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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.

Aims: Atypical atrial flutter (AAFl) encompasses a diverse group of macro-reentrant arrhythmias with variable circuits, presenting diagnostic and therapeutic challenges. This European Heart Rhythm Association (EHRA) survey aimed to assess current practices across European centres regarding the management of AAFl.

Methods and results: A 26-item online questionnaire distributed by the EHRA Scientific Initiatives Committee yielded 214 responses from physicians in 36 countries. Catheter ablation was considered first-line therapy by 67.6% of respondents. In patients presenting in sinus rhythm with non-inducible clinical AAFl at the time of ablation, management strategies were heterogeneous, with combined pulmonary vein isolation and substrate ablation being the most common approach (46.8%). Activation mapping was the preferred method to define the circuit (63.7%), ahead of entrainment manoeuvers. Most respondents (87.1%) used ablation lines connecting scar or unexcitable tissue, whereas only 7.5% targeted the critical isthmus alone. The most frequent endpoints were validation of conduction block (73.1%), interruption of the clinical arrhythmia (71.0%), and non-inducibility of the clinical flutter (56.5%), while non-inducibility of any atrial flutter was rarely pursued. In patients without prior cardiac intervention, the left atrial anterior wall was perceived to be the most frequently involved structure (59.4%). Finally, in case of recurrence, 74.3% of respondents preferred redo ablation.

Conclusion: This EHRA survey reveals consensus on ablation endpoints but marked variability in ablation timing and strategies when AAFl is non-inducible at the time of ablation, underscoring the need for standardized protocols and further collaborative research to optimize outcomes.

Aims: Atrial fibrillation (AF) and cancer are both highly prevalent conditions and are known to be associated. Our aim was to identify predictors and develop models for all cancer types, in men and women, and for the four most common cancer types in the AF population using linked primary and secondary care data from the UK.

Methods and results: We included 163 549 patients diagnosed with AF between January 1998 and May 2016, and no previous history of cancer. Following TRIPOD methodology, we developed a ridge-penalized multivariable logistic regression model to predict 1-year cancer incidence after AF diagnosis, using 70% of the data for derivation and 30% for validation. Age was associated with an increased risk across all cancer types. Socioeconomic deprivation, smoking, excessive alcohol intake, family history of cancer, chronic kidney disease, anaemia, and several cancer-related symptoms and clinical signs (e.g. rectal bleeding, loss of appetite) were associated with an increased risk in one or more cancer types. The prediction models showed moderate-to-good discrimination in the validation set, with c-statistic of 0.69 (0.68-0.70) for all cancer in men, 0.63 (0.62-0.65) for all cancer in women, 0.70 (0.68-0.73) for lung cancer, 0.70 (0.66-0.73) for colorectal cancer, 0.59 (0.53-0.65) for breast cancer, and 0.78 (0.72-0.84) for prostate cancer.

Conclusion: Most of the identified potential risk factors for cancer in the AF population are also associated with cardiovascular disease. The 1-year cancer prediction models showed moderate to good predictive performance and may help improve the management of patients with AF.

Aims: Patients with atrial fibrillation (AF) undergoing cardioversion (CV) are exposed to increased risk of ischaemic stroke (IS), but the exact magnitude is unknown. We compared IS rates during the post-CV period with the long-term risk in AF patients using guideline-recommended anticoagulation therapy.

Methods and results: This nationwide register-based study included all AF patients undergoing first-ever elective CV between 2012 and 2018 in Finland. Breakpoint analysis identified a cut-off point in the IS rate at 2 weeks after CV. Follow-up was split into two intervals: the immediate 2-week post-CV period and the subsequent period up to 360 days. Stroke rates were calculated, and incidence rate ratios were estimated with Poisson regression. Interactions between the two follow-up periods and conventional IS risk factors as well as anticoagulation treatment were assessed. A total of 9625 patients were identified (mean age 67.7 ± 9.9 years, 61.2% men, mean CHA2DS2-VA score 2.2 ± 1.4). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) patients. Overall, 92 (1.0%) patients experienced IS during the year after CV. Breakpoint analysis and survival plot displayed a higher incidence of IS within the first 2 weeks after CV, stabilizing thereafter to a consistent level. The adjusted IS rate during the first 2 weeks was 7.5-fold (95% confidence interval: 4.8-11.8) compared to the subsequent IS rate. This excess risk was independent of the anticoagulation type or conventional stroke risk factors.

Conclusion: The rate of IS was roughly seven times higher during the first 2 weeks after elective CV compared to the subsequent 360 days.

Cardiac implantable electronic device upgrade and downgrade procedures are increasingly being performed. Whilst the most appropriate guideline-recommended device may have been followed during a patient's initial procedure, the requirements of patients can change over time. This could be due to worsening of cardiac function due to detrimental effects of pacing itself or the diagnosis, development, or progression of another cardiac comorbidity. Device downgrades are also performed when a patient's clinical state changes and are often considered in patients with increased frailty and comorbidity. This clinical consensus statement aims to provide a framework for screening patients for device upgrade, pre-procedural planning considerations, available procedural strategies, namely a summary of techniques and approaches for vascular access, including ipsilateral and contralateral options, and a framework for when extraction to gain access may be appropriate. The document also provides advice on how to frame an ethical discussion with patients and carers on available options.

Aims: Antiarrhythmic drugs are used during cardiopulmonary resuscitation (CPR) to improve the chances of return of spontaneous circulation (ROSC) in shockable rhythms. To date, their impact on clinical outcomes remains uncertain. This review aimed to provide an evaluation of respective up-to-date evidence.

Methods and results: We searched Embase, MEDLINE®, and Cochrane Central Register of Controlled Trials. Data on study design, population characteristics, antiarrhythmic drugs used, and predefined outcomes were extracted. A meta-analysis was conducted in groups with at least three studies reporting the same outcome. Additionally, we performed subgroup analysis according to the study design. Initially, 5080 studies were identified, and 29 were included, with, in total, 60 205 patients. A statistically significant difference in achieving ROSC was found comparing (i) lidocaine and no lidocaine, favouring lidocaine [odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.11-2.32, P = 0.01]; (ii) nifekalant and lidocaine, favouring nifekalant (OR = 4.18, 95% CI: 2.23-7.83, P < 0.00001); and (iii) esmolol and no esmolol, favouring esmolol (OR = 3.0, 95% CI: 1.40-6.40, P = 0.005). For the effect on survival to hospital discharge, a significant difference between lidocaine and no lidocaine, favouring lidocaine (OR = 1.66, 95% CI: 1.02-2.7, P = 0.04), was found.

Conclusion: Evidence supporting the use of any antiarrhythmic drugs during CPR remains limited and is partly inconclusive. For the effect on survival to hospital discharge, a statistically significant difference was only found favouring the administration of lidocaine compared to no lidocaine. Further research with improved trial design and into novel drug options should be conducted.