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Aims: Multimorbidity frequently coexists with atrial fibrillation (AF) and complicates treatment decisions. While current guidelines offer selective recommendations for catheter ablation in this group, evidence remains limited. This study aimed to evaluate whether comorbidity burden modifies the effectiveness of catheter ablation vs. antiarrhythmic drug therapy.

Methods and results: In this post hoc analysis of the CABANA trial, patients were stratified by overall comorbidity burden using a data-driven threshold based on the distribution of 15 pre-specified conditions. The primary outcome was a composite of all-cause mortality, disabling stroke, serious bleeding, or cardiac arrest. Secondary outcomes included cardiovascular hospitalization and a composite of all-cause mortality or cardiovascular hospitalization. Additional outcomes included AF recurrence and AF-related quality of life in a sub-cohort. Of 2204 patients, 736 had high comorbidity burden {≥4 conditions, based on a data-driven threshold; median age 68.0 [interquartile range (IQR): 63.0-73.0], 67.1% male} and 1468 had low burden [median age 67.0 (IQR: 61.0-71.0), 60.7% male]. Over a median follow-up of 3.9 years (IQR: 2.4-5.1), for the primary outcome, the adjusted hazard ratio for catheter ablation vs. drug therapy was 0.62 [95% confidence interval (CI): 0.42-0.93] in patients with high comorbidity burden and 1.16 (95% CI: 0.76-1.77) in those with low burden (interaction P = 0.038). Secondary outcomes also tended to favour ablation in the high comorbidity burden group. Moreover, catheter ablation significantly reduced AF recurrence, with relative risk reductions of 49% and 40% in the low- and high-burden groups, respectively. Furthermore, catheter ablation improved AF-related quality of life in both comorbidity groups, with more sustained and pronounced benefits over time in patients with high comorbidity burden.

Conclusion: Catheter ablation was associated with more favourable clinical outcomes in AF patients with high comorbidity burden, which support broader consideration of ablation in this population, though prospective trials are needed to confirm and guide clinical decision-making in personalized rhythm management.

Pre-registered clinical trial number: NCT00911508.

Aims: To evaluate in patients with heart failure with reduced ejection fraction (HFrEF) the association between patient characteristics and likelihood of receiving cardiac resynchronization therapy (CRT), as well as between CRT and clinical outcomes, according to comorbid atrial fibrillation (AF).

Methods and results: Patients in the Swedish Heart Failure (HF) Registry who met the guidelines' recommendation for CRT between 2014 and 2022 were included. The primary endpoint was the composite of time to first HF hospitalization or cardiovascular (CV) death. Secondary endpoints were its individual components, all-cause death, and the total number of HF hospitalizations. Out of 3530 patients with HFrEF and an indication for CRT, 24.7% received a CRT. A history of or concomitant AF were observed in 51.6% of patients. AF was not associated with the likelihood of receiving a CRT, and the patient characteristics independently associated with CRT were consistent regardless of AF, except for CRT being less likely implanted in patients with valvular disease without AF, and more likely among those with AF and university (vs. compulsory) education. Regardless of AF, CRT use was associated with a lower adjusted risk of CV death/first HF hospitalization [hazard ratio (HR): 0.71, 95% confidence interval (CI) 0.64-0.79], of its individual components, and of all-cause death (HR: 0.72, 95% CI 0.64-0.81), but not with total number of HF hospitalizations.

Conclusion: A diagnosis of AF was not associated with the likelihood of receiving CRT in real-world HF care, nor did it affect the association between CRT and lower risk of clinical outcomes.

Aims: Automated QTc measurements from commercial ECG systems often diverge from expert readings. We developed QTcNet, a deep learning model trained and validated on multiple large ECG datasets to improve automated QTc measurement accuracy.

Methods and results: QTcNet employs a regression-based convolutional neural network architecture. It was trained on 120 300 algorithm-labelled ECGs (60 150 from an internal hospital cohort and 60 150 from the MIMIC-IV dataset) after correction for a vendor-specific +15 ms bias. Performance was evaluated against expert QTc measurements in three independent datasets: PTB Diagnostic ECG Database (n = 100 ECGs in validation set), QTcMS (n = 210), and ECGRDVQ (n = 5219). The effect of fine-tuning on cardiologist-annotated ECGs was tested in the PTB database (n = 449 in fine-tuning set). Model explainability analyses were performed with Integrated Gradient maps. QTcNet reduced cross-cohort mean absolute error (MAE) from 23.4 to 13.4 ms and root mean square error (RMSE) from 40.1 to 22.1 ms, almost halving large (>50 ms) outliers. Fine-tuning only reduced errors in the PTB dataset but did not improve cross-cohort performance. Integrated Gradient maps confirmed that the model concentrated on QRS onset and T wave offset, supporting physiological plausibility.

