Heart rhythm最新文献

Background: Catheter ablation (CA) is superior to antiarrhythmic drugs (AADs) for maintaining sinus rhythm in atrial fibrillation (AF). However, most randomised controlled trials (RCTs) lack the power to assess CA safety.

Objective: To evaluate complication rates and relative risks of CA compared with AADs for AF rhythm management.

Methods: MEDLINE, Embase and Cochrane CENTRAL (inception-Oct 24, 2024) were searched for RCTs comparing CA vs. AADs in AF management. The primary endpoint was a composite of serious adverse events (SAE), including death, additional intervention, prolonged or unplanned hospitalisation or disability. Secondary endpoints included SAE components. A random-effects meta-analysis estimated pooled risk ratios (RR) with 95% confidence intervals (CI).

Results: Twenty-four randomised trials comprising 6,665 participants were included in the meta-analysis, with 3,554 patients (53.2%) assigned to the catheter ablation group and 3,111 patients (46.7%) to the antiarrhythmic drug group. During a 12-month median follow-up (6-60 months), CA was associated with a 20% lower risk of SAE compared with AAD (RR 0.80, 95% CI 0.69-0.93, I² 0%, p < 0.01) and 47% reduction in risk unplanned hospitalisation (RR 0.53, 95% CI 0.38-0.72, I² 73%, p < 0.01). CA was also associated with a 37% lower risk of adverse cardiovascular events (RR 0.63, 95% CI 0.44-0.90, I2 42%, p = 0.01).

Conclusions: CA for AF rhythm management reduced SAEs, unplanned hospitalisation and adverse cardiovascular events compared with AADs. When patient safety is being considered, AAD appears to have a less favourable safety profile than catheter ablation in AF.

Background: Radiofrequency (RF) energy is the most commonly used technique to create ablation lesions as treatment strategy for various arrhythmias.. In order to have long-term freedom of arrhythmias, each lesion must be transmural and continuous throughout its entirety.

Objective: To evaluate changes in unipolar, bipolar and omnipolar potential voltages during various stages of linear RF ablation applications to define the most suitable technique to assess lesion transmurality and continuity.

Methods: Epicardial mapping of porcine hearts (N=5) was performed during 3 stages of lesion application: nontransmural-discontinuous, transmural-discontinuous and transmural-continuous. Unipolar electrograms were recorded, and bipolar and omnipolar electrograms were obtained. Potential voltage was defined as the peak-to-peak amplitude of the steepest deflection (unipolar) or highest peak (bipolar/omnipolar). Low-voltage areas were defined as bipolar/omnipolar voltage ≤0.5mV and unipolar voltage ≤1.0mV.

Results: Both unipolar and omnipolar voltages at the lesion site decreased during stage 1 compared to baseline (27.5-67.5% and 59.4-92.8%, respectively). Using omnipolar electrograms, clear isolated areas of higher potential voltages reflecting a gap could be identified within the lesion area. However, no clear patterns could be identified using unipolar electrograms. The lowest unipolar and omnipolar potential voltages were found during ablation stage 3 (1.6-2.8 and 0.4-2.2 mV, respectively).

Conclusions: Omnipolar voltage mapping is the most effective technique to assess ablation lesion continuity and transmurality. Unipolar voltage mapping of the lesion area is highly variable and not suitable to detect a gap in the lesion. Future studies should investigate whether omnipolar voltage mapping could aid in long-term arrhythmia free survival.

Background: Left atrial appendage occlusion (LAAO) device dislodgment or embolization is a rare but potentially life-threatening complication. Though there is a designated apparatus available for delivery and implantation of these devices, there are no predefined instructions or required equipment available for extraction of dislodged device.

Objectives: This multicenter experience aims to provide a detailed description of the Watchman extraction procedure and to evaluate both its success rates and the potential complications.

