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Novel technologies and ablation techniques for identification of atrial fibrillation (AF) sources and personalized substrate modification may be required to improve outcomes for persistent AF. We hypothesize that a unison of electrophysiologic phase and optical flow mapping could be used to selectively prioritize ablation targets and optimize patient outcome while minimizing the tissue ablated. We aim to evaluate the efficacy of a novel electro-optic flow (EOF)-based ablation strategy for persistent AF patients using a virtual cohort of bi-atrial digital twins (DTs). A patient cohort (n=250) from a bi-atrial in silico population with different atrial fibrosis distributions was utilized to simulate five AF episodes per case. Phase singularity (PS) and average optical flow maps were computed for post-pulmonary vein isolation (PVI) sustained AF. Concordant regions, overlapping in at least three binarized PS maps were used to define regions to search for the highest optical curl cluster centroids as candidate EOF targets. Using optical curl as the weight, the centroid of five candidate EOF targets were computed and selected as an ablation target inside each concordant boundary. Six clinical ablation strategies were simulated. An inducibility-to-ablated tissue area metric was calculated to evaluate the efficacy of the tested ablation strategies. The pipeline automatically identified extra-PV targets and generated patient-specific EOF ablation plans. Electro-optic flow-guided ablations resulted in an average 32±2% AF inducibility, outperforming PVI (90±5%), and PVI+empiric (87±6%). Consensus-EOF further reduced inducibility to 20±5% while sparing 28±2% tissue as compared to PVI+PS ablation. Consensus mapping provides a novel method for assessing the dynamic nature of AF, while EOF offers a promising multimodal metric for identifying critical ablation targets outside of PVI. These findings underscore the potential of EOF-guided ablation planning in advancing the clinical translation of DT-based personalized therapy for PeAF patients.

Aims: We sought to systematically catalogue and compare outcomes definitions across prospective clinical trials and registries evaluating ablation in VT to assess the impact of heterogeneous definitions on reported outcomes.

Methods and results: A systematic review (PROSPERO: CRD 42024595265) was performed in accordance with PRISMA guidelines. We searched for prospective studies from January 2000 to November 2024. Randomized trials, single-arm feasibility studies, and prospective registries involving ≥10 patients undergoing VT ablation were included. Study outcomes and their definitions were extracted and categorized. Pooled analyses were performed for comparable randomized trial subgroups, and meta-regression evaluated the effect of VT outcome definitions on reported success and complications. Fifty-nine studies were included: 15 randomized trials, 6 feasibility studies, and 38 prospective studies/registries. Definitions of acute procedural success varied, with most using acute clinical VT non-inducibility and others using only elimination of the clinical VT. VT recurrence was the most frequently reported long-term outcome; however, definitions differed markedly (VT recurrence or recurrence causing device therapy). Pooled analysis of prophylactic ablation vs. delayed ablation showed reduced VT recurrence (HR 0.63, 95% CI: 46-0.86) but no difference in hospitalization or mortality. Meta-regression demonstrated that an outcome of any VT recurrence yielded a higher failure rate of 51.0% compared to stricter definitions, such as VT-causing therapy at 37.3% or VT-causing shock only at 23.4% (P = 0.002). Safety outcomes were inconsistently reported.

Conclusion: Outcome definition in VT ablation trials showed substantial heterogeneity, limiting cross-trial comparability and meta-analytic synthesis. Development of a minimum set of standardized outcomes for VT ablation may improve consistency and clinical interpretability of VT trials.

Aims: The rising burden of cardiovascular diseases, especially atrial fibrillation, has increased demand for electrophysiology (EP) procedures in Europe, driving greater reliance on disposable devices like diagnostic and ablation catheters. Reprocessing single-use medical devices offers potential economic and environmental benefits, yet concerns persist regarding device integrity and safety. Under the European Union Medical Device Regulation, reprocessing is permitted if national laws allow it; however, implementation varies across Member States. This systematic literature review evaluates the safety and performance of reprocessed cardiac EP catheters originally intended for single use.

