Heart rhythm最新文献

Background: It has been hypothesized that both atrial fibrillation (AF) and medications for AF, are poorly tolerated in athletes.

Objective: To determine the impact of AF and AF treatments on sports performance METHODS: An internet-based survey, initiated via StopAfib.org, queried the impact of AF and treatment modalities on sports performance, training, and symptoms. Performance, (rated in comparison to personal best), frequency of training and competition were compared prior to onset of AF symptoms versus when symptoms at worst, via paired Wilcoxon, and then similarly compared in relation to participants' AF treatments.

Results: Between 5/13/19 and 2/29/20, 1055 athletes responded, 78% male, median age 61-70 years. Most reported sports were cycling (25%) and running (20%). Development of AF was associated with declining sports performance, competition, and training frequency. Of 565 participants who detrained, 31% reported no change in symptoms, 56% reported decreased frequency, and 13% reported no further AF. Among athletes that received treatment, ablation was associated with greater improvement in sports performance than use of medications. Of 262 athletes currently on medication, 27% reported that it was completely effective, 58% partially effective, and 15% not effective. Of 653 athletes that have taken medication currently and/or in the past, 43% reported side effects, most commonly fatigue, low energy, or decreased athletic performance.

Conclusion: Athletes reported that AF was associated with worsening sports performance. Among AF treatment modalities, ablation was associated with the greater reported improvement in sports performance than use of medications which also had a high frequency of side effects.

Background: The utility of repeat ablation for premature ventricular contractions (PVCs) after prior ablation failure is not clear.

Objective: To assess the outcomes of repeat ablation and the use of different techniques in patients who failed prior PVC ablation.

Methods: We reviewed 239 consecutive patients who underwent PVC ablation. When standard endocardial ablation with normal or half normal saline failed, we considered an advanced ablation technique. Acute success was defined as abolition of the target PVC. Clinical and procedural findings, PVC origins and acute and follow-up outcomes were compared in those with and without a prior failed ablation procedure.

Results: Of 239 patients, 75 (31%) patients had failed a prior ablation procedure and they more often had LVOT PVCs. Despite failing prior ablation repeat standard ablation was acutely successful in 59% of patients and 75% of these patients had long-term success. Acute standard ablation success rate was lower and long-term recurrence rate was higher compared to patients without prior ablation (59% vs 95%; P<0.001, 29% vs 17%; P<0.05, respectively). Of the 31 repeat standard procedures that again failed, advanced techniques were performed in 23 (16 Needle, 5 epicardial and 2 simultaneous ablation), and were acutely successful in 16 (70%) with long-term success in 14 (45%). Over all long-term success for patients with prior failed standard ablation was 71%.

Conclusion: Although success is lower for patients with prior failed ablation, repeat ablation appears reasonable for many and the use of advanced techniques increased success to 71% in this group.

Background: Data on the predictors of percutaneous stellate ganglion block (PSGB) efficacy in electrical storm (ES) are scanty.

Objective: To assess whether the PSGB efficacy is influenced by the arrhythmia type and cycle length prior to the procedure.

Methods: A sub-analysis of the multicenter STAR study. The population was stratified into 3 groups according to the median cycle length of the latest ventricular arrhythmia before PSGB: ventricular fibrillation (VF), fast-VT and slow-VT. The primary outcome was the number of treated arrhythmic episodes (with ATPs and/or DC-shocks) in the hour immediately after PSGB compared to the hour before.

Results: We considered 139 PSGBs from 112 patients divided in 51 VF, 44 fast-VT (VT cycle<375 msec) and 44 slow-VT (VT cycle≥375 msec). The number of treated arrhythmic episodes in the hour after every PSGB was significantly lower compared to the hour before in all groups [VF:0 (IQR,0-1) vs 5 (IQR,2-8), p<0.001; fast-VT:0 (IQR,0-0) vs 1 (IQR,0-6.5), p<0.001; slow-VT:0 (IQR,0-0) vs 1 (IQR,0-4.5), p=0.001]. Analyzing the reduction of the number of ATPs/DC-shocks from the hour before to the hour after PSGB, a significant trend was observed across the groups (Jonckheere-Terpstra trend p<0.001) and a significant difference was observed comparing slow-VT vs VF and fast-VT versus VF, but not comparing slow-VT versus fast-VT. VF was independently associated with the probability of reduction of treated event after PSGB.