Methods: We analyzed consecutive patients undergoing percutaneous retrieval of Watchman 2.5 or FLX devices at two U.S. centers between 2019 and 2024. Retrieval was attempted via single or double transseptal approach, with a transfabric access if the device was firmly attached to the left atrial appendage ostium. Procedural success was described as complete extraction of Watchman without procedural complication.

Results: 10 (6, 60% male) patients underwent percutaneous retrieval of LAAO devices, dislodged in 9 (90%) and embolized in 1 (10%). Retrieval procedure was performed within 1 week in 3 (30%) and within 3 months in 7 (70%) patients. A single transseptal approach was used in 3 (30%) patients, with only 1 (33%) successful. Retrieval via double transseptal approach was successful in 7 (70%) patients, including 4 (40%) who required transfabric access due to device firmly anchored to the LAA ostium.

Conclusions: Percutaneous Watchman retrieval is technically feasible when performed in highly experienced centers with dedicated equipment and surgical backup. For Watchman FLX devices firmly anchored to the LAA ostium, a transfabric technique can facilitate retrieval.

Background and aims: Antidepressants are among the most widely prescribed medications worldwide. While prior studies suggest associations between antidepressant use and adverse cardiovascular outcomes, the impact of treatment duration and recency on sudden cardiac death (SCD) risk remains unclear, limiting clinical risk stratification.

Objective: To investigate whether cumulative duration and recency of antidepressant treatment are associated with SCD risk, and whether associations differ across drug classes.

Methods: We conducted a nationwide cohort study of 4.3 million Danish residents aged 18-90 years during 2010. Antidepressant exposure was ascertained from the national prescription registry (1999-2009). Deaths were adjudicated as SCD or non-SCD. Multivariable Cox models estimated hazard ratios (HRs). Antidepressant use was defined as ≥2 prescriptions within one calendar year and categorized by cumulative duration (1-5 years vs ≥6 years) and recency (remote, recent, or current).

Results: Among 6002 SCDs, 1907 (32%) occurred in antidepressant users. Adjusted HRs were 1.41 (95% CI 1.31-1.51) for 1-5 years and 1.74 (95% CI 1.59-1.90) for ≥6 years of use. A temporal gradient emerged: current users showed highest risk (HR 1.71, 95% CI 1.59-1.83) versus recent (HR 1.24, 95% CI 1.09-1.42) and remote (HR 1.11, 95% CI 0.97-1.27) users. Associations were consistent across drug classes: Selective Serotonin Receptor Inhibitors (SSRI) HR 1.38 (95% CI:1.28-1.49) and 1.57(95% CI:1.42-1.75) and Tricyclic Antidepressants(TCA) 1.24 (95% Cl:1.09-1.42) and 1.40 (95% CI:1.15-1.71) for 1-5 and ≥6 years respectively.

Conclusion: Long-term antidepressant treatment was associated with increased SCD risk in a duration- and recency-dependent manner across major drug classes. While causality cannot be inferred, these findings identify patients receiving prolonged antidepressant therapy as a population at elevated cardiovascular risk warranting further investigation.

Background: Optimal ablation strategies of pulsed field ablation (PFA) in persistent atrial fibrillation (PerAF) remain under investigation.

Objective: This study explores an innovative electrogram(EGM)- guided PFA approach for PerAF ablation.

Methods: This prospective cohort study used 3D-Carto mapping combined with the Farawave catheter for ablation. 85 patients with PerAF who underwent EGM-guided PFA [pulmonary vein isolation (PVI), posterior wall isolation (PWI) and target EGM ablation] were enrolled (EGM group). Another cohort of 85 patients treated with anatomical PVI plus PWI using the same PFA system were also included as the control group (PWI group). The procedure endpoint was AF termination or complete ablation of all target sites. The primary efficacy endpoint was freedom from AF/atrial tachycardia (AT) recurrence at 12 months after a single procedure, off anti-arrhythmic drugs. Safety outcomes included PFA-related adverse events.

