Europace最新文献

Aims: A novel impedance filtering function that averages impedance values was developed to mitigate cardiac and respiratory oscillations. We aimed to evaluate the clinical significance of averaging real-time impedance in predicting steam pops (SPs) and lesion characteristics.

Methods and results: Radiofrequency (RF) ablation was performed in 20 swine using a flexible-tip temperature-controlled power regulation catheter. Both unfiltered and filtered (averaged) impedance values were recorded using the EnSite™ X system. For each RF application, absolute (ΔImp-drop) and relative (%Imp-drop) impedance drops were quantified. Associations between impedance parameters and SP occurrence, atrial lesion transmurality, and ventricular lesion dimensions were evaluated. Among 959 lesions, SPs occurred in 36 applications (3.8%), all within the ventricles. Notably, 6 SPs occurred within 90 s despite RF power ≤ 40 W, with 4 during left ventricular ablation under low systolic blood pressure (<40 mmHg). Lesions with SPs exhibited significantly greater unfiltered and averaged ΔImp-drop and %Imp-drop (all P < 0.001). Averaged %Imp-drop showed the highest predictive value for SPs (AUC = 0.93), with a 20.9% cut-off yielding 88.9% sensitivity and 85.5% specificity. The time to reach the initial 10%, 15%, and 20% reduction in averaged %Imp-drop was not associated with SP occurrence. Both unfiltered and averaged impedance drops correlated with atrial transmural lesion formation. Averaged impedance drops significantly improved estimation of lesion depth, surface area, and volume compared with unfiltered values (P < 0.01).

Conclusion: The averaged relative impedance drop demonstrated the strongest association with SP occurrence, and averaging impedance provided a more accurate assessment of lesion characteristics than unfiltered measurements.

Aims: Left ventricular ejection fraction (LVEF) remains the key determinant in the evaluation for the risk of sudden cardiac death (SCD). Myocardial fibrosis has gained increasingly more interest in the context of various myocardial diseases. We determined the spectrum of LVEF and evaluated the association between myocardial fibrosis and pre-SCD LVEF in a population-based SCD cohort.

Methods and results: The Fingesture study and clinical data have been collected from consecutive autopsy-verified SCD victims from Northern Finland between 1998 and 2017 (n = 5869). The cause of death was verified in medicolegal autopsy in all subjects. Electronic health records were used to identify those with pre-mortem echocardiography data. The extent of myocardial fibrosis at autopsy was characterized macroscopically and from histology samples. The LVEF recorded median 2 years (interquartile range 1-5) prior to SCD was evaluated in 716 SCD subjects. Proportional LVEF values were as follows: 62.7% (n = 449) normal LVEF (≥50%), 21.9% (n = 157) mildly reduced LVEF (36-49%), and 15.4% (n = 110) severely reduced LVEF (≤35%). At autopsy 19.6% (n = 140) had substantial, 53.8% (n = 386) moderate, and 22.1% (n = 158) mild fibrosis, and 4.5% (n = 32) had no myocardial fibrosis. The extent of myocardial fibrosis and LVEF had poor correlation (Spearman's ρ 0.21, CI 0.141-0.285, P < 0.001). Only 21.4% of those with substantial fibrosis at autopsy had LVEF ≤35%.

Conclusion: The proportion of SCD subjects with LVEF ≤35% is low, and the prevalence of myocardial fibrosis is high. The LVEF has a weak correlation with the extent of myocardial fibrosis. Our study suggests that LVEF is a poor surrogate of myocardial fibrosis in SCD victims.

Aims: Ventricular tachycardia (VT) in ischaemic heart disease (IHD) requires complex management strategies including catheter ablation (CA) and anti-arrhythmic drugs (AADs). The aim of this study is to compare efficacy and safety of CA vs. AADs in patients with IHD and VT.

