Heart rhythm最新文献

Background: Catheter ablation is effective in the treatment of atrial fibrillation (AF), however, it requires a significant amount of resources that may not be available in all areas.

Objective: We sought to understand geographic, racial, ethnic, and socioeconomic differences in the utilization of catheter ablation for AF.

Methods: Medicare fee-for-service beneficiaries with a diagnosis of AF were identified from the Medicare Inpatient and Outpatient data files between 2016 and 2019. To study inequities in utilization, we generated Generalized Estimating Equations to model the association between ZIP code-level racial, ethnic, and socioeconomic composition and ZIP code-level catheter ablation rates among patients with AF.

Results: For each 10% increase in the percentage of patients who were dual-eligible for Medicaid (a marker of poverty) in a ZIP code, 275 fewer patients per 10,000 underwent AF ablation (P = .0003). After adjusting for dual-eligible status, for each 10% increase in the percentage of Black patients in a ZIP code, 618 fewer underwent AF ablation (P < .0001), whereas for each 10% increase in the percentage of Hispanic patients, 430 fewer underwent AF ablation (P = .002).

Conclusion: There are significant inequities in utilization of AF ablation, associated with racial, ethnic, and socioeconomic differences. Inequitable utilization in marginalized groups of patients may generate and propagate inequities in health.

Background: The bidirectional liver-heart axis is increasingly recognized. Although compelling evidence links liver fibrosis to adverse cardiovascular outcomes, its specific link to sudden cardiac arrest (SCA) in the general population remains less well elucidated.

Objective: We aimed to investigate the association between liver fibrosis and SCA.

Methods: This prospective analysis included 452,454 participants from the United Kingdom Biobank. Liver fibrosis was non-invasively assessed using the Fibrosis-4 (FIB-4) index, with participants categorized into low (<1.30), indeterminate (1.30-2.67), and high (>2.67) risk groups. The primary outcome was incident SCA. Associations were evaluated using Cox proportional hazards models, adjusted for comprehensive cardiovascular risk factors.

Results: The analysis included participants with a median age of 58 years, and 45.8% were male. During a median follow-up of 13.8 years, 2889 incident SCA cases were documented. Participants with higher FIB-4 scores exhibited significantly higher cumulative incidence of SCA (log-rank P < .001). Compared with the low-risk group, the adjusted hazard ratios for SCA were 1.26 (95% confidential interval [CI]: 1.15-1.39) in the indeterminate-risk group and 1.69 (95% CI: 1.36-2.12) in the high-risk group. Dose-response analysis revealed a nonlinear yet positive association between continuous FIB-4 index and SCA risk. Each standard deviation increase in FIB-4 was associated with a 20% higher SCA risk (adjusted hazard ratios 1.20, 95% CI: 1.15-1.27).

Conclusion: Liver fibrosis, as assessed by the FIB-4 index, is an independent and graded predictor of SCA risk in the general population. This readily available biomarker could enhance SCA risk stratification and primary prevention strategies.

Background: Pulsed-field ablation (PFA) is a non-thermal modality for atrial fibrillation (AF) ablation; concerns persist regarding intravascular hemolysis and acute kidney injury (AKI).

Objective: This study aimed to compare biomarker-defined hemolysis and clinical AKI after PFA vs thermal ablation.

Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-adherent systematic review and random-effects meta-analysis of comparative observational studies in adults undergoing AF ablation. Major databases and trial registries were searched. Risk of bias was assessed with the Risk of Bias in Non-Randomized Studies of Interventions tool. Co-primary outcomes were change-from-baseline hemolysis biomarkers (lactate dehydrogenase [LDH], haptoglobin, bilirubin) and AKI incidence (preferentially Kidney Disease: Improving Global Outcomes-defined).

Results: 12 studies (n = 5158; AKI analysis n = 4884; 2122 PFA, 2762 thermal) met criteria. Compared with thermal ablation, PFA produced significantly greater hemolysis: LDH mean difference (MD) +63.79 U/L (P < .001); haptoglobin MD -0.30 g/L (P = .036); bilirubin MD +1.91 μmol/L (P = .023). AKI risk did not differ (risk ratio [RR], 1.14; 95% confidence interval [CI], 0.42-3.12; P = .80; absolute rates 3.5% vs 3.1%). PFA was associated with significantly lower major bleeding (RR, 0.15; 95% CI, 0.04-0.62; P = .009) and shorter procedure time (MD, -25.81 min; 95% CI, -49.26 to -2.36; P = .031). Hemolysis magnitude varied by PFA platform; AKI did not. Limitations include observational designs and heterogeneity.

