Heart rhythm最新文献

Background: Biventricular (Bi-V) pacing improves left ventricular (LV) systolic function by correcting dyssynchrony, but potential proarrhythmic effects have been reported. The relationship between Bi-V pacing and ventricular tachycardia (VT) recurrence after catheter ablation (CA) remains unclear.

Objective: To assess the impact of Bi-V pacing on VT recurrence after CA in patients with structural heart disease, considering VT origin.

Methods: Out of 795 consecutive patients who underwent CA for VT, 384 met inclusion criteria of ≥90% Bi-V pacing (Bi-V pacing group) or intrinsic AV conduction with ≤10% ventricular pacing (Intrinsic Rhythm group). VT origin was classified as septal, lateral, and anterior/inferior. Baseline characteristics were balanced by propensity score matching (1:1) .

Results: 146 patients were included per group (median follow-up 473 days). All-cause mortality (26.0% vs. 24.7%, log-rank p=0.49) and heart failure hospitalization (21.9% vs. 21.9%, log-rank p=0.63) did not differ significantly between groups. VT/VF recurrence was higher in the Bi-V pacing group (37.0% vs. 19.2%, log-rank p<0.01) than in the intrinsic rhythm group and was largely due to greater VT recurrence in patients with lateral wall VT origins and Bi-V pacing (55.9% vs. 21.9% log-rank p<0.01). In the absence of Bi-V pacing a lateral wall VT origin was not associated with greater VT recurrences. On multivariable Cox regression, an LV lateral wall VT with Bi-V pacing was an independent predictor of VT recurrence (HR 3.04, 95% CI 1.65-5.60; p<0.01).

Conclusions: Bi-V pacing with an LV lateral wall substrate was associated with increased VT/VF recurrence after CA.

Background: Desmoglein-2 (DSG2)-associated cardiomyopathy represents a distinct subset of arrhythmogenic cardiomyopathy (ACM). A founder variant, NM_001943.5 (DSG2): c.T1592G (p.Phe531Cys), was identified with high frequency in China.

Objective: The study aimed to describe clinical features and outcomes of this founder variant.

Methods: Individuals with DSG2 c.T1592G (p.Phe531Cys) variants were recruited from 9 centers across China and categorized as single heterozygous, compound heterozygous (single variant plus rare variants of uncertain significance; abbreviated as compound) and homozygous. Clinical features and risk factors for malignant ventricular arrhythmias (MVA), end-stage heart failure (ESHF), and composite events of heart transplantation or cardiac death were analyzed.

Results: Ninety-one subjects were included: 21 (23.1%) single heterozygous, 21 (23.1%) compound, and 49 (53.8%) homozygous. Most of subjects (74.7%) showed right ventricular dilatation and nearly half (49.5%) had biventricular involvement. In patients with contrast-enhanced magnetic resonance imaging, 75.9% exhibited biventricular involvement. Compared with single heterozygous, compound and homozygous had younger age at onset, more T wave inversion, epsilon waves, and biventricular involvement (all pairwise P<0.05). Homozygous experienced significantly earlier MVA than compound (P=0.013), and single heterozygous (P<0.001), with a trend toward earlier MVA in compound compared with single heterozygous (P=0.089). Compound and homozygous exhibited significantly higher incidences of ESHF and composite events while single heterozygous remains event-free (all P<0.05).

Conclusion: DSG2 c.T1592G (p.Phe531Cys) founder variant defines a distinct ACM subset with high prevalence of biventricular involvement. Single heterozygous variant carriers held less severe phenotype and relatively favorable prognosis, while compound and homozygous held advanced phenotype and poorer prognosis.

Background: Left atrial low-voltage areas (LVAs), indicative of atrial fibrosis and structural remodeling, are present in a subset of patients with paroxysmal atrial fibrillation (AF).

Objective: This study aimed to develop and validate a novel predictive model for identifying LVAs in paroxysmal AF patients.