Results: Seventy-two (84.7%) patients in the EGM group experienced intra-procedural AF termination, which was significantly higher than the PWI group (10/85, 11.8%; p<0.001). At 12 months, the primary efficacy outcome (AF/AT-free survival) achieved in 82.4% (70/85) patients in the EGM group versus 65.9% (56/85) in the PWI group (log-rank p = 0.017; HR = 0.47, 95% CI 0.25-0.87). Patients who reached procedural AF termination had a higher rate of AF/AT-free survival of 84.1% versus 64.8% of non-AF termination (log-rank p = 0.007; HR = 0.40, 95% CI 0.21-0.77). The primary safety endpoint occurred in 1 patient (1.2%) with hemolysis in the EGM group. No other PFA-related adverse event was observed.

Conclusion: In this single-center, non-randomized comparative cohort study, EGM-guided PFA demonstrated preliminary efficacy and safety in the ablation of PerAF, suggesting promising prospects as an innovative strategy for PerAF ablation. (ClinicalTrials, NCT06729866, EGM Guided PFA for PerAF).

Background: The safety and effectiveness of concomitant catheter ablation at the time of left atrial appendage occlusion (LAAO) are not well-characterized.

Objective: Describe the safety and effectiveness of LAAO during concomitant ablation of AF with LAAO performed as a stand-alone procedure.

Methods: Patients from SURPASS who underwent concomitant ablation and LAAO were compared with patients who underwent LAAO alone. The primary effectiveness endpoint was complete seal of the LAA and the primary safety endpoint was the occurrence of major adverse events at 45 days.

Results: Among 96,968 patients, 1.9% (n=1844) underwent concomitant ablation; these patients were younger (median 73 [Q1,Q3:68,78] vs 76 [72,82] years), had lower CHA₂DS₂-VASc scores (4 [3,5] vs 5 [4,6]), prior clinically relevant bleeding (32.4 vs 56.6%), or fall risk (30.2 vs 42.2%). The most common discharge drug therapy in the concomitant AF ablation group was DOAC plus aspirin (56.2%) followed by DOAC alone (30.0%). Immediately post-implant, patients undergoing concomitant ablation had lower rates of any residual leak (1.6 vs 3.7%, p<0.001); no difference was seen at 45 days (15.7 vs 16.9%, p=0.29). In-hospital major adverse events were more frequent in those undergoing LAAO with concomitant ablation versus LAAO without ablation (1.9% vs 1.2%, p=0.0111). In-hospital major bleeding (1.6% vs 1.0%, p=0.0073) and pericardial effusion requiring intervention (0.8% vs 0.4%, p=0.0108) were more frequent with combined LAAO and AF ablation. At 1 year post-procedure, the composite of all-cause mortality, stroke, or systemic embolism was less frequent in those undergoing LAAO with concomitant ablation (5.2% vs 9.3%, p<0.0001).

Conclusion: Patients undergoing concomitant AF ablation at the time of LAAO are younger and have fewer comorbidities. There was no clinically important difference in LAA seal peri-device leaks with concomitant LAAO, however, there was a higher rate of major bleeding and pericardial effusion requiring intervention.

Background: Ultra-high-frequency ECG (UHF-ECG) which visualizes electrical ventricular dyssynchrony may be a valuable tool for improving the selection and treatment of patients with indication to cardiac resynchronization therapy (CRT).

Objective: To compare noninvasive assessment of left ventricular (LV) delay using UHF-ECG with invasive QLV in CRT candidates, and to evaluate whether UHF-ECG can identify patients who will achieve resynchronization and LV reverse remodeling after biventricular CRT.

Methods: Consecutive patients undergoing CRT at two centers were included. QLV was measured in basal, midventricular and apical LV segment. UHF-ECG LV delay was measured from QRS onset to local activation in leads V5-V8. Global LV dyssynchrony (lv-DYS) was assessed during spontaneous rhythm and pacing from the earliest activation to the latest activation in leads V5-V8 and was used to identify CRT responders.

