Europace最新文献

Aims: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. However, the optimal strategy during repeat ablation is not clear. This European Heart Rhythm Association (EHRA) survey aims to assess real-world ablation strategies in patients undergoing repeat AF ablation.

Methods and results: A 25-item questionnaire was distributed among healthcare professionals via EHRA between 22 May and 21 June 2024. Of the 211 respondents from 43 countries, 58.1% of respondents planned a redo after multiple symptomatic recurrences of atrial arrhythmias. Most repeat procedures (68.0%) are performed within 3 months after the decision for re-intervention. 3D mapping and radiofrequency (RF) catheters with contact force (CF) sensing are the most common modality used for repeat ablation. In patients with more than one pulmonary vein (PV) reconnection, most commonly reisolation of the PVs plus individualized substrate-based ablation is performed (62.2%). When empirical ablation is performed, the most common targets include cavotricuspid isthmus (22.5%), posterior wall isolation (20.7%), left atrial roofline (16.1%), anterior line (12.9%), superior vena cava (8.6%), and vein of Marshall (8.6%). In patients without PV reconnection at repeat procedure, substrate mapping/individualized ablation is the preferred strategy (77.9%). No additional right atrial ablation beyond the CTI was reported. The majority of respondents (60.7%) consider rate control after ≥3 failed ablations.

Conclusion: Real-world strategies for repeat AF ablation show significant variability. 3D mapping and CF-guided RF ablation are commonly utilized. Re-PVI and substrate-based ablation are the predominant approaches. However, the optimal strategy beyond durable PVI remains to be further evaluated.

Aims: The differentiation of human-induced pluripotent stem cells (hiPSCs) into sinoatrial node (SAN)-like cells (SANLCs) remains challenged by complex differentiation protocols and low efficiency. This study aims to reveal the role of AMPK signalling in the differentiation process of hiPSCs into SANLCs, providing new strategies for obtaining SANLCs in vitro.

Methods and results: Cells from the cardiac mesodermal stage, cardiac progenitor cell stage, and cardiomyocyte stage during differentiation of hiPSCs to cardiomyocytes (hiPSC-CMs) were taken for transcriptome sequencing and analyses. PCR, immunostaining, western blot, FACS, and patch-clamp techniques were employed for the analyses of differentiated hiPSC-CMs. Kyoto Encyclopedia of Genes and Genomes analysis identified that the AMPK signalling pathway is significantly enriched with the expression of NKX2.5 (sinus node cell development-related transcription factor). The early activation and late inhibition of AMPK signalling were both effective in the up-regulation of SANLC markers. In addition, the combined manipulation of both stages further enhanced the differentiation efficiency reflected by higher SANLC marker expression, which was also confirmed at the protein level by immunofluorescence, western blot, and flow cytometry analyses. SANLCs obtained from the differentiation with combined modulation of AMPK signalling displayed typical features of native pacemaker cells in the heart, including ion channel currents (IKAch, ICaT, ICaL, If), action potentials, and robust autonomic responsiveness to both β-adrenergic and muscarinic stimulation.

Conclusion: Early activation and then inhibition of the AMPK signalling pathway during the differentiation process can promote hiPSC differentiation to SANLCs, which may provide a novel strategy for obtaining SANLCs for studies on SAN diseases.

Aims: Atrial fibrillation (AF) ablation is associated with complications. These are sometimes categorized as mild or severe based on unspecified criteria. We conducted a survey of European electrophysiologists (EPs) to rank the perceived complication severity.

Methods and results: A physician-based survey was conducted by the Scientific Initiative Committee of the European Heart Rhythm Association (EHRA). An online questionnaire was created asking EPs to score a list of complications on a scale from 0 (no complication) to 100 (procedural death). Three hundred respondents participated in the survey; however, 105 were excluded due to incomplete responses. Unexplained periprocedural death (90, interquartile range 50-100), atrio-oesophageal fistula (AEF 92, 80-100), procedural stroke (80, 59-89), and tamponade requiring surgery (70, 80-83) were the complications associated with highest scores. Among the intermediate complications, phrenic nerve palsy at discharge (49, 25-67) was ranked similarly to tamponade treated with pericardial puncture (50, 25-70) or periprocedural transient ischaemic attack (50, 25-70). Institutional infrastructural features such as cardiac surgery or stroke units had no impact on the scoring. Most respondents (89%) have experienced cardiac tamponade, procedural stroke (53%), and AEF (25%). When applied retrospectively to existing studies, the proposed EHRA AF ablation safety score demonstrated a trend towards improved AF ablation safety over time.

Conclusion: The EHRA complication severity score provides a standardized, quantitative ranking of AF ablation complications, identifying periprocedural death and AEF as the most severe events. Based on the findings, we propose a novel EHRA AF ablation safety score that may contribute to a more objective safety comparison of AF ablation trials.

Aims: While transvenous pacemakers (TV-VVI) are standard for bradyarrhythmia, lead- and pocket-related complications remain concerns. Leadless pacemakers (LPMs) may reduce these risks. However, direct comparisons between LPMs and single-chamber TV pacemakers are limited. This study aimed to compare clinically meaningful outcomes between LPM and TV-VVI using real-world data.