Methods and results: Following PRISMA guidelines, literature searches of PubMed and Embase identified in vitro and in vivo studies that examined the safety and functionality of reprocessed EP catheters. Key outcomes included infection risk, device sterility, mechanical and electrical integrity, and adverse events. Twelve studies (four in vivo and eight in vitro) involving >1200 patients and multiple catheter brands were included. Under stringent reprocessing protocols, reprocessed EP catheters showed comparable safety and mechanical performance to new devices. However, gaps remain in evidence regarding prion and fungal contamination, the maximum number of safe reprocessing cycles, and the detection of rare complications.

Conclusion: The absence of adverse events and reliable performance associated with reprocessed EP catheters reported in this study may encourage European countries that have not yet authorized single-use medical device reprocessing to consider its adoption. However, the broader implementation of this practice remains contingent on its applicability and logistical feasibility within each national context.

Aims: Cardioneuroablation (CNA) is a catheter-based intervention for reflex syncope and functional bradyarrhythmias that consists in the modulation of the parasympathetic cardiac autonomic nervous by targeting ganglionated plexi (GPs).To compare an ablation strategy of selective GP targeting based on clinical phenotype (tailored approach) vs. the standard approach of targeting all GPs (standard approach).

Methods and results: This is a prospective, multicentre European study (ELEGANCE study), including 123 patients who underwent CNA (73 men; median age 50 years). Among them 54 (44%) were treated with a tailored approach, targeting the superior paraseptal ganglionated plexus (SPSGP) for sinus node dysfunction and the inferior paraseptal ganglionated plexus (IPSGP) for AV block. Procedural data and clinical outcomes were compared with the remaining 69 patients treated using a standard approach.Clinical phenotypes included isolated functional sinus node dysfunction (43.1%), isolated functional AV block (9.8%), and dual presentations (47.2%). In the tailored group 1.6 ± 0.7 GPs were targeted per patient. Compared to the standard approach, the tailored group had significantly shorter procedure times (63 vs. 85 min, P = 0.005) and reduced RF time (5.4 vs. 10.4 min, P < 0.001). Acute procedural success (tailored: 93% vs. standard: 90%, P = 0.98) and the increase in heart rate (tailored: 40 ± 30.7% vs. standard: 40 ± 31.4%, P = 0.96) were similar between groups. During a median 15.9 months [IQR: 9.8, 24.6] follow-up, there were no differences in syncope recurrence rate (log-rank P = 0.96). Inappropriate sinus tachycardia occurred in 8.1% of patients, (tailored 8.6% vs. standard 7.4%; P = 0.79).

Conclusion: An individualized CNA strategy, simplified by targeting specific GPs according to patient's pathophysiology, achieved outcomes equivalent to the standard approach while improving procedural efficiency through reduced RF delivery, shorter procedure duration, and limited ablation extent.

Aims: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation, but recurrences are frequent. Ablating AF sources beyond PVI may prevent re-initiations. This proof-of-principle in silico study compares a novel source-based ablation approach to conventional strategies in preventing AF re-initiation.

Methods and results: We compared two conventional ablation strategies [PVI and PVI + posterior wall isolation (box ablation)] with our source-based approach. After PVI, a high-density mapping catheter was guided sequentially upstream of local repetitive conduction patterns until a source was identified. Located targets were ablated, connecting them to non-conducting boundaries. Strategies were compared based on their AF re-initiation rates after incremental pacing and ablated and electrically isolated areas. Analyses were performed in seven different scenarios with atria of different sizes, without (n = 3) and with fibrosis (n = 4), to assess different AF progression stages. Compared to no ablation, PVI reduced initiation rates in non-fibrotic atria (23 ± 8% control vs. 15 ± 0% PVI) but was less effective with fibrosis (60 ± 4% vs. 53 ± 10%). Box ablation was not superior to PVI while isolating more of the left atrium (isolated area in PVI: 31.5 ± 0.7% vs. box: 43.6 ± 0.5%). Conversely, source ablation completely prevented AF initiation in all scenarios, achieving comparable left atrial isolation with box ablation (isolated area without fibrosis: 36.3 ± 1.4%; with fibrosis: 43.2 ± 2.6%) and including right atrial lesions. Although macro-re-entrant tachycardias occurred frequently after source ablation, they were terminated with minimal lesions.

