Heart rhythm最新文献

Background: Focal pulsed field ablation (F-PFA) integrated in electroanatomic mapping systems allows tailored lesion sets in patients with atrial fibrillation (AF).

Objective: We aimed to determine feasibility, safety, and 6-month outcome of F-PFA for a tailored substrate-based catheter ablation approach in patients with AF and advanced atrial substrate.

Methods: Consecutive patients with AF and advanced atrial substrate treated by an F-PFA system (CardioFocus) through contact force-sensing catheters integrated in electroanatomic mapping systems were prospectively enrolled. The tailored substrate-based catheter ablation approach included isolation of all pulmonary veins with wide area circumferential ablation, posterior wall isolation, mitral anterior line, and cavotricuspid isthmus ablation, according to substrate. At 6 months, feasibility, arrhythmia recurrence, and safety were evaluated.

Results: In 83 patients (33% female; indexed left atrial volume, 44 ± 15 mL/m²; 80% persistent AF or atrial flutter [AFl]; 57% redo procedures), successful de novo pulmonary vein isolation was performed in 36 patients and pulmonary vein reisolation in 30 patients. Mitral anterior line was performed in 19 patients with atypical AFl or anterior low-voltage areas; posterior wall isolation was performed in 38 patients with low-voltage areas or evoked delayed electrograms during premature atrial extrastimuli; and cavotricuspid isthmus ablation was performed in 24 patients with typical AFl. Median procedural and fluoroscopy times were 115 and 7 minutes, respectively. No complications occurred. At 6 months, arrhythmia recurred in 30 of 83 patients (21 AF; 9 atypical AFl).

Conclusion: Tailored substrate-based F-PFA in patients with AF and advanced atrial substrate is safe and effective. Acute procedural success was 100% with 64% freedom from arrhythmias after 6 months.

Background: The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial enrolled patients with vascular disease but excluded patients requiring oral anticoagulation.

Objective: We aimed to explore the clinical significance of a new diagnosis of atrial fibrillation (AF) during follow-up.

Methods: New AF was identified from hospitalization, study drug discontinuation, and adverse event reports. Multivariable Cox regression was used to determine risk factors for new AF. Time-updated covariate analysis was used to study the association of new AF with outcomes.

Results: During a mean follow-up of 23 months, 655 of 27,395 participants (2.4%) were diagnosed with AF (incidence, 1.3 per 100 patient-years). In adjusted analyses, advanced age, male sex, White ethnicity, higher body mass index, higher systolic blood pressure, heart failure, and prior myocardial infarction were associated with new AF. Compared with participants without a new diagnosis of AF during follow-up or before receiving a diagnosis of new AF, participants were at increased risk of a composite outcome of cardiovascular death, stroke, or myocardial infarction after a new diagnosis of AF (8.8 vs 2.4 per 100 patient-years; hazard ratio [HR], 3.66; 95% confidence interval [CI], 2.81-4.75). Risk increases with new AF were also observed for hospitalization for heart failure (6.8 vs 0.8 per 100 patient-years; HR, 8.64; 95% CI, 6.31-11.83) and major bleeding (3.9 vs 1.3 per 100 patient-years; HR, 3.18; 95% CI, 2.15-4.69).

Conclusion: In patients with vascular disease, a new diagnosis of AF was associated with a marked increase in risk of adverse outcomes, especially hospitalization for heart failure.

Background: Implantable cardiac monitors (ICMs) provide valuable insights into managing atrial fibrillation (AF). Data suggest that ICMs increase AF detection, but their impact on management is still uncertain.

Objective: We aimed to evaluate and to compare the impact of ICMs on the clinical management of AF.

Methods: MONITOR-AF (NCT06352060) was a retrospective, multicenter study of patients with AF who received an ICM or routine monitoring with electrocardiograms or long-term monitoring between 2018 and 2021. Patients were observed for 12 months, with note made of AF-related clinical outcomes.