Methods and results: Using the National Readmissions Database (NRD), we analysed demographics, readmission rates, and 30-day outcomes of patients aged ≥65 years who underwent LPM or TV-VVI implantation between 2016 and 2022. Admissions were identified via ICD-10 codes. Outcomes were assessed in the propensity score-matched population (10 594 patients per group) through multivariable logistic regression after 1:1 high-dimensional propensity score matching (caliper 0.1 SD) to adjust for confounding. Among 49 852 patients, 44.8% received LPM. Median age was 84 vs. 81 years in TV-VVI and LPM groups; 46.2% were female. TV-VVI patients had significantly higher rates of device-related complications [adjusted OR (aOR): 0.45, 95% CI (0.30-0.65), P < 0.001], device revision or replacement [aOR: 0.20, 95% CI (0.11-0.36), P < 0.001], implant-related complications [aOR: 0.58, 95% CI (0.34-0.97), P = 0.040]. Crude rates of arteriovenous fistula, pseudoaneurysm, and pericardial complications were higher in LPM, but adjusted differences were non-significant. Thirty-day readmission rates were similar between LPM and TV-VVI groups at 15.5% and 15.9%, respectively. Mortality and prolonged length of hospital stay also showed no significant differences.

Conclusion: Nationally representative data indicate that LPM implantation is associated with fewer device-related complications compared to TV-VVI, though further studies are needed to evaluate long-term outcomes.

Aims: In non-ischaemic cardiomyopathy (NICM), late gadolinium enhancement (LGE) detected by cardiovascular magnetic resonance is related to ventricular arrhythmia (VA) and sudden cardiac death (SCD) risk. The incremental prognostic value of quantifying LGE volume or mass beyond its mere presence, however, remains unresolved. The aim was to evaluate whether LGE quantification improves the prediction of SCD.

Methods and results: PubMed, Embase, and Web of Science were searched on 20 November 2024 for observational studies that related quantified LGE burden to ventricular arrhythmia (VA)/SCD in NICM. Forty-one studies met prespecified criteria. Hazard ratios (HRs) were pooled with random-effects models, and quantification information was depicted in figures. Presence of any LGE was associated with a three-fold increase in VA/SCD risk (pooled HR 3.31, 95% confidence interval: 2.58-4.24). Beyond this binary marker, every additional 1% (or 1 g) of LGE was associated with a 12% relative risk increase (range 10-20%), independent of left ventricular ejection fraction and consistent across eight semi-automated thresholding techniques. This included 2-6 standard deviations above the reference myocardium and the full-width half-maximum method. Additionally, results were prone to substantial methodological heterogeneity (τ² = 1.49) and small-study bias. Once the presence of LGE was accounted for, scar quantification and location conferred minimal additional prognostic value.

Conclusion: Quantitative LGE assessment provides little incremental prognostic utility over dichotomous LGE detection. Consensus imaging standards and prospective validation are requisite before LGE burden can guide primary implantable cardioverter defibrillator allocation in NICM.

Aims: Patients with end-stage renal disease (ESRD) and atrial fibrillation present a challenge for thromboembolic prevention, given their elevated risks of both thromboembolism and bleeding. Anticoagulants carry a higher bleeding risk in this population without clear evidence of thromboembolic benefit. This study aims to define the role of left atrial appendage occlusion (LAAO) as a preventive strategy for patients with ESRD.

Methods and results: A systematic literature review was conducted to identify studies reporting outcomes in patients with ESRD who underwent LAAO. Meta-analyses of aggregate and individual patient data were performed to evaluate acute and long-term outcomes and compare them with those of patients without ESRD. Seventeen studies reporting data from 24 127 patients, including 1047 with ESRD, were included. Procedural complications were more common in patients with ESRD (RR 2.23; P = 0.02), with a pooled rate of 4% (95% CI, 1-9%). There was no significant difference in thromboembolic event rates during follow-up between the groups (IRR 1.44; P = 0.16), but major bleeding incidence was higher among patients with ESRD (IRR 1.84; P < 0.01). Individual patient-level data from seven studies comprising 4745 patients (268 with ESRD) were obtained and analysed. Similarly, there was no significant association between ESRD and stroke/TIA incidence (HR, 1.22; 95% CI, 0.66-2.26), but major bleeding was higher on patients with ESRD (HR, 1.65; 95% CI, 1.01-2.69).

Conclusion: LAAO represents a feasible option for thromboembolic prevention in patients with ESRD, although these patients have an increased risk of complications and bleeding.

Aims: Extra-pulmonary vein triggers (ExPVTs) are recognized as important contributors to atrial fibrillation (AF) recurrence after radio-frequency catheter ablation (RFCA). This study aimed to investigate the clinical characteristics, diagnostic value, and prognostic implications of isoproterenol-induced ExPVTs in patients undergoing de novo RFCA with circumferential pulmonary vein isolation (CPVI).

Methods and results: We analysed 2619 non-valvular AF patients (25.8% female, mean age 59.4 ± 10.9 years, 60.7% with paroxysmal AF) who underwent CPVI and standardized isoproterenol provocation testing; 98.2% also received empirical right atrial (RA) ablation. We evaluated the clinical and prognostic significance of ExPVTs for AF recurrence within 2 years, considering their anatomical location and targeted ablation status. ExPVTs were identified in 13.5% of patients. Lower mean left atrial (LA) voltage was independently associated with ExPVTs, irrespective of sex. Importantly, ExPVTs remained independently associated with AF recurrence [hazard ratio (HR) 1.81 (95% confidence interval 1.39-2.35)], alongside AF type, body mass index, LA volume index, and mean LA voltage as significant predictors. LA [HR 1.50 (1.04-2.17)] and septal [HR 1.51 (1.02-2.23)] triggers were significantly associated with recurrence, while RA triggers were not, given the high rate of empirical RA ablation (98.9%). Recurrence risk was highest in patients with multiple or unmappable triggers and in those without ExPVT-targeted ablation.

Conclusion: ExPVTs are strongly associated with lower LA voltage and carry independent prognostic value for AF recurrence, with outcomes varying by anatomical location and targeted ablation status. These findings underscore the importance of systematic ExPVT assessment and selective targeting in individualized ablation strategies.

Clinical trial registration: NCT02138695.