Conclusion: Ablating AF sources using our high-density mapping approach was more efficient in preventing AF re-initiation in silico than anatomy-based strategies.

Aims: To explore the prevalence and incidence of paediatric implantable cardioverter-defibrillator (ICD) patients in Sweden and identify risk factors associated with appropriate shocks and adverse events.

Methods and results: We performed a nationwide, retrospective cohort study of ICD use in paediatric patients (<19 years) between 1995 and 2017; 120 patients underwent ICD implantation at median age 14.7 (range 1.1-18.9) years and were followed for 7.1 (0.3-20.4) years. Fifty-four patients (45%) received a primary preventive ICD; 46% had cardiomyopathy, and 41% had primary electrical disease. The estimated 5-year survival without appropriate shocks was 68% (confidence interval 59-78). Secondary preventive ICDs and lower weight (<30 kg) at implantation were associated with a higher rate of appropriate shocks, respectively. Lower weight at implantation was not a risk factor for adverse events. Inadequate medication and insufficient compliance were common in patients who experienced shocks. Less than half (46%) of the cases with inappropriate shocks were adequately medicated with good compliance. Secondly, an incidence and prevalence study of all paediatric and adult patients who had an ICD implanted in Sweden was analysed in 4-year periods between 2002 and 2021. The incidence of paediatric ICD implantations in Sweden peaked at 0.56 per 100 000 person-years in 2010-13, decreasing to 0.45 per 100 000 person-years in the last study period (2018-21).

Conclusion: Appropriate shocks were more than twice as common in the youngest patient group, whereas adverse events were not more frequent than in the older patient group. Inadequate medication and lack of compliance were common in connection with ICD shocks.

Introduction: Ventricular tachycardia (VT) in patients with structural heart disease can be life-threatening and may persist despite antiarrhythmic therapy and catheter ablation. When standard treatments are ineffective or contraindicated, stereotactic arrhythmia radioablation (STAR) has emerged as a non-invasive salvage option.

Methods: This prospective, single-center study included 19 patients with structural heart disease and recurrent VT unresponsive to conventional therapy and who were ineligible for ablation. Patients were selected by a multidisciplinary team and underwent cardiac CT and electroanatomic mapping for substrate characterization. STAR was delivered in a single 25Gy fraction using volumetric modulated arc therapy. Primary endpoints included safety (adverse events within 12 months) and efficacy (reduction in VT burden, assessed by ICD-recorded anti-tachycardia pacing [ATP] and shocks).

Results: During a median follow-up of 14 months [IQR 9-15], STAR was associated with a significant reduction in ICD therapies, with an average decrease of 81%. Mean ATP interventions/month dropped from 4.5±6.5 to 0.8±2.3 (p=0.029), and total ICD therapies/month decreased from 4.8±7.0 to 0.9±2.5 (p=0.032). Mild pulmonary injury and pericardial effusion occurred in 22.2% of patients. Most cases were asymptomatic; one patient (5.5%) required non-urgent pericardiocentesis. No significant changes in left ventricular function, valvular status, or coronary artery disease progression (assessed by CAD-RADS and PCAT analysis) were observed. One-year mortality was 33.3%; no deaths were directly attributable to STAR.

Conclusion: STAR shows promise as a safe, noninvasive option for patients with refractory VT and advanced cardiomyopathy. Larger multicenter studies are needed to confirm long-term outcomes and better define its clinical role.