Conclusion: PSGB is an effective treatment for ES in patients with all type of ventricular arrhythmias. However, its effectiveness was more pronounced in patients with VF.

Background: Even though aging has been demonstrated to be associated with a higher risk of atrial fibrillation (AF). It is unclear whether biological aging is associated with risk of incident AF.

Objective: This study aims to investigate the association between biological aging and AF.

Methods: A total of 371,882 participants without AF at baseline from the UK Biobank were included. The incident AF was ascertained through linkage to the UK National Health Services register. Biological age was evaluated from clinical traits using the Klemera-Doubal method Biological Age (KDM-BA) and PhenoAge algorithm, respectively. The residual discrepancies between biological age with chronological age were defined as the age accelerations (KDM-BA acceleration and PhenoAge acceleration). The Cox proportional hazards model was used to evaluate the effects of age accelerations with the risk of incident AF.

Results: During a mean follow-up of 13.04 years, a total of 28,076 new cases of AF were identified. Accelerated biological age was associated with an increased risk of AF, with a hazard ratio (HR) of 1.11 (95% confidence intervals [CIs] 1.10 - 1.13) per standard deviations (SD) increase in KDM-BA acceleration (10.9 years), and 1.28 (95%CI 1.27 - 1.30) in PhenoAge acceleration (5.6 years), respectively.

Conclusion: Accelerated biological age quantified by clinical biomarkers is associated with increased risks of AF. Biological aging may represent a potential risk factor for incident AF in midlife and older adults and a potential target for risk assessment and intervention.

Background: Patients with cardiovascular implantable electronic devices (CIEDs) indication are complicated with special cardiomyopathy or other unspecified cardiac abnormalities and may need endomyocardial biopsy (EMB). However, EMB by a bioptome is usually avoided to reduce the risk of lead displacement in the CIED peri-procedural period.

Objective: We aimed to assess the safety and feasibility of a novel approach for transvenous right ventricular (RV) EMB using the lead-sheath method (L-S-M) during CIED implantation and compared it to the traditional bioptome method (T-B-M).

Methods: Consecutive eighty patients referred for EMB were enrolled. In the L-S-M group, a sheath with a lumenless pacing lead was positioned toward the middle to apical interventricular septum under fluoroscopy (n=60). The CIED implantation was performed through the same venous access site. In the T-B-M group, a bioptome was used (n=20). The clinical characteristics, procedural details, success rate and complications were evaluated.

Results: 380 RV EMBs procedures were performed with comparable 4.1±0.8 in the L-S-M group and 3.8±0.8 samples/patient in the T-B-M group. In the L-S-M group, seven (11.7%) patients experienced minor complications with 3 transient right bundle branch block, 2 transient atrioventricular block (AVB) and 2 regional minor device pocket hematomas. In the T-B-M group, three (15%) experienced one temporary pacing for transient AVB, one chest discomfort and one regional hematoma. No cardiac tamponade was detected.

Conclusions: RV EMB by the innovative L-S-M method is technically feasible, safe and can yield valuable and early diagnostic insights for patients who are candidates for CIEDs.

Background: Left bundle branch area pacing (LBBAP) requires implantation of the lead deep in the interventricular septum. We developed a novel implantation method, which does not require dedicated delivery catheters, but only a manually shaped three-dimensional (3D) stiff stylet.

Objective: The aim of the study was to characterize procedural outcomes of this technique when used as a routine approach for LBBAP.

Methods: A case-control study compared procedural outcomes of consecutive patients who underwent pacemaker implantation at two centers: one using only the 3D stylet-based LBBAP technique and the other using the conventional catheter-based LBBAP lead implantation.