Methods and results: We performed a meta-analysis of randomized controlled trials (RCTs) enrolling patients with IHD and ICD randomized to CA or AADs. Primary outcome was appropriate ICD therapy. Secondary outcomes included inappropriate ICD therapy, cardiovascular (CV) re-hospitalization, all-cause/CV mortality, and adverse events. Subgroup analyses were conducted for amiodarone and sotalol, with an exploratory evaluation of a composite endpoint (ICD shock, VT storm, all-cause death). Four RCTs including 947 patients (mean age 68 ± 2 years; 93% male) were analysed. CA significantly reduced the risk of appropriate ICD therapy compared with AADs (149/470 [31.7%] vs. 229/477 [48.0%]; RR 0.81; 95% CI [0.67, 0.97]; P = 0.02). Among secondary outcomes, CA decreased the incidence of CV re-hospitalization [RR 0.84; 95% CI (0.72, 0.99); P = 0.04] and adverse events [RR 0.42; 95% CI (0.28, 0.62); P < 0.01], while no differences were observed in all-cause/CV mortality and inappropriate ICD therapy. In subgroup analyses, CA was superior to sotalol in reducing the composite endpoint of ICD shock, VT storm and all-cause death [RR: 0.82, 95% CI (0.69, 0.98), P = 0.03]; whereas, no significant benefit was seen compared to amiodarone [RR: 0.92; 95% CI (0.78, 1.09), P = 0.32].

Conclusion: In ischaemic heart disease and VT, CA compared with anti-arrhythmic drugs is associated with a reduction of appropriate ICD therapy, cardiovascular re-hospitalization, and adverse events with benefits most evident versus sotalol.

Aims: Sarcopenia, characterized by reduced muscle mass and function, has been increasingly implicated in cardiovascular disorders. However, its prognostic relevance in atrial fibrillation (AF) remains unclear. We aimed to evaluate the association between sarcopenia and adverse outcomes in individuals with AF using UK Biobank data.

Methods and results: This retrospective cohort study included individuals with AF enrolled between 2006 and 2010 at 22 centres. Sarcopenia was defined per European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria as low muscle strength and/or low muscle mass measured by handgrip and bioelectrical impedance analysis. Propensity score weighting adjusted for baseline differences. The primary outcome was a composite of all-cause mortality, major bleeding, thromboembolic events (stroke/systemic embolism), and heart failure admission; each component was also assessed individually. Among 5144 patients with AF (median age, 64.0 years; 24.1% female), 16.7% had sarcopenia. After propensity score weighting, sarcopenia was associated with a higher incidence of the primary composite outcome [43.9 per 1000 person-years (PYRs)], with an adjusted hazard ratio (HR) of 1.30 [95% confidence interval (CI), 1.15-1.46]. This risk was mainly driven by elevated rates of all-cause mortality (26.4 per 1000 PYRs; aHR, 1.44; 95% CI 1.24-1.68) and major bleeding (14.4 per 1000 PYRs; aHR, 1.34; 95% CI 1.10-1.65). Subgroup analyses demonstrated consistent results.

Conclusion: Even after PS weighting analysis, some residual confounders may remain; however, sarcopenia was independently associated with adverse clinical outcomes, particularly mortality and bleeding risk. Screening for sarcopenia may enhance risk stratification and management, particularly in patients receiving anticoagulation.

Aims: Clinical complexity (CC) in atrial fibrillation (AF) reflects overlapping risk factors that raise vulnerability to both thromboembolism and bleeding. Ethnic differences in the expression of CC remain poorly characterized.

Methods and results: We performed a post hoc analysis of the EORP-AF and APHRS-AF registries. CC was defined as a CHA₂DS₂-VASc score ≥2 plus ≥1 of: (i) age ≥75 and BMI <23 kg/m², (ii) chronic kidney disease, or (iii) prior major bleeding. Multivariable logistic regression identified predictors of CC, oral anticoagulant (OAC) use, and rhythm control. The primary outcome was a composite of all-cause death and major adverse cardiovascular events (MACE), defined as cardiovascular death, acute coronary syndromes, and thromboembolic events. Secondary outcomes included each individual component and major bleeding. Associations were assessed using Cox regression models. Among 14 055 patients, 2794 (19.9%) met CC criteria (mean age 77 ± 9 years; 46% female). Compared to Europeans, Asian patients with CC had a distinct clinical profile and were less likely to receive OAC (OR 0.75, 95% CI 0.57-1.01) or rhythm control (OR 0.53, 95% CI 0.41-0.69). CC was independently associated with increased risk of composite outcome (HR 1.55, 95% CI 1.35-1.77), all-cause death (HR 1.65, 95% CI 1.42-1.93), MACE (HR 1.50, 95% CI 1.26-1.80), cardiovascular death (HR 1.81, 95% CI 1.40-2.36), and major bleeding (HR 2.02, 95% CI 1.47-2.77). The excess risk of the composite outcome was greater in Asians (HR 2.28, 95% CI 1.57-3.32) than in Europeans (HR 1.51, 95% CI 1.31-1.75; P-interaction = 0.036).