Conclusion: PFA increases biomarker-defined intravascular hemolysis relative to thermal ablation without increasing population-level AKI. Coupled with reduced major bleeding and enhanced procedural efficiency, these data support PFA use; dose discipline, hydration, and platform selection remain important for high-risk patients.

Background: Unipolar electrograms (u-EGM) may help assess lesion durability with pulsed field ablation (PFA).

Objective: We aimed to validate the voltages associated with u-EGM changes after PFA and assess the predictive value for lesion durability.

Methods: Patients undergoing PFA using a pentaspline catheter were enrolled. Unipolar and bipolar voltage maps were created (baseline and every 5 minutes post-PFA), after a single or double PFA application. In group 1 (N = 10), areas with loss of S wave on u-EGM ("core") were correlated with unipolar voltage amplitude using receiver operator characteristic analysis. In group 2 (N = 41), lesion durability was correlated with unipolar voltage. In group 3 (N = 69), an esophageal catheter recorded EGMs as surrogates of epicardial EGMs. In group 4 (N = 21), u-EGMs of initial ablations were evaluated in patients undergoing redo procedures.

Results: Unipolar voltage ≤0.4 mV optimally predicted S-wave loss. Core lesions defined by this threshold remained temporally stable, whereas halo regions (>1.08 mV unipolar, >0.5 mV bipolar) demonstrated recovery. Double applications produced larger and more durable lesions than single applications (2.27 cm² vs 0.49 cm², P = .0075). Esophageal S-wave re-emergence occurred in single but not double applications, suggesting reversible electroporation. In redo procedures, we found that a unipolar voltage ≥0.4 mV independently predicted areas of conduction recovery.

Conclusion: A unipolar voltage ≤0.4 mV and loss of the terminal S wave on the u-EGM identify regions of durable ablation. Unipolar mapping may provide critical insights into durability and guide more effective PFA.

Background: Atrial septal defect (ASD) is a simple defect but carries considerable morbidity, especially arrhythmias.

Objectives: Data on the impact and timing of ASD closure and the risk of (recurrent) arrhythmia remain scarce and will be the focus of this study.

Methods: This Danish nationwide cohort study included all patients diagnosed with secundum ASD (1977-2024), followed until arrhythmia, death, emigration, or study end (January 2024). The risk of (recurrent) arrhythmias was assessed based on ASD closure status and closure technique.

Results: Among 6469 patients with ASD (43.3% men), 34.6% underwent ASD closure (65.5% surgically and 34.5% percutaneously). The incidence rate of arrhythmia was 13.3 (95% confidence interval [CI], 12.6-14.2) per 1000 person-years (PY), with atrial fibrillation/flutter being the most prevalent. Older age at diagnosis and closure were linked to higher incidence and recurrence of arrhythmia. In time-dependent Cox regression analyses, surgical ASD closure was associated with an increased risk of arrhythmias compared withwith no closure (adjusted hazard ratio [HR], 1.38 [95% CI, 1.19-1.60]), whereas no difference was found for percutaneous closure. Overall, 3 in 4 patients experienced arrhythmia recurrence. ASD closure was associated with a decreased risk of recurrence; however, statistical significance was observed only when comparing percutaneous closure to no closure (adjusted HR, 0.79 [95% CI, 0.64-0.98]).

Conclusion: The incidence rate of arrhythmia among patients with ASD was 13 per 1000 PY, with age and closure technique being pivotal factors. Surgical closure was associated with an increased risk of arrhythmias compared with no closure, whereas percutaneous closure was associated with a decreased risk of recurrence.

Background: The incidence of atrial fibrillation (AF) in younger patients has increased in recent years, but there are limited data.

Objective: This study aims to evaluate the clinical characteristics and risk factors for ischemic stroke (IS) in hospitalized young patients with AF.

Methods: We evaluated consecutive patients with AF aged 18-50 years hospitalized in a large tertiary medical center (2014-2023). Cox regression was used to analyze risk factors for major adverse cardiac and cerebrovascular events (MACE) and new-onset IS. Propensity score matching was employed to analyze the impact of catheter ablation (CA) on the occurrence of MACE with Kaplan-Meier survival curves.