Results: A total of 400 patients (age 75.3 ± 9.8 y., 48.3% female) were analyzed and 230 were matched and included in a 1:1 ratio in each arm of the implantation techniques. No differences were observed in the success rate (95.0% vs 94.8%), fluoroscopy time (9.9 min. vs 9.6 min.), paced QRS duration (151 ms vs. 148 ms) and sensitivity values (8.2 mV vs. 8.5 mV) between the 3D stylet-based and catheter-based techniques, respectively. Small differences were observed in V₆ R-wave peak time (73.2 ms vs 76.5 ms), capture threshold (0.63 V vs 0.83 V), higher percentage of confirmed LBB captures, (98.3% vs. 77.4%) and a numerically higher occurrence of delayed perforations (2/115 vs. 0/115) in 3D styled group.

Conclusion: LBBAP lead implantation with the use of manually shaped stiff 3D stylet is feasible and results in comparable outcomes to those achieved with leads implanted using dedicated pre-shaped delivery catheters.

The international Working Group of the Signal Summit is a consortium of experts in the field of cardiac electrophysiology, dedicated to advancing knowledge on understanding and clinical application of signal recording and processing techniques. In 2023, the working group met in Reykjavik, Iceland and lay the foundation for this manuscript. Atrial fibrillation (AF) is the most common arrhythmia in adults, with a rapidly increasing prevalence worldwide. Despite substantial research efforts, advancements in elucidating the underlying mechanisms of AF have been relatively modest. Since the discovery of pulmonary veins as a frequent trigger region for AF initiation over two and a half decades ago, advancements in patient care have primarily focused on technological innovations to improve the safety and efficacy of pulmonary vein isolation (PVI). Several factors may explain the limited scientific progress made. Firstly, while AF initiation usually begins with an ectopic beat, the mechanisms of initiation, maintenance, and electrical propagation have not been fully elucidated in humans, largely due to suboptimal spatiotemporal mapping. Secondly, underlying structural changes have not been clarified and may involve different types of re-entry. Thirdly, inconsistent definitions and terminology regarding fibrillatory characteristics contribute to the challenges of comparing results between studies. Fourthly, a growing appreciation for phenotypical differences likely explains the wide range of clinical outcomes to catheter ablation among patients with seemingly similar AF types. Lastly, restoring sinus rhythm in advanced phenotypic forms of AF is often not feasible or may require extensive ablation with minimal or no positive impact on quality of life. The aims of this international position paper are to provide practical definitions as a foundation for discussing potential mechanisms and mapping results, and to propose pathways toward meaningful advancements in AF research, ultimately leading to improved therapies for AF.

Background: Electrocardiogram criteria for left bundle branch block (LBBB) inadequately predict left ventricular electrical dyssynchrony, complicating cardiac resynchronization therapy (CRT) candidate selection.

Objective: To investigate the predictive value of the horizontal QRS axis for CRT response in heart failure (HF) patients with LBBB patterns.

Methods: The direction and magnitude of the horizontal QRS axis were calculated using the net amplitudes in leads V₂ and V₆. CRT response was defined as a ≥10% increase in left ventricular ejection fraction (LVEF) and at least one New York Heart Association (NYHA) class reduction one-year post-CRT implantation. The composite endpoint included HF hospitalization or all-cause mortality.

Results: Among 244 consecutive CRT recipients, 156 (63.9%) responded favorably, while 88 (36.1%) were non-responders. The horizontal QRS axis demonstrated significant backward deviation [-75.5° (-79.7°, -69.0°) vs. -65.0° (-73.0°, -46.5°), P <0.001] and larger magnitude (35.5±10.9 mm vs. 25.5±10.5 mm, P <0.001) in CRT responders compared to non-responders. The direction and magnitude independently predicted CRT response with an area under the curve (AUC) of 0.778 (95% CI: 0.717, 0.839) and 0.749 (95% CI: 0.685, 0.814), respectively. Combining both parameters increased the AUC to 0.814 (95% CI: 0.760, 0.868). Moreover, the direction and magnitude of the horizontal QRS axis, or their combination, predicted the composite endpoint of HF hospitalization or all-cause mortality, with hazard ratios (HR) of 0.36 (95% CI: 0.22, 0.60), 0.41 (95% CI: 0.25, 0.67), and 0.25 (95% CI: 0.15, 0.41), respectively.