Methods: Paroxysmal AF patients receiving their initial radiofrequency ablation in the Department of Cardiology at Shanghai East Hospital were enrolled. LVAs were defined as regions with a bipolar voltage of less than 0.5 mV during left atrial voltage mapping. Logistic regression analysis was used to identify independent predictors and construct the prediction model. An independent prospective cohort and a multicenter cohort of paroxysmal AF patients were used for validation.

Results: A total of 383 patients with paroxysmal AF were enrolled respectively, among whom 104 patients (27.2%) had left atrial LVAs. Multivariate logistic regression analysis identified female, prior stroke, left atrial diameter, PR interval, hemoglobin level, and serum creatinine level were independent predictors of LVAs. The HeSLeF-PC score was developed based on these factors, and could predict the presence of left atrial LVAs in paroxysmal AF patients (AUC = 0.810, 95% CI: 0.762-0.859), which was further validated in the prospective cohort (AUC = 0.826, 95% CI: 0.757-0.896) and the multicenter cohort (AUC = 0.767, 95% CI 0.678-0.857). Decision curve analysis confirmed its clinical utility.

Conclusions: The HeSLeF-PC score could effectively predict the presence of left atrial LVAs in paroxysmal AF patients and may assist in preprocedural risk stratification and ablation planning.

Background: Among patients with persistent atrial fibrillation (PerAF), linear ablation lesions beyond pulmonary vein isolation (PVI) are often performed with variable efficacy and inconsistent added value. New catheter designs and energy sources have the potential to improve outcomes.

Objective: To examine: 1) the performance of a novel dual-energy (pulsed field [PF] /radiofrequency [RF]) lattice-tip mapping and ablation system for linear ablation, and 2) the impact of the ablation strategy on outcomes in the randomized SPHERE Per-AF trial.

Methods: Linear lesion characteristics, safety, and effectiveness were assessed for a conventional RF ablation system in the control arm vs. the dual-energy lattice-tip system in the investigational arm.

Results: In the investigational arm, 203 (95.8%) received left atrial roof and/or posterior wall isolation (LAPWI), 117 (55.2%) cavotricuspid isthmus (CTI) line, and 76 (35.8%) mitral line. In the control arm, 102 (68.9%) patients received LAPWI, 76 (51.4%) CTI, and 19 (12.8%) mitral line ablation. Transpired ablation and energy application times were shorter for each lesion type using the investigational vs. control catheter (all p<0.0001). Overall, there was a trend towards numerically higher 12-month effectiveness of a "PVI + all linear lesions combined" (n=25) approach compared to a PVI-only (n=56) ablation strategy (p=0.07), and the effect was more pronounced in the investigational arm, but sub-groups were small.

Conclusion: There was a trend towards numerically higher effectiveness with linear lesions vs. PVI-alone. These findings are exploratory and hypothesis-generating and should prompt future randomized controlled trials of additional lesion sets vs. PVI with this new technology.

Clinical trial registration: NCT05120193- Treatment of Persistent Atrial Fibrillation with Sphere-9 and Affera Mapping and Ablation System (SPHERE Per-AF).

Background: Catheter ablation (CA) is a curative therapy for atrioventricular reentrant tachycardia (AVRT) caused by accessory pathways (APs), but precise AP localization with conventional mapping can be challenging. While omnipolar technology near-field (OTNF) provides novel frequency-based analysis, its clinical utility for AP ablation remains unproven.

Objective: We aimed to characterize the spatial relationship between high-frequency areas identified by OTNF-derived peak frequency maps and successful AP ablation sites.

Methods: This multicenter retrospective study analyzed OTNF data from 33 patients undergoing successful CA for AVRT. Offline peak frequency analysis was performed on acquired open-window mapping data. We measured: (1) the peak frequency (PF) at the successful ablation site, (2) the highest PF in the immediate vicinity, (3) the spatial distance, and (4) the directional displacement between these two points.