Conclusion: Among AF patients with CC, those enrolled in Asia exhibited marked differences in clinical profiles, management strategies, and outcomes, suggesting greater vulnerability to CC in the Asian population.

Aims: Despite technical advances, transvenous lead extraction (TLE) remains a challenging procedure. Cardiac computed tomography (CT) has emerged as a valuable tool for pre-procedural assessment, but its role in predicting outcomes in rotational mechanical TLE as a first-line strategy is not well defined. The aim was to determine whether pre-procedural CT can predict complications and procedural complexity in patients undergoing rotational mechanical TLE.

Methods and results: This retrospective study included 115 patients. All had pre-procedural contrast-enhanced CT with a dedicated lead extraction protocol. Two procedural outcomes were evaluated: (i) complicated procedure, defined as major complication, incomplete lead removal, or snare use, and (ii) complex procedure, defined as requiring either a snare or a tissue stabilization sheath. Logistic regression and receiver operating characteristic analyses were used to identify predictors. A total of 215 leads were extracted (mean dwelling time 95 ± 73 months). Complicated procedures occurred in 20.9% and were independently associated with longest fibrosis length on CT (odds ratio 1.1; P < 0.001); a fibrosis length of >40 mm predicted complicated procedures [area under the curve (AUC) 0.92; 95% confidence interval (CI) 0.88-0.97]. Complex procedures occurred in 37.4% and were associated with longest fibrosis length, lead calcification, dwelling time, and systolic heart failure. A fibrosis length of >30 mm predicted complex procedures (AUC 0.72; 95% CI 0.64-0.81).

Conclusion: Pre-procedural CT allows accurate identification of high-risk anatomical features, particularly fibrosis length and calcifications, which independently predict both complicated and complex rotational mechanical TLE. These findings support the integration of CT imaging into procedural planning and individualized risk stratification.

For patients with heart failure (HF) and bundle branch block, cardiac resynchronization therapy (CRT) by biventricular pacing (BiVP) has been found effective and has been widely used for around 20 years. The effects of BiVP are well documented in a row of large randomized controlled trials (RCTs) with long-term follow-up to include prolonged survival, less HF hospitalizations, and better quality of life for the patients. More recently, conduction system pacing (CSP) as His bundle pacing or left bundle branch area pacing has been introduced for CRT and shown to in best cases establish a normal or near-to-normal electrical activation of the left ventricular myocardium. Data from large RCTs documenting the beneficial effects of CSP are awaited. Currently, the question is to what extent the contemporary literature supports a transition from BiVP to CSP for CRT in patients with HF and bundle branch block. This Europace Controversy article presents opposing viewpoints on this topic. H.B., M.J., and J.J. argue in favour of CSP being superior to BiVP. Conversely, C.L., N.B., and J.C.D. advocate for BiVP still being the first choice for CRT. This Controversy aims to present data and their interpretation from different expert perspectives on an important topic in CRT for HF.

Background: With the introduction of pulsed field ablation (PFA) to treat atrial fibrillation (AF), there is interest in studying workflow and sedation strategies to optimize integration into clinical practice. This sub-analysis characterizes early real-world use of general anesthesia versus deep sedation during AF ablation using the pentaspline PFA catheter.

Methods: EU-PORIA is an all-comer AF registry enrolling consecutive patients at seven high-volume centers in Europe. Patients were treated based on institutional standard-of-care. During follow-up, any episode of atrial tachycardia (AT) or AF >30s was considered an arrhythmia recurrence.

Results: EU-PORIA enrolled 1233 patients, of which 250 (20%) and 983 (80%) cases were performed using general anesthesia and deep sedation, respectively. Patients treated with general anesthesia were more often male and non-paroxysmal AF. In the general anesthesia group, 72% received pulmonary vein isolation (PVI)-only versus 90% in the deep sedation group (p<0.01), and 3D mapping was used in 60% of general anesthesia and 27% of deep sedation cases (p<0.01). Procedure and fluoroscopy times were shorter with deep sedation (51[36-84] vs 75[60-90] min; 13[8-19] vs 19[15-26] min; p<0.01). There were no differences in the incidence of serious adverse events. At 1-year follow-up, 74.8% and 73.8% of patients in the general anesthesia and deep sedation groups, respectively, were free from recurrent AF/AT (p=0.87).

Conclusion: AF ablation using deep sedation with the pentaspline PFA catheter demonstrated a safety and efficacy profile consistent with procedures performed under general anesthesia. This characterization of real-world use warrants further evaluation to understand optimal sedation strategies with PFA technologies.