Conclusion: Horizontal QRS axis accurately predicts CRT response and prognosis in HF patients with LBBB.

Background: Early rhythm control reduces the risk of cardiovascular events in patients with atrial fibrillation (AF). Despite the superiority of catheter ablation in maintaining sinus rhythm, the knowledge gaps regarding the prognostic benefits of non-early (onset of AF ≥1 year) ablation remain.

Objective: To describe outcomes of non-early AF in the CABANA trial.

Methods: CABANA randomized AF participants to catheter ablation or drug therapy. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Secondary endpoints included all-cause mortality, and all-cause mortality or cardiovascular hospitalization.

Results: A total of 2178 patients (median age 67 years; 810 [37.2%] female) were included, 1122 (51.5%) of whom with non-early AF. For the primary outcome, the adjusted hazard ratio (aHR) of ablation vs. drug therapy was 0.83 (95% CI 0.53-1.30, P=0.413) in non-early AF patients and 0.78 (95% CI 0.52-1.16, P=0.220) in early AF patients (interaction p-value =0.787). Non-early ablation resulted in a relative reduction of 26% and 23% in all-cause mortality (aHR 0.74, 95% CI 0.42-1.33, P=0.314) and all-cause mortality or cardiovascular hospitalization (aHR 0.77, 95% CI 0.65-0.91, P=0.002), respectively. After excluding patients with prior heart failure, non-early AF patients receiving ablation still had a significantly lower risk of all-cause mortality or cardiovascular hospitalization (aHR 0.78, 95% CI 0.65-0.93, P=0.005).

Conclusion: Non-early AF patients may benefit similarly from catheter ablation as early AF patients. Catheter ablation may be an effective treatment strategy to reduce the composite risk of all-cause mortality or cardiovascular hospitalization in non-early AF patients, regardless of heart failure history.

Background: Patients with atrial fibrillation and malignant left atrial appendage (LAA) may benefit from LAA closure (LAAC); however, evidence is limited.

Objective: The purpose of this study was to determine management strategies and clinical outcomes in patients with atrial fibrillation and malignant LAA.

Methods: Malignant LAA was defined as ischemic stroke or LAA thrombus formation despite continuous oral anticoagulation (OAC) therapy (continuous for ≥3 weeks). We studied 80 patients with malignant LAA treated with LAAC. We compared these patients first against 44 patients with malignant LAA treated with OAC alone and second against 114 patients without malignant LAA who were treated with LAAC for conventional indications.

Results: Among patients with malignant LAA (first comparison), those treated with LAAC had a higher 1-year cumulative incidence of ischemic stroke than did patients treated with OAC alone (6.3% vs 5.3%; log-rank, P = .09) whereas the difference in stroke risk while receiving OAC was comparable (2.7% vs 5.3%; log-rank, P = .84). Furthermore, all disabling stroke events in patients with malignant LAA treated with LAAC occurred only while not receiving OAC. Among patients treated with LAAC (second comparison), those with malignant LAA had a higher 1-year cumulative incidence of ischemic stroke (and ischemic stroke due to device-related thrombosis) than did those without malignant LAA (6.3% vs 2.2%; log-rank, P = .009 and 2.2% vs 0%; log-rank, P = .04, respectively). However, these differences in stroke risk were no longer significant while receiving OAC (2.7% vs 1.0%; log-rank, P = .11).

Conclusion: Both performing LAAC and continuation of OAC may be options to prevent ischemic stroke in patients with high thromboembolic risk and malignant LAA.