Heart rhythm最新文献

Background: Strategies for persistent atrial fibrillation (PsAF) ablation remain limited.

Objective: This study aimed to determine optimal PsAF ablation strategies.

Methods: REAL-AF (NCT04088971) is a multicenter, prospective, observational registry enrolling patients undergoing de novo ablation for atrial fibrillation. Between January 2018 and August 2024, 746 patients with PsAF were treated with radiofrequency ablation (RFA); 3 ablation methods were analyzed: group 1, pulmonary vein isolation (PVI) only; group 2, PVI + substrate modification (SM) + vein of Marshall (VoM) by RFA; and group 3, PVI + SM + VoM by ethanol (EtOH).

Results: Of the overall 746 patients, 564 patients (75.6%) were treated with PVI only (group 1), 94 (12.6%) with PVI + SM + VoM RFA (group 2), and 88 (11.8%) with PVI + SM + VoM EtOH (group 3). Scar burden was higher in group 2 than groups 1 or 3 (20%, 1.0%, and 11%, respectively; P < .001). Procedure times were higher in group 3 (147 minutes; interquartile range 125.0-171.0) than groups 1 (81.0 minutes; 64.0-104.0) and 2 (90.5 minutes; 64.8-119.3). Acute complication rates were low in all groups, lowest in group 3 (0%; P = .438), and 12-month rates remained lowest in group 3 (2.3%; P = .896). Arrhythmia recurrence was reduced in group 3 through 12 months (15.3%) vs groups 1 (24.4%) and 2 (35.3%) (P = .023). Repeat ablations through 12 months trended lowest in group 3 (3.4%) vs groups 1 (5.3%) and 2 (6.4%) (P = .654).

Conclusion: VoM EtOH ablation for PsAF seems safe and efficacious as an adjunctive strategy for the treatment of PsAF. Findings are not based on cohort size, but on comparative effectiveness and safety across distinct ablation strategies in real-world practice.

Background: Catheter ablation (CA) is a widely used therapy for atrial fibrillation (AF), but limited research compares the effectiveness of CA with antiarrhythmic drugs (AADs) in an elderly population.

Objective: This study aimed to compare AF recurrence and other clinical outcomes for CA with AADs in an elderly population with drug-refractory AF.

Methods: A large nationally representative sample of elderly patients (aged ≥65 years) was studied using the Optum Clinformatics database from 2016 to 2022. The primary outcome was atrial tachyarrhythmia recurrence. Secondary outcomes included direct current cardioversions, heart failure (HF) hospitalizations, myocardial infarctions, ischemic strokes, and death. Propensity score matching was used to balance cohorts.

Results: 13,311 patients were identified, with 7230 in the AAD cohort and 6081 in the CA cohort. Patients who underwent CA were 24% less likely to experience recurrence compared with those treated with AADs (hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.65-0.89). The risk of direct current cardioversion (HR 0.74; 95% CI 0.60-0.91), HF hospitalization (HR 0.63; 95% CI 0.45-0.90), and ischemic stroke (HR 0.45; 95% CI 0.28-0.72) was significantly reduced, without differences in death or myocardial infarction. The rate of complications was 5.9% in the CA cohort, whereas adverse events were frequent in the AAD cohort (45.4%).

Conclusion: CA treatment was associated with a lower risk of atrial tachyarrhythmia, cardioversion, HF hospitalization, and ischemic stroke than AADs. AADs were poorly tolerated in this cohort, and complication rates from CA were similar to those of younger groups. Favorable safety and efficacy support consideration of CA in elderly patients.

Background: Class Ic antiarrhythmic drugs (AADs) are generally avoided in patients with coronary artery disease owing to concerns about their proarrhythmic potential. However, their impact on mortality and arrhythmic risk in patients with chronic coronary syndrome (CCS) who have undergone percutaneous coronary intervention (PCI) remains unclear.

Objective: This study aimed to assess the safety of class Ic AADs compared with nonuse in patients with new-onset atrial fibrillation (NOAF) after PCI.

Methods: A retrospective cohort study using Taiwan's National Health Insurance Research Database included adults with NOAF after PCI. Participants were divided into class Ic users and nonusers. Outcomes evaluated included major adverse cardiovascular events (MACEs), all-cause mortality, ventricular arrhythmia, and cerebrovascular events. Cox models and competing risk analyses estimated hazard ratios.

