-SCREENing (NORSCREEN) trial is to assess whether self-screening for AF with continuous electrocardiogram (ECG) for 3-7 days in individuals aged 65 years or older with at least one additional risk factor for stroke, and initiation of guideline-recommended therapy in patients with detected AF, will reduce the occurrence of stroke.

Methods and results: This study is a nationwide open, siteless, randomized, controlled trial. Individuals ≥65 years of age are randomly identified from the National Population Register of Norway and are invited to take a digital inclusion/exclusion test. Individuals passing the inclusion/exclusion test are randomized to either the intervention group or the control group. A total of 35 000 participants will be enrolled. In the intervention group, self-screening is performed continuously over 3-7 days at home with a patch ECG device (ECG247) at inclusion and after 12-18 months. If AF is detected, guideline-recommended therapy will be initiated. Patients will be followed up for 5 years through national health registries. The primary outcome is time to a first stroke (ischaemic or haemorrhagic stroke). The first participant in the NORSCREEN trial was enrolled on 1 September 2023.

Conclusion: The results from the NORSCREEN trial will provide new insights regarding the efficacy of digital siteless self-screening for AF with respect to stroke prevention in individuals at an increased risk of stroke.

Trial registration: Clinical trials: NCT05914883.