Europace最新文献

Aims: Though pulsed-field ablation (PFA) has demonstrated an excellent safety profile in reducing collateral injury to the oesophagus and phrenic nerve, it is still associated with specific effects, including electrode heating, haemolysis, and electrolysis due to excessive energy dispersion. This study aims to assess whether saline irrigation during PFA application could mitigate these risks.

Methods and results: To comprehensively evaluate the effect of irrigation with the variable-loop circular catheter (VLCC), the following experiments were performed: (i) ex-vivo potato model: to evaluate the lesion depth, bubble formation, and thermal effects in different irrigation regimens; (ii) in vitro blood pool and cardiac ablation: to determine the haemolysis status and tissue temperature change after PFA; (iii) in vivo swine ablation (n = 8), and (iv) clinical randomized trial (n = 25): to compare the efficacy and safety profile between low (4 mL/min) and high (30 mL/min) flow irrigation using the VLCC. Though peak core temperatures at 5 mm depth were all < 50°C under low- and high-irrigation, high irrigation significantly mitigated the instant electrode and deep tissue heating both in the potato and isolated cardiac models. Ex vivo potato slices showed that high-flow irrigation produced the deepest lesion sets when compared to low-flow irrigation (5.94 ± 0.29 mm vs. 5.36 ± 0.33 mm, P = 0.043). Assessment from a high-speed camera and bubble detector demonstrated that high-flow irrigation significantly reduced the total number of gaseous bubbles (54.50 IQR 53.00-56.75 vs. 82.00 IQR 72.00-83.00, P < 0.001) and eliminated the occurrence of larger bubbles. The high-flow irrigation group showed a smaller increase in the level of free haemoglobin immediately after the procedure across the blood pool, swine, and clinical models. Haptoglobin and lactate dehydrogenase levels were also attenuated by high irrigation in the in vivo swine model and clinical trial. One swine in the low-irrigation group developed an acute cerebral lesion (3 mm). The clinical trial confirmed that the incidence of silent cerebral lesions was significantly lower in the high-flow irrigation group (16.7% vs. 66.7%, P = 0.036).

Conclusion: Proper saline irrigation during PFA with VLCC may mitigate electrode-associated haemolysis, reduce electrode and tissue temperature, limit bubble aggregation, and be associated with a lower incidence of silent cerebral lesions, the clinical significance of which remains unclear.

Aims: Intracardiac echocardiography (ICE) is increasingly incorporated into atrial fibrillation (AF) ablation workflows, enabling real-time anatomic guidance and procedural precision. Nevertheless, ICE utilization shows substantial geographic variability, and its clinical benefit remains incompletely understood. This meta-analysis evaluated the efficacy, safety, and procedural performance of ICE-guided vs. non-ICE-guided AF ablation.

Methods and results: MEDLINE, the Cochrane Library, and Scopus were systematically searched through 3 August 2025. Three reviewers independently performed study selection, data extraction, and risk-of-bias assessment. Random-effects models were used to pool data from 44 AF ablation studies comprising 482 043 patients. ICE guidance was associated with lower odds of any complication (OR 0.69; 95% CI 0.53-0.89), including significant reductions in cardiac tamponade (OR 0.58; 95% CI 0.53-0.62) and mortality (OR 0.21; 95% CI 0.16-0.27). ICE-guided ablation was also associated with shorter total procedure and fluoroscopy times, reduced radiation exposure, and lower contrast agent utilization. Atrial tachyarrhythmia (AT) recurrence did not differ between groups (OR 0.92; 95% CI 0.79-1.06). However, ICE use was associated with higher odds of first-pass pulmonary vein isolation (OR 1.62; 95% CI 1.09-2.41) and successful isolation of all pulmonary veins at the end of the procedure (OR 2.12; 95% CI 1.37-3.27), and lower odds of repeat ablation (OR 0.65; 95% CI 0.59-0.72).

Conclusion: ICE-guided AF ablation is associated with superior procedural safety and efficiency and a similar risk of AT recurrence compared to non-ICE-guided approaches.

Aims: Electromechanical coupling and mechano-electrical feedback (MEF) are crucial for cardiac function, but their pro-arrhythmic roles in short and long QT syndromes (SQT1 and LQT2) are not fully understood. We aimed to evaluate MEF-induced electrical changes, their arrhythmic impact, and the involvement of stretch-activated channels (SACs) in transgenic rabbit models of SQT1 and LQT2.