Results: There were 2293 patients who received an ICM (n = 1115) or routine monitoring (n = 1178). Although comorbidities were significantly different between ICM and non-ICM groups, none of the AF-related characteristics were significantly different. Patients in the ICM group had more attempts at rhythm control with antiarrhythmic drugs (100% vs 59.9%; P < .001) and catheter ablation (91.7% vs 59.7%; P < .001). This led to higher freedom from AF at 12 months (86.0% vs 61.8%; P < .001) and freedom from antiarrhythmic drug (75.9% vs 39.4%; P < .001) and oral anticoagulation (69.6% vs 39.4%; P < .001) use and was associated with reduced rates of stroke (0.3% vs 1.6%; P < .001) and major bleeding (1.6% vs 2.9%; P < .001).

Conclusion: Dynamic monitoring with ICM is associated with beneficial AF outcomes with improved freedom from AF at 12 months and fewer complications. Thus, ICM use should be considered for the management of chronic AF.

Background: Atypical atrial tachycardia (AT) is a commonly encountered rhythm disorder, especially in patients with underlying atrial scar. Peak frequency (PF) annotation of bipolar electrograms is a novel method that mainly aims to discriminate near-field and far-field signals.

Objective: This study aimed to evaluate the PF annotation of low-voltage zones and deceleration zones during sinus/paced rhythm and their role in predicting the critical isthmus (CI) and termination sites of atypical ATs.

Methods: We retrospectively included a total of 25 patients (mean age, 60 ± 12 years; 13 [52%] male) who underwent high-density mapping during both sinus/paced rhythm and AT. Omnipolar voltage and isochronal late activation maps of the left atrium were created on the basis of PF annotation. The CI of the AT was defined on the basis of both activation mapping and successful termination site/change in AT during ablation.

Results: A total of 30 ATs were mapped in the left atrium (22 [73.3%], localized reentry; 8 [26.7%], macroreentry). Median PF of the termination site was significantly higher compared with low-voltage zones alone (345 [209-530] Hz vs 235 (47-417] Hz; P < .001). PF had a significant predictive value for the termination site (area under the curve, 0.83; 95% confidence interval, 0.719-0.950; P < .001). When the cutoff value for PF was taken as 280 Hz, the sensitivity of the test was determined to be 80.0% and the specificity was determined to be 78.3%.

Conclusion: A PF annotation algorithm with a cutoff of 280 Hz accurately detects the CI of atypical ATs and accurately predicts deceleration zones during isochronal late activation mapping.

Background: Cardioneuroablation (CNA) targets the ganglionated plexus (GP) to treat neurally mediated syncope, yet a standardized GP identification method is lacking. Postprocessing of cardiac computed tomography (CT) data identifies epicardial fat, thus allowing fat pad identification. Whereas the feasibility of CT-guided CNA is documented, data about GP anatomy and comprehensive evaluations of GP targeting methods remain scarce.

Objective: This study sought to describe GP anatomy using CT fat pad segmentation and to evaluate the accuracy of different approaches in locating these GPs.

Methods: The study included 26 CNA or atrial fibrillation ablation patients. GPs were identified through CT-based fat segmentation. CT-derived atrial meshes were merged with corresponding meshes from electroanatomic mapping. Spatial correlation was studied between atrial fractionated electrograms (FEGMs) and epicardial fat pads. Several target areas from the different ablation approaches (FEGM, anatomic, CT-based fat pad identification, and target line) were spatially compared.

Results: Correlation between epicardial fat pads and signal fragmentation was weak in the left atrium (ρ = 0.01 ± 0.13 [P = .73]; ϕ = -0.00 ± 0.10 [P = .94]) and even negative in the right atrium (ρ = 0.11 ± 0.09 [P < .001]; ϕ = -0.10 ± 0.08 [P < .001]). The FEGM approach was associated with a more extensive ablation area (3.74% vs 17.0% [P < .001] for the anatomic and the FEGM approach for the left atrium and 3.45% vs 9.53% [P < .001] for the anatomic and the FEGM approach for the right atrium).

Conclusion: CT-based fat pad segmentation reveals significant interpatient variability in GP anatomy. GPs show low colocalization with signal fragmentation, causing inaccurate localization based on fragmentation alone. An anatomy-focused approach offers a more targeted ablation strategy.

Background: There are limited data comparing arrhythmia burden of patients with congenitally corrected transposition of the great arteries (cc-TGA) undergoing anatomic repair, physiologic repair, and nonsurgical management.

