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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.

Atrial tachycardias (AT) represent an increasingly recognized cause of morbidity and mortality. Over the past decade, the mechanistic understanding and therapeutic concepts guiding AT treatment have undergone rapid progress. Catheter ablation has become the most effective therapy for maintaining sinus rhythm in patients with regular AT, while mapping and ablation concepts and technologies have improved significantly. Accordingly, international cardiac electrophysiology professional societies aimed at outlining best practices on the management of regular AT, with a special focus on indications, timing, and technical aspects of AT mapping and ablation. After reviewing and discussing available evidence, including a systematic literature review and meta-analysis, an expert writing group summarized current knowledge and practice and has proposed strategies in the here outlined 10-Point Plan for SMART-AT care (Standardized Management and Ablation Roadmap for Treatment of Patients with Atrial Tachycardia).

Pulsed field ablation (PFA) represents one of the most significant technological advances in atrial fibrillation (AF) therapy in recent decades. By harnessing irreversible electroporation, PFA produces myocardial lesions within milliseconds, enabling rapid and efficient pulmonary vein (PV) isolation. Early clinical experience from pivotal investigational device exemption (IDE) trials has shown acute and one-year arrhythmia-free outcomes that are non-inferior to conventional radiofrequency (RF) and cryothermal ablation. The large MANIFEST-17 K registry, encompassing over 17 000 patients treated with the Farawave system, reported an exceptionally low 0.98% major complication rate with no atrio-oesophageal fistula, phrenic nerve injury, or PV stenosis. These findings have accelerated PFA adoption across many centres. However, as experience broadens, nuances in lesion formation and durability are becoming evident. Factors such as contact force, catheter rotation, pulse train configuration, and target tissue geometry influence lesion depth and transmurality. While PV isolation appears consistently durable, data remain limited for non-PV targets such as the posterior wall, mitral isthmus, and cavotricuspid isthmus. Moreover, novel PFA-specific complications including transient left atrial dysfunction, haemolysis, and coronary artery spasm warrant ongoing vigilance. PFA has undoubtedly transformed expectations for procedural safety and efficiency. Yet whether it should already be considered the standard technique for all AF ablation candidates remains an open question. This Controversy piece explores the balance between innovation and evidence, examining whether PFA's rapid rise represents the inevitable new standard or a technology still undergoing critical refinement.

Aims: Anatomical studies have documented a close topographical relationship between the ganglionated plexi (GP) containing parasympathetic inputs to the sinus node (SN) and atrioventricular node (AVN) and the epicardial fat pads (FPs) within the Waterston's interatrial groove. We aimed to investigate the feasibility and outcomes of a novel anatomical approach to cardioneuroablation (CNA) that targets the atrial areas adjacent to the interatrial FPs identified with intracardiac echocardiography (ICE).

Methods and results: About 17 patients [37.3 ± 10.2 years, 47% female] undergoing CNA for recurrent vasovagal syncope and documented sinus pauses (n = 13, 76%) and/or AVN block (AVB, n = 4, 16%) were included. The right superior RS-FP containing the RS-GP (target for SN vagal denervation) and the right inferior RI-FP containing the RI-GP (target for AVN vagal denervation) were identified with ICE and reconstructed on a 3D electroanatomic map. At baseline, all patients had provocable sinus pauses/AVB with extracardiac high-frequency vagal stimulation (ECVS). The target FPs could be identified in all patients and were adjacent to septal LA and RA sites covering an average surface area of 3.7 ± 1.4 cm2 and 2.97 ± 1.21 cm2, respectively. A total of 33 ± 15 RF ablations (30-40W, 60 s) were delivered to cover the target LA/RA area. A > 25% shortening of the PP interval was observed within the first 1-2 RF lesions in all cases. After ablation, complete abolition of sinus pauses/AVB response with ECVS was achieved in all patients, and 2 mg of atropine infusion resulted in no PP/PR interval change. After a median follow-up of 12 months (range 4-25 months), 16 patients (94%) remained free of recurrent symptoms (1 patient underwent repeat CNA for recurrent pre-syncope and AVB, 1 patient underwent PPM implant following ECG recording of asymptomatic diurnal AVB).

Conclusion: An ICE-guided anatomical approach to CNA targeting visible FPs at the Waterston's groove is a feasible and effective strategy to achieve SN/AVN vagal denervation, with good outcomes at mid-term follow-up.

Aims: Device-detected subclinical atrial fibrillation (DDAF) is increasingly documented either with implantable cardiac electronic devices (CIED) or with consumer-based mobile or wearable monitors. We aimed to investigate phisician's reaction to DDAF, which management is still matter of debate.

Methods: This is a physician-based survey with 24 multiple-choice questions.

Results: A total of 222 physicians from 46 countries responded the survey. DDAF is frequent, occurring in >10% of CIEDs follow-up for 37% of respondents. Oral anticoagulation is prescribed according to CHA2DS2-VA and AF duration; 34% of the respondents initiate anticoagulation with AF >24 h, 26% with AF >6 h, and 15% with AF >5-6 min. Respondents from non-European countries and Mediterranean Europe are more likely to prescribe diagnostic exams and therapy than respondents from North Europe. Systematic long-term AF screening with implantable loop recorder (ILR) after cryptogenic stroke ranges from 43 ± 27% of ILR implanted for that purpose in Mediterranean countries to 10 ± 20% in North Europe. The majority of responders recommends the use of consumer-based devices to screen for AF mainly in specific situations (undiagnosed palpitations, ischaemic stroke, or AF burden monitoring) and not routinely, just according to CHA2DS2-VA or age.

Conclusion: AF screening is not routinely performed, either in primary or secondary prevention of stroke. Device-detected AF is not uncommon and generally managed based on thromboembolic risk and duration of episodes; the cut-offs of AF duration, global burden, and number of episodes are yet to be determined in terms of role and clinical value. Clinicians' approaches to subclinical AF remain heterogeneous.