Results: Among 3750 patients (mean age 74.70; 69.33% male; CHA₂DS₂-VASc score 3.98), class Ic users showed significantly lower risks of MACEs (adjusted subdistribution hazard ratio [asHR] 0.64; 95% confidence interval [CI] 0.59-0.68; P < .01), all-cause mortality (asHR 0.61; 95% CI 0.57-0.66; P < .01), and cerebrovascular events (asHR 0.81; 95% CI 0.66-0.99; P = .04). No increased risk of ventricular arrhythmia was observed (asHR 0.89; 95% CI 0.69-1.15; P = .37).

Conclusion: In patients with CCS who developed NOAF, the use of class Ic AADs was associated with significantly lower risks of MACEs, all-cause mortality, and cerebrovascular events and without an increased risk of ventricular arrhythmia. These findings suggest that class Ic agents may be a safe and effective option for rhythm control in carefully selected patients with CCS.

Background: Vein of Marshall Ethanol Infusion (VOMEI) has benefit in patients with persistent atrial fibrillation (AF) and perimitral atrial flutter, while coronary sinus ablation (CS RFA) improves mitral isthmus (MI) block. Atrial arrhythmias frequently coexist with left ventricular (LV) systolic dysfunction, for which cardiac resynchronisation (CRT) may be indicated OBJECTIVE: To evaluate the safety, feasibility, and outcomes of VOMEI±CS RFA in patients with CRT METHOD: Coding data was used to identify consecutive patients with CRT who underwent VOMEI±CS RFA at two centres. Controls without CRT who underwent contemporaneous VOMEI±CS RFA provided comparison. Clinical and procedural characteristics as well as recurrence within 12 months were recorded for all patients. Lead parameters were compared pre- and post-ablation in patients with CRT, and any lead dysfunction over 43±21months follow up recorded RESULTS: VOMEI was feasible in 94% (94% CRT vs 97% control, P=0.92), and CS RFA in 89% (84% vs 93%, P=0.71). Complications occurred in 5% (6% vs 3%, P=0.54), precluding successful VOMEI without causing patient morbidity. No difference in the need for alternative fluoroscopic projections, balloon-occlusion venography, or MI block achievement was seen. No significant change in LV lead parameters was observed, and only one case of lead dysfunction was seen (phrenic capture, 2%). Arrhythmia recurrence within one year was 42% vs 24% CONCLUSION: VOMEI and CS RFA is feasible and safe in patients with LV leads. Complications are uncommon and preclude VOMEI without causing patient morbidity when they occur, and the risk of clinically significant lead dysfunction is low.

Background: In the long QT syndrome, longer QT intervals indicate increased arrhythmic risk, and a QTc ≥500 msec denotes high risk. Establishing similar associations in the short QT syndrome (SQTS) remains elusive.

Objective: To demonstrate that shorter QT intervals denote a higher risk of malignant arrhythmias in the SQTS and to define the "high-risk" QTc value in the SQTS.

Methods: Pooled analysis of patients treated in our institutions or reported in the literature revealed 162 SQTS patients and known symptomatic status; 57 (35.2%) of them had arrhythmic symptoms (sudden death, cardiac arrest, or malignant syncope).

Results: There was a significant inverse association between the QTc and arrhythmic symptoms [with a median QTc of 315.0 (IQR 300.5 - 338.0) msec among symptomatic patients, vs 330.0 (IQR 312.5 - 355.0) msec among asymptomatic patients, p=0.0023]. Receiver operator characteristics (ROC) analysis showed that shorter QTc values were associated with higher risk (AUC = 0.64 ±0.04, p=0.0024). When patients were grouped by QTc range, the majority of those with QTc ≤320 msec had malignant arrhythmic symptoms, whereas the reverse was true for QTc ≥320 msec. Male patients were overrepresented in the SQTS cohort and more so in the subgroup with malignant symptoms.

Conclusion: This pooled analysis of patients with SQTS demonstrates that, among patients with congenital SQTS, a shorter QTc is associated with a higher risk of malignant ventricular arrhythmias. A QTc shorter than 320 msec correlates with higher arrhythmic risk. Males appear to be at higher risk.