Results: 48 patients were included (75% male, age 67±12 years, LVEF 31±6%, QRSd 167±20 ms). UHF-ECG in V8, V7 and V6 did not differ from QLV in the basal, midventricular or apical segments (mean differences: 3±14 ms, p=0.52; -3±17 ms, p=0.18 and 0±17 ms, p=0.92) and strong correlation was observed between them (r=0.84, p<0.001). The lv-DYS strongly correlated with the longest QLV (r=0.76, p<0.001). Patients with baseline lv-DYS above 58 ms showed a more significant reduction in LV dyssynchrony and were more often responders to CRT than patients with shorter values (Δlv-DYS -70 ms vs. -8 ms, and responders 97% vs. 32%).

Conclusion: UHF-ECG enables noninvasive assessment of QLV and can help with identification of patients who will benefit from CRT.

Background: Risk stratification for ventricular fibrillation (VF) in Brugada syndrome (BrS) remains a major clinical challenge. Atrial fibrillation is relatively common in BrS, suggesting that atrial conduction abnormalities may be related to arrhythmogenesis. A notched P wave on the surface electrocardiogram (ECG) reflects atrial conduction delay, but its prognostic significance for VF in BrS has not been fully established.

Objective: To evaluate the association between notched P waves and life-threatening arrhythmic events in patients with BrS.

Methods: We analyzed 510 patients with BrS (mean age, 51 ± 14 years; 95% men) enrolled in a prospective multicenter registry across 61 hospitals in Japan. Clinical and ECG parameters at enrollment were assessed, and patients were followed for cardiac events (VF, sustained ventricular tachycardia, or sudden cardiac death).

Results: During a mean follow-up of 107 ± 62 months, 58 patients (11%) experienced cardiac events. Notched P waves were present in 52 patients (10%). Patients with notched P waves had a significantly higher incidence of cardiac events compared with those without (27% vs. 10%, p < 0.001). Kaplan-Meier analysis demonstrated lower event-free survival in patients with notched P waves (p < 0.001). In multivariable Cox regression, a notched P wave remained an independent predictor of cardiac events (hazard ratio: 2.63; 95% CI: 1.35-4.78; p = 0.006), along with a history of VF.

Conclusions: A notched P wave on a standard 12-lead ECG independently predicts life-threatening arrhythmias in BrS and may improve risk stratification by complementing conventional predictors.

Background: Activated clotting time (ACT) is used to guide intraprocedural heparin anticoagulation during left atrial ablation, with guideline-recommended target values generally assumed to be device-independent.

Objective: To assess whether measured ACT values differ across measurement platforms and whether contemporary anticoagulation strategies vary accordingly in clinical practice.

Methods: We performed a PRISMA-registered systematic review of studies directly comparing ACT values across different measurement platforms during left atrial ablation. In parallel, we conducted an international physician survey assessing ACT platforms, heparin dosing strategies and targeted ACT ranges.

Results: The systematic review identified four electrophysiology-specific studies comparing ACT platforms. Across all studies, simultaneously measured ACT values differed substantially between platforms, with mean paired differences of 50-60 seconds, corresponding to a 15-25% discrepancy at ACT targets of 300-350 s. These inter-platform differences persisted despite high correlation between devices. The survey was completed by 164 electrophysiologists (82% Europe, 13% North America). The most commonly used platforms were Hemochron (42%), Medtronic ACT Plus (27%), and Abbott i-STAT (16%). Target ACT ranges and heparin dosing strategies varied by platform: higher ACT targets and higher weight-based heparin doses were most frequently reported with Hemochron, lower targets and doses were more common with i-STAT; Medtronic users showed an intermediate pattern. Nearly one-third of respondents reported modifying heparin dosing after switching ACT platforms.

Conclusion: Available cross-validation data demonstrate substantial differences between ACT platforms. Real-world heparin administration strategies and ACT targets vary markedly by platform. These findings challenge the assumption of universal ACT targets and highlight the need for platform-specific interpretation.