Results: The final cohort included 1358 patients with a median age of 45 (interquartile range [IQR], 40.8-48) years, 72.8% were men and 70.4% presented with comorbidities. During 4.5 (IQR, 2.7-7.2) years follow-up, 238 patients developed MACE, among which heart failure episodes had the highest incidence. CA can reduce the risk of MACE (hazard ratio [HR], 0.494; P = .002), and the occurrence of MACE is associated with CHA₂DS₂-VA scores in young patients with AF. Prior IS (HR, 10.412; P < .001) and antiplatelet therapy (HR, 3.447; P = .001) were independent risk factors for new-onset IS, whereas left ventricular ejection fraction >0.5 (HR, 0.367; P = .013) was a protective factor.

Conclusion: The findings show that patients with AF ≤50 years old have an unfavorable prognosis, and MACE primarily occurs in those with comorbidities. CA is associated with a reduced risk of MACE. Further prospective controlled studies are needed to provide greater attention and tailored management strategies for this growing population.

Background: Atrial fibrillation (AF) markedly impairs quality of life (QoL) and increases health care burden. Long-term outcomes of catheter ablation (CA) using continuous rhythm monitoring remain undercharacterized.

Objectives: The goals of this study were to assess atrial tachyarrhythmia burden (ATaB) using implantable cardiac monitors (ICMs) before and up to 4 years after CA and to examine the association between ATaB reduction and QoL. In an exploratory proof-of-concept analysis, we evaluated whether simulated intermittent monitoring (Burden-by-Sampling [BBS]) can approximate ICM-derived ATaB.

Methods: In this single-center prospective cohort, 165 patients with paroxysmal or persistent AF underwent first-time CA after preablation ICM insertion. ATaB (percentage time in AF/atrial tachycardia) was continuously recorded for up to 4 years. Annual QoL assessments used the Short Form-36 Health Survey and an AF-specific symptom questionnaire. Retrospective BBS simulation sampled ICM data at varying frequencies to explore intermittent monitoring performance.

Results: The median follow-up period was 40.9 months. The median ATaB declined from 15% (0%-100%) to 0% (0%-22.5%) (P < .001). In the recurrence subgroup (n = 76), ATaB decreased from 93% to 0.45% (0.09%-8.2) (P < .001); >90% of patients achieved ≥75% reduction. QoL improved significantly at 1 year and remained stable, although physical Short Form-36 Health Survey scores were not consistently significant beyond 1 year. BBS performance improved with increased sampling frequency but remained exploratory.

Conclusion: CA produces a durable, substantial reduction in ATaB over 4 years, with a sustained QoL benefit. These findings challenge binary definitions of ablation success and support burden-based, patient-centered end points. Exploratory BBS simulations suggest potential for intermittent monitoring but require prospective validation.

Background: Elevated remnant cholesterol (RC) is recognized as a risk factor for atherosclerotic cardiovascular disease. However, its association with cardiac conduction block (CCB) remains unclear.

Objective: This study aimed to investigate the relationship between serially measured RC levels and incident CCB.

Methods: This study used data from the Kailuan study. RC level was measured at baseline in 2006 and at biennial follow-up visits. Cumulative average RC levels were calculated using all available RC measurements before incident cases of CCB or the end of follow-up (December 31, 2019). Cox proportional hazards regression and restricted cubic splines were applied to assess the associations.

Results: A total of 80,853 participants (78.12% men; mean age 51.55 ± 12.53 years) were included. During a median follow-up of 10.40 years, 3203 incident CCB cases were identified. A U-shaped association was observed between cumulative average RC levels and the risk of CCB (P nonlinearity = .001). Compared with participants with RC levels of 0.76-1.05 mmol/L, the multivariable-adjusted hazard ratios for CCB were 1.55 (95% confidence interval 1.39-1.72) for RC of <0.76 mmol/L and 1.78 (95% confidence interval 1.61-1.97) for RC of ≥1.40 mmol/L. These findings remained consistent across multiple sensitivity analyses. Similar U-shaped associations were observed for the major subtypes of CCB, including atrioventricular block, left bundle branch block, and right bundle branch block.

Conclusion: Both low and high cumulative average RC levels were associated with an increased risk of CCB and its major subtypes, suggesting the importance of maintaining RC within an optimal range.