Objective: We aimed to examine the difference in rate of bradyarrhythmias and tachyarrhythmias in patients with cc-TGA stratified by treatment pathway.

Methods: A retrospective cohort study was conducted including all patients with cc-TGA observed at Cleveland Clinic Children's (1995-2021).

Results: A total of 170 patients were included with a median follow-up of 11.8 years: 82 with anatomic repair (median age, 1.5 years), 46 with physiologic repair (median age, 25.2 years), and 42 with nonsurgical management (median age, 35.7 years). Heart block/permanent pacemaker implantation occurred in 49 (29%) patients, with higher prevalence in the physiologic repair group compared with anatomic repair and nonsurgical management (50% vs 22% vs 19%; P = .001). Freedom from postoperative complete heart block/permanent pacemaker implantation at 5 years was higher in patients who underwent anatomic repair vs physiologic repair (85% vs 68%; P = .02). Tachyarrhythmias affected 29% of patients, with varying prevalence of atrial fibrillation and atrial flutter based on treatment pathway. Atrial fibrillation was more prevalent in physiologic repair and nonsurgical management groups compared with the anatomic repair group (30% vs 31% vs 0%; P < .0001). Prevalence of atrial flutter was 9.8% vs 13% vs 0% in the anatomic repair, physiologic repair, and nonsurgical management groups, respectively.

Conclusion: Burden and type of arrhythmias in patients with cc-TGA varied on the basis of treatment pathway. Further studies assessing long-term follow-up after anatomic repair are needed to identify the surgical approach that would yield the lowest arrhythmia morbidity.

Background: Causal machine learning (ML) provides an efficient way of identifying heterogeneous treatment effect groups from hundreds of possible combinations, especially for randomized trial data.

Objective: The aim of this paper is to illustrate the potential of applying causal ML on the DECAAF II trial data. We proposed a causal ML model to predict the treatment response heterogeneity.

Methods: We applied causal tree learning to the DECAAF II trial data as an example of real applications, identifying subgroups that may be superior when subject to one of the treatments over the other through an easily interpretable process. For each subgroup identified, the characteristics were summarized, and the relationship between treatment arms and risk for recurrence of atrial tachyarrhythmia (aTA) among subjects was assessed.

Results: Causal tree learning demonstrated that, among all the preablation predictors, dividing subgroups according to age, with a cutoff of 58 years, provides the most heterogeneous subgroups in response to fibrosis-guided ablation in addition to pulmonary vein isolation (PVI) compared with PVI alone. The difference in the risk of recurrence of aTA between 2 treatments was nonsignificant in older patients (hazard ratio [HR] 1.06; 95% confidence interval [CI] 0.77-1.47; P = .72). However, among the younger patients, the risk of aTA recurrence was significantly lower in the fibrosis-guided ablation group compared with PVI-only (HR 0.50; 95% CI 0.28-0.90); P = .02).

Conclusion: Applying causal ML on random controlled trial datasets helped us identify groups of patients that profited from the treatment of interest in an efficient and unbiased manner.

Background: Although drug interactions between clarithromycin/erythromycin/fluconazole and direct oral anticoagulants (DOACs) are mechanistically plausible, it is uncertain whether they are clinically relevant.

Objective: This study aims to investigate the association among coprescribed DOACs and antimicrobials and bleeding, cardiovascular disease and mortality.

Methods: We identified DOAC users in the Clinical Practice Research Datalink Aurum from January 1, 2011 to March 29, 2021. We used a cohort design to estimate hazard ratios (HRs) for bleeding outcomes (intracranial bleeding, gastrointestinal bleeding, other bleeding), comparing DOACs + clarithromycin/erythromycin/fluconazole users with DOACs users not receiving these antimicrobials. Cardiovascular outcomes were ischaemic stroke, myocardial infarction, venous thromboembolism, cardiovascular mortality, and all-cause mortality. A 6-parameter case-crossover design comparing odds of exposure with different drug initiation patterns for all outcomes in hazard window vs referent window within an individual was also conducted.