Methods and results: Patch-clamp and fluorescence imaging were used to analyse action potential duration (APD), Ca²⁺ transients, and contractility in ventricular cardiomyocytes (VCMs) from LQT2, SQT1 and wild-type (WT) rabbits. LQT2 cells showed prolonged APD and Ca²⁺ transients, increased early afterdepolarizations, Ca²⁺ oscillations, and impaired mechanics compared to WT and SQT1. The cellular electromechanical window (Ca²⁺-transient duration minus APD) was more negative in LQT2 and more positive in SQT1 than in WT. QTc prolonged with preload/afterload increase and decreased with preload reduction across all genotypes, but MEF-induced QTc changes and dispersion were most pronounced in LQT2. Ex vivo Langendorff experiments showed that increased right ventricular (RV) pressure prolonged APD and QTc in WT hearts. This was attenuated by the SAC blocker GSMTx4, suggesting a role for SACs in MEF. In silico models of human VCMs including SACs confirmed higher vulnerability to stretch/MEF-induced arrhythmias, including re-entry, in SQT1 and LQT2.

Conclusion: Mechano-electrical feedback-induced electrical changes, partly mediated by SACs, occur in WT, SQT1, and LQT2, but MEF effects are strongest in LQT2. Mechano-electrical feedback induces pro-arrhythmic effects in silico more prominently in LQT2 and SQT1 than in WT, highlighting the potential pro-arrhythmic role of MEF in a vulnerable electrophysiological substrate.

Aims: This study aimed to assess current clinical practices in the diagnosis and management of atrial fibrillation (AF) among patients with active cancer or a history of cancer therapy.

Methods and results: A 25-item, physician-based survey was developed by the European Heart Rhythm Association in collaboration with the European Society of Cardiology Council of Cardio-Oncology and the International Cardio-Oncology Society. The survey was disseminated electronically. A total of 380 participants from 74 countries completed the questionnaire, with respondents primarily working as electrophysiologists (30%), general cardiologists (25%), and cardio-oncologists (22%). Nearly two-thirds reported that active cancer 'definitely' or 'most probably' influenced clinical decisions regarding AF diagnosis and management. When AF was diagnosed, rhythm control was the preferred management strategy for symptomatic patients, while rate control was favoured for asymptomatic individuals. A little over 40% reported that a history of cancer therapy 'definitely' or 'most probably' influenced clinical decisions regarding AF. The rhythm control was the most common strategy (40%). In both populations, opportunistic screening for AF and direct oral anticoagulants (DOACs) were preferred strategies. A high level of uncertainty was noted concerning the role of invasive treatment options.

Conclusion: The survey revealed that, despite the lack of robust evidence specific to this patient cohort, contemporary treatment of AF in patients with active cancer or a history of cancer therapy generally follows guidelines developed for the broader AF population. These findings highlight the urgent need for more dedicated data to inform clinical decision-making in cardio-oncology patients with AF.

Aims: Intracardiac echocardiography-based electroanatomical mapping (EAM) improves procedural efficiency and safety in atrial fibrillation (AF) ablation and remains the standard of care. The CARTOSOUND FAM (AI FAM) module uses a deep-learning algorithm that automates left atrial reconstruction without manual contouring. This study aims to evaluate the 1-year outcomes of AI FAM compared to standard-of-care EAM in AF ablation.

Methods and results: This study included 298 patients undergoing radiofrequency AF ablation between January 2021 and December 2023. Patients treated before January 2023 underwent standard-of-care EAM, while those in 2023 utilized AI FAM-based reconstruction. Baseline demographics, comorbidities, AF type, and medication use were recorded. Procedural characteristics, acute success, complications, and AF recurrence at 1-year follow-up were analysed. Of the 298 patients, 115 underwent mapping with AI FAM and 183 with EAM. Baseline characteristics were comparable. AI FAM reduced mean total procedure time (122.5 ± 23.5 vs. 129.0 ± 30.4 min, P = 0.040) and left atrial (LA) dwell time (78.3 ± 21.45 vs. 87.5 ± 28.2 min, P = 0.001). Acute procedural success was 98.3% in AI FAM vs. 98.9% in EAM with fewer complications observed in the AI FAM group (1 vs. 4). At 1 year, freedom from AF recurrence was comparable (80.0% AI FAM vs. 81.4% EAM at 1 year, LogRank P = 0.610).

Conclusion: AI FAM was associated with incremental but significant procedural advantages over conventional contouring via reduced total procedure time and LA dwell time, without compromising acute and long-term safety and rhythm control efficacy. AI FAM integration with pulsed field ablation will mark another step towards making AF ablation more streamlined and accessible.