Results: While successful ablation sites were located in areas of high frequency (mean 332 ± 206 Hz), the absolute highest PF was consistently found in the immediate vicinity (mean 435 ± 56 Hz; p < 0.01). Critically, the site of the highest PF was spatially displaced from the successful ablation site by a median distance of 4 mm (IQR: 0-6 mm). Directionally, when viewed from the annulus, the highest frequency site was co-located with the successful site in 21 cases (64%), shifted counter-clockwise in 9 cases (27%), and clockwise in 3 cases (9%).

Conclusion: High-frequency areas on OTNF maps are consistently located adjacent to, but spatially distinct from, successful AP ablation sites. This quantifiable spatial dissociation represents a novel electrophysiological target that may improve the precision and efficiency of AP catheter ablation.

Background: Elevated blood pressure (BP) levels are associated with a higher risk of stroke in patients with atrial fibrillation (AF). However, limited data exist regarding the effect of systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) on ischemic stroke risk in young AF patients.

Objective: To evaluate the association between BP levels and incident ischemic stroke in young adults with AF.

Methods: Using the Korean Health Insurance Service database, we identified patients aged 20 -39 years, newly diagnosed as AF between January 2009 and December 2016. The primary outcome was incident ischemic stroke.

Results: A total of 15,980 patients (mean age 32.4±4.8 years, 66.9% men) were included. Mean CHA₂DS₂-VASc score was 0.7±0.8 and oral anticoagulation rate was 5.6%. During a median 5.2 years (IQR 3.1-7.3) of follow-up, 73 patients had incident ischemic stroke (incidence rate 0.9 per 1,000 person-years). After multivariable adjustments, SBP 140-159 mmHg and ≥160 mmHg were associated with higher risks of ischemic stroke compared to SBP <100 mmHg (HRs 8.39 [95% CI 1.02-68.73] and 11.59 [1.14-118.05], respectively). Compared to DBP<65 mmHg, DBP≥95mmHg was associated with higher risk of ischemic stroke, with HR 4.18 [95% CI 1.26-13.87]. Those with PP <30, 50-59 and ≥60 mmHg were associated with higher risks of ischemic stroke compared to patients with PP 40-49 mmHg (HRs 3.96 [95% CI 1.36-11.53], 1.82 [1.04-3.18] and 3.15 [1.49-6.64], respectively).

Conclusion: For young patients aged 20-39 years diagnosed with AF, elevated SBP, DBP, and extreme PP are associated with increased risks of ischemic stroke.

Background: The prevalence and impact of frailty in patients undergoing left atrial appendage closure (LAAC) remains unknow.

Objective: To evaluate the prevalence and prognostic implications of frailty in patients undergoing LAAC.

Methods: The Frail-LAAC trial was an international, multicenter, prospective study that included consecutive patients undergoing LAAC in four University centers (2022-2024). Frailty was assessed pre-procedurally using the Essential Frailty Toolset (EFT) and defined as an EFT score ≥ 3 (and pre-frail as an EFT=1-2). Clinical outcomes were evaluated at follow-up.

Results: A total of 452 consecutive patients were included (mean age: 76±8 years; 34% of women), and frailty was identified in 101 (22.4%) of them. Frail patients were older, more commonly female, and had a higher comorbidity burden. Device success (99.6%) and procedural success (97.3%) were high across all groups, without differences in procedural-related complications. After a median follow-up of 12 (4-22) months, frail patients had a higher risk of all-cause mortality or ischemic events compared to non-frail patients [36.6% vs. 9.4%; adjusted HR = 4.85 (95% CI: 2.85-8.24); p<0.001], primarily driven by an increased mortality risk (33.7% vs. 7.7%; adjusted HR = 5.28 [95% CI: 2.94-9.46]; p<0.001). In contrast, pre-frailty was not associated with mortality compared to robust patients [adjusted HR = 2.87 (95% CI: 0.83-9.98), p = 0.115]. The inclusion of frailty in predictive models significantly improved mortality risk stratification.

Conclusions: Frailty is common in patients undergoing LAAC and is associated with a five-fold increased mortality risk. Incorporating frailty assessment into pre-procedural evaluations enhance risk stratification, highlighting the need for careful patient selection, particularly in those with advanced frailty, to optimize outcomes and avoid futile interventions.