Results: Of 483,815 DOAC users, we identified 21,701 coprescribed clarithromycin, 4532 coprescribed erythromycin, and 4840 coprescribed fluconazole. We observed an increased risk of gastrointestinal bleeding over 7 days following coprescription of DOAC + erythromycin vs DOAC alone (HR 3.66; 99% confidence interval [CI] 1.27-10.51), with wide CIs in case-crossover analysis. No evidence of increased risk of bleeding outcomes was seen for DOAC + clarithromycin/fluconazole in cohort and case-crossover analyses. For cardiovascular outcomes, compared with DOAC alone, an increased risk of cardiovascular mortality with DOAC + clarithromycin (HR 3.36; 99% CI 1.73-6.52) and increased risk of all-cause mortality with DOAC + clarithromycin/erythromycin/fluconazole were observed in cohort analysis. However, similar risks were found when initiating erythromycin/fluconazole with and without DOACs.

Conclusion: We found no strong evidence of increased risks of bleeding and cardiovascular outcomes in DOACs + clarithromycin/fluconazole/erythromycin users except a possible short-term increased risk of gastrointestinal bleeding in DOACs + erythromycin users.

Background: Although smartphone-based devices have been developed to record 1-lead electrocardiogram (ECG), existing solutions for automatic detection of atrial fibrillation (AF) often has poor positive predictive value.

Objective: This study aimed to validate a Cloud-based deep-learning platform for automatic AF detection in a large cohort of patients using 1-lead ECG records.

Methods: We analyzed 8528 patients with 30-second ECG records from a single-lead handheld ECG device. Ground truth for AF presence was established through a benchmark algorithm and expert manual labeling. The Willem Artificial Intelligence (AI) platform, not trained on these ECGs, was used for automatic arrhythmia detection, including AF. A rules-based algorithm was also used for comparison. An expert cardiology committee reviewed false positives and negatives, and performance metrics were computed.

Results: The AI platform achieved an accuracy of 96.1% (initial labels) and 96.4% (expert review), with sensitivities of 83.3% and 84.2%, and specificities of 97.3% and 97.6%, respectively. The positive predictive value was 75.2% and 78.0%, and the negative predictive value was 98.4%. Performance of the AI platform largely exceeded the performance of the rules-based algorithm for all metrics. The AI also detected other arrhythmias, such as premature ventricular complexes, premature atrial complexes along with 1-degree atrioventricular blocks.

Conclusion: The result of this external validation indicates that the AI platform can match cardiologist-level accuracy in AF detection from 1-lead ECGs. Such tools are promising for AF screening and have the potential to improve accuracy in noncardiology expert health care professional interpretation and trigger further tests for effective patient management.

Background: Better risk stratification is needed to evaluate patients with nonischemic cardiomyopathy (NICM) for prophylactic implantable cardioverter-defibrillators (ICDs). Growing evidence suggests that cardiac magnetic resonance (CMR) imaging may be useful in this regard.

Objective: We aimed to determine if late gadolinium enhancement (LGE) seen on CMR (dichotomized as none or minimal <2% vs significant ≥2%) predicts appropriate ICD therapies (primary endpoint) or all-cause mortality/transplant/left-ventricular assist device (LVAD) implantation (secondary endpoint) in patients with NICM.

Methods: We identified 344 patients with NICM who underwent primary prevention ICD implantation at Cleveland Clinic between 2003 and 2021 with CMR within 12 months before implant. LGE was calculated as percentage myocardium with pixel intensity ≥5 standard deviations higher than that of reference myocardium. Endpoints were adjudicated retrospectively by chart review.

Results: A total of 125 of 344 patients (36%) had none or minimal LGE, and 219 (64%) had significant LGE. Over a median follow-up of 61 months, 53 patients (24%) with significant LGE vs 10 (8%) with none or minimal LGE met the primary endpoint, and 56 patients (26%) vs 21 (17%) met the secondary endpoint, respectively. Significant LGE predicted the primary outcome in multivariable competing-risks regression (hazard ratio [HR] 2.99, 95% confidence interval [CI] 1.48-6.02, P = .002), but did not predict the secondary outcome in multivariable Cox regression (HR 1.34, 95% CI 0.78-2.29, P = .287).

Conclusion: In patients with NICM and primary prevention ICDs, LGE ≥2% is predictive of appropriate device therapies but not all-cause mortality/LVAD/transplant. LGE may be a relatively specific predictor of sudden cardiac arrest risk and therefore could potentially be used during evaluation for prophylactic ICD implantation.