Aims: Calcium release channel deficiency syndrome (CRCDS) results from loss-of-function (LOF) variants in the RYR2-encoded type 2 ryanodine receptor (RyR2), predisposing patients to sudden cardiac arrest/death (SCA/SCD) without abnormalities on a stress electrocardiogram (ECG). Undetected CRCDS may underlie idiopathic ventricular fibrillation (IVF) and sudden unexplained death in the young (SUDY). We aimed to determine the prevalence of potential CRCDS-causative RYR2 variants in IVF and SUDY.

Methods and results: We reviewed clinical evaluation and RYR2 genetic analysis of 169 IVF patients and 279 SUDY victims. Only ultra-rare (<0.005% in gnomAD) nonsynonymous RYR2 variants were considered potentially pathogenic. Among IVF patients, 6/169 (3%) overall-and 6/67 (9%) with exertion-related SCA-harboured an RYR2 variant and represent potential CRCDS cases. All exhibited normal resting and stress ECGs. Genetic analysis revealed six distinct RYR2 variants, two previously characterized as LOF. In SUDY, 31/279 victims (11%) had a RYR2 variant (30 unique variants), predominantly observed in exertion-related SCD 20/83 (24%) vs. rest-related 11/196 (6%). Of the 14 SUDY victims with functionally characterized RYR2 variants, five (2% of total cohort) had a LOF variant; among the 56 exertion-related SUDY cases, four (7%) had a LOF variant.

Conclusion: CRCDS may account for 3% of IVF overall and 9% of exertion-related SCA in IVF. Ultra-rare RYR2 variants may underlie up to 11% of SUDY, with 65% of RYR2-positive cases occurring during exertion. LOF-RYR2 variants may contribute to ≥7% of exercise-associated SUDY. Accurate identification of the underlying ryanodinopathy is essential for clinical management of affected patients.

Aims: Cardiac implantable electronic device (CIED) infection carries a substantial burden of morbidity, mortality, and cost. The Prevention of Arrhythmia Device Infection Trial (PADIT) risk score improves identification of high-risk patients and may guide targeted strategies to reduce infection. Recent work has categorized CIED infection into localized pocket vs. systemic infection, with early reports suggesting different risk factors for each. However, no current risk score has been validated for infection subtypes.ObjectivesIndependently validate the PADIT infection risk score.Compare risk factors for infection subtypes.Assess PADIT performance in predicting subtype-specific infection.

Methods and results: A prospective registry was initiated at the University of Ottawa Heart Institute in 2007 to capture all CIED procedures and prospectively identify infections in collaboration with the infection prevention team. PADIT risk score components were documented for each procedure. All suspected infections were adjudicated independently by two physicians (with a third if required), blinded to PADIT score and baseline variables, and subclassified as pocket or systemic infection. Logistic regression models were generated to validate PADIT performance for each subtype, with evaluation using Akaike and Bayesian information criteria (AIC/BIC), C-statistics, and calibration slope. Between 2007 and 2020, 14,225 procedures were performed (mean age 72 ± 14 years, 35% female, 70% new implants, 18% generator changes, 11% upgrades). A total of 103 infections (0.73%) were adjudicated, of which 71 (69%) were pocket and 32 (31%) systemic. The PADIT score showed good predictive performance with a C-statistic of 0.687 (95% CI 0.655-0.743), similar to the derivation cohort (0.702, 95% CI 0.661-0.741). Notably, the number of prior procedures was strongly associated with pocket infection but not systemic infection. PADIT discrimination was consistent across subtypes: pocket infection C-statistic 0.691 (95% CI 0.649-0.761) and systemic infection 0.746 (95% CI 0.707-0.848). Calibration slopes demonstrated good agreement between predicted and observed events, with the best fit for systemic infection.

Conclusion: The PADIT score was independently validated with discrimination and calibration similar to the original derivation cohort. Importantly, prior procedures predicted pocket but not systemic infection. Overall, PADIT performed well in predicting both subtypes, with the strongest model fit observed for systemic infection.

Aims: Loss-of-function (LOF) mutations of the cardiac Na+ channel (SCN5A) are causatively associated with the Brugada Syndrome (BrS). However, the onset of Ventricular Fibrillation (VF) is a rare event, and critical factors favouring the pathological phenotype remain often elusive. This study explores how concomitant triggering conditions may impact on VF onset in a symptomatic proband carrying the S805L/SCN5A BrS mutation.