Conclusion: QTcNet, trained on large-scale algorithmically labelled data, consistently outperformed conventional algorithms across three independent, external validation datasets. Fine-tuning of QTcNet may adapt the model to the characteristics of specific cohorts but reduces external validity in other cohorts. We openly release the full model and code, along with a ready-to-use online implementation at https://qtcnet.uni-muenster.de, facilitating further research and community-driven improvement.

Aims: Catheter ablation for premature ventricular contractions (PVCs) triggering ventricular fibrillation (VF) after acute myocardial infarction (AMI) has proven effective, with Purkinje potentials often serving as the target. However, the electrophysiological features of Purkinje potentials and their relationship with the conduction system in VF-triggering PVCs remain unclear.

Methods: This multicentre retrospective study analysed patients who underwent catheter ablation for VF-triggering PVCs during the acute or subacute phase of AMI. Characteristics of Purkinje potentials, including retrograde conduction from the Purkinje network and subsequent anterograde conduction to the right bundle branch (RB), were evaluated for PVC morphology.

Results: Fifty-three patients (mean age 66±11 years; 13% female) with 67 VF-triggering PVCs were analysed. The mean PVC width was 157 ± 42 ms, with 87% showing RB branch block morphology. Purkinje potentials preceded 72% of PVCs (mean interval 68 ± 42 ms). PVCs with preceding Purkinje potentials had narrower QRS duration (145 ± 26 ms vs. 198 ± 57 ms, P < 0.0001). The coupling interval from the preceding sinus beat was inversely correlated with the interval from Purkinje potential to PVC onset (P < 0.0001). Retrograde Purkinje conduction with subsequent anterograde RB conduction was identified in 9%. In these cases, the coupling interval from the preceding sinus beat was longer (391 ± 12 ms vs. 467 ± 34 ms, P = 0.041).

Conclusion: Purkinje potentials show distinct properties that influence both QRS duration and PVC timing. The presence of preceding Purkinje potentials together with QRS duration may help guide ablation strategies. In rare cases, Purkinje activity conducts retrogradely from the left bundle and anterogradely through the RB, modifying PVC morphology.

Aims: Pulsed field ablation (PFA) has rapidly emerged as a non-thermal ablation technology for pulmonary vein isolation (PVI), with an unprecedented adoption across Europe. The aim of this survey was to characterize current practice patterns.

Methods and results: The European Heart Rhythm Association (EHRA) Scientific Initiatives Committee designed a 30-item questionnaire addressing temporal adoption of PFA, pre-, intra-, and post-procedural workflows, and future perspectives. The survey was distributed between April and June 2025. A total of 216 responses were obtained from 43 countries. At the time of the survey, 23% of respondents had not yet initiated a PFA programme. Overall, PFA is now used in half (49%) of first atrial fibrillation (AF) ablation procedures. Adoption was significantly higher in high-volume centres and 'Western European' countries. The primary driver for adoption was time efficiency (60%). Intra-procedural workflows showed marked heterogeneity: approximately half of the operators relied exclusively on fluoroscopy without any intra-procedural imaging/mapping. Additional ablation lesions beyond PVI were common, with one-third employing standardized PVI+ protocols in persistent AF, most frequently posterior wall isolation. General anaesthesia and deep sedation were used in equal proportions.

Conclusion: This EHRA survey demonstrates both rapid implementation and significant heterogeneity in PFA use across Europe. Standardized protocols and prospective studies are needed to define best practices.

Aims: Leadless pacemakers (LLPs) offer a valuable option for selected patients requiring ventricular pacing. However, data on revision procedures-defined as any intervention on an implanted LLP to correct dysfunction or upgrade the system, with or without removal-remain scarce. This study aimed to evaluate the real-world incidence, characteristics, and outcomes of LLP revisions, with particular emphasis on the feasibility and safety of removal.

Methods and results: This multicentre retrospective study involved 46 French centres performing LLP implantations between 2015 and 2023. Among 8994 Micra LLPs implanted, 100 revision procedures (1.1%) were performed in 100 patients, including 73 Micra VR and 27 Micra AV devices, at a median follow-up of 229 (68.5-629.8) days. Seventy revisions were managed without device removal, while 30 involved removal. Revision indications included device upgrade (55%), high pacing threshold (33%), battery depletion (3%), ventricular arrhythmias (3%), and miscellaneous causes (6%). No significant differences were observed in pacing indications, implantation characteristics, or initial device indication between the two groups. Revisions occurred significantly earlier in the removal group than in the group without removal [median 81.5 (8-211.5) days, vs. 334 (130.25-882.5) days, P < 0.001], with 80% occurring within 1 year. Device removal was successful in 97% of cases (one failure at 157 days of follow-up), with no major complications reported.

Conclusion: LLP revisions are infrequent and predominantly managed without device removal. However, given the high procedural success rate and the low complication rate, device removal appears to be underutilized and should be considered more frequently on a case-by-case basis.