Methods and results: Clinical, in-vitro, numerical, and structural analyses were performed. A 67-year-old male was resuscitated after cardiac arrest, and clinical analysis upon hospitalisation revealed severe hypokalaemia (2.5 mEq/L). The ECG showed a coved type-I BrS pattern and the SCN5A mutation (S805L) was identified. Patch-clamp studies carried out in a heterologous expression system (HEK293 cells) revealed that WT/S805L channels exhibit two different phenotypes (normal and LOF); the main parameter controlling this distribution is the cell membrane potential. A protected/normal behaviour was observed at -80 mV; conversely, LOF occurred at more negative potentials (-100/-120 mV). Further analyses in isolated outflow tract ventricular cardiomyocytes showed that hypokalaemia (and bradycardia) induced diastolic potential hyperpolarisation, thus favouring the Na+ current LOF. Computational and molecular modelling confirmed our findings and revealed the structural determinant of this alteration.

Conclusion: WT/S805L Na+ channels exhibit either a LOF or a wild-type-like behaviour depending on the membrane potential. Since hypokalaemia and slow pacing rate induce cell hyperpolarisation and the associated LOF, they represent concurrent elements creating the scenario responsible for the VF and cardiac arrest. These results may represent an interpretative paradigm applicable to other BrS mutations.

Aims: Procurement of cardiac implantable electronic devices (CIEDs) across the European Union is shaped by diverse healthcare systems, reimbursement mechanisms and levels of clinician involvement. Despite a shared legal framework, limited comparative data are available on how procurement is implemented across countries.

Objective: The objectives of this study are to examine CIED procurement strategies in 22 European countries where public tendering is mandatory and to explore how clinical, economic and structural factors influence procurement processes.

Methods and results: We conducted 23 structured interviews with cardiologists and one industry expert across 22 European countries. A thematic analysis was used to synthesize procurement models, clinical involvement and reimbursement structures. No formal outcome or cost-effectiveness analysis was performed. Procurement models varied widely, encompassing centralized, decentralized and hybrid systems. Clinician involvement ranged from leading device selection based on clinical criteria to being excluded from decision-making in systems driven primarily by price. Reimbursement pathways also differed, with procedure tariffs for single-chamber pacemakers ranging from €1059 to €14 889. A single region in Finland had implemented a pilot value-based procurement model linking payment to patient outcomes.

Conclusion: Cardiac implantable electronic device procurement across Europe is heterogeneous and predominantly cost driven, with limited integration of clinical outcomes or value-based principles. While not designed to evaluate cost-effectiveness directly, this study identifies procurement structures that may support or hinder value-based decision-making. Further research is needed to assess how procurement impacts clinical outcomes, innovation adoption and system sustainability.

Aims: Obesity adversely affects atrial fibrillation (AF) outcomes and is associated with higher recurrence after catheter ablation. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) promote weight loss and improve metabolic inflammation, but their role as adjuncts to ablation has not been completely defined. This study investigated the impact of semaglutide on post-ablation rhythm outcomes in obese patients with AF.

Methods and results: This single-centre, propensity-matched study included obese patients [body mass index (BMI) ≥ 30 kg/m²] undergoing first-time catheter ablation for paroxysmal AF (2019-2024). Patients who initiated semaglutide within 3 months before or 1 month after ablation were compared with matched controls who did not receive GLP-1RA therapy. All patients underwent continuous rhythm monitoring using implantable cardiac monitors. The primary endpoint was any atrial tachyarrhythmia recurrence beyond a 2-month blanking period. The final cohort included 181 semaglutide-treated patients and 181 controls with matched clinical and procedural characteristics. At 18-month follow-up, freedom from recurrence was 80.2% vs. 65.2%; semaglutide was associated with a significantly lower risk of recurrence (hazard ratio 0.52; 95% confidence interval 0.34-0.78; P = 0.002). Weight and BMI decreased significantly in the semaglutide group (-11.8 ± 3.8 kg; -4.0 ± 1.4 kg/m²) compared with controls (-1.9 ± 1.2 kg; -0.3 ± 0.8 kg/m²; both P < 0.001). A substantial proportion of treated patients achieved ≥10% weight reduction.

Conclusion: Glucagon-like peptide-1 receptor agonist therapy using semaglutide is associated with a reduced risk of AF recurrence in obese patients undergoing AF catheter ablation, indicating its potential as an adjunctive treatment. Further studies are needed to confirm these findings and elucidate the effects of GLP-1RA on AF recurrence.