Heart rhythm最新文献

Background: Despite the well-established physiological and survival benefits of cardiac implantable electronic devices, evidence highlights the psychosocial distress experienced by patients.

Objective: This systematic review examined the effectiveness of psychosocial interventions for improving psychosocial outcomes of patients with a cardiac implantable electronic device.

Methods: Eight databases (CINAHL, Cochrane Library, Embase, Emcare, PsycINFO, PubMed, Scopus, and Web of Science) were searched. Two reviewers screened all records. Methodological quality was assessed using the QualSyst checklist. Intervention effects and attrition were evaluated using random-effects meta-analyses, supported by a narrative synthesis of studies not included in the meta-analysis.

Results: Of the 9631 records screened, 34 articles representing 26 independent studies (3370 participants; 2952 with an implantable cardioverter-defibrillator, 418 with a pacemaker) were included. The attrition rate was 12.1% (95%CI 0.08 to 0.18), lower in education-based interventions (8.6%) than psychotherapy-based ones (23.5%). Psychosocial interventions significantly reduced anxiety for patients with an implantable cardioverter-defibrillator compared to controls, with a small to medium effect following intervention (Hedges' g = -0.30, 95%CI -0.51 to -0.09); moderator analysis indicated that psychotherapy based on cognitive-behavioral principles and face-to-face interventions were more effective. No effects were found for cardiac-specific anxiety, depression, or quality of life in the 12 studies available in the meta-analysis. The narrative synthesis supported these findings. Only four studies considered patients with a pacemaker.

Conclusion: Psychosocial interventions appear promising for improving the psychosocial outcomes of these patients. Further robust trials are needed to determine the effectiveness of these interventions, the patients who benefit most, and differences in outcomes.

Background: Pulmonary vein isolation can be performed by radiofrequency (RF) or cryoballoon (CB) ablation. Guidelines do not favor one technique, and knowledge about complication rates is limited.

Objective: We aimed to report the procedural safety of RF and CB ablation using data from a German nationwide real-world registry.

Methods: By use of health records, all left atrial catheter ablation procedures with RF or CB ablation in Germany from 2013 to 2021 were analyzed. After adjustment for confounders, safety performance end points were compared.

Results: From 2013 to 2021, RF ablation was performed in 184,616 patients and CB ablation in 118,984 patients with increasing trends in patient numbers and performing centers for both procedures. Patients with RF ablation had slightly more comorbidities. In-hospital mortality (RF, 0.08%; CB, 0.06%) and other investigated complications were rare. After adjustment for patient baseline characteristics, the risk of in-hospital mortality, serious bleeding, stroke, intracerebral bleeding, and acute kidney injury did not differ. The risk of pericardiocentesis (relative risk, 0.50; 95% confidence interval, 0.46-0.55; P < .001), vascular complication (0.36; 0.33-0.39; P < .001), and ventilation >48 hours (0.81; 0.66-0.99; P = .042) was significantly lower for CB ablation. Pericardiocentesis risk negatively correlated with annual procedure numbers per center with a faster learning curve for CB ablation (both P < .01).

Conclusion: RF and CB ablation had low overall procedural complication rates, with CB ablation showing a 50% reduced risk of pericardiocentesis. Centers with higher volume provided a better in-hospital safety with a faster learning curve for CB ablation.

Background: Pulsed field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation. Large-area focal PFA catheter designs might be suitable to deliver deep and durable lesions in ventricular myocardium.

Objective: We aimed to investigate the dose-response of a novel large-area focal 3-dimensional (3D)-enabled map-and-ablate PFA catheter for ventricular ablation in a chronic preclinical swine model.

Methods: An 8F catheter with a 9-mm hexaspline tip was used for 3D mapping of both ventricles in a porcine model. Using a PFA generator with a proprietary waveform optimized for the catheter, left and right ventricular lesions were placed with either a monopolar or bipolar ablation vector and with 1, 2, or 4 applications per site (2.0 kV/application). Tissue contact was ensured by intracardiac echocardiography and electrograms. The animals were kept alive for 1 week. Ablation lesions were assessed macroscopically after triphenyl tetrazolium chloride staining and by histopathology.

Results: A total of 69 chronic ventricular lesions from 7 pigs were available for analysis. By stacking 4 PFA applications rather than a single application, median chronic lesion depth increased from 4.8 mm (interquartile range [IQR], 4.1-5.6 mm) to 5.5 mm (IQR, 5.0-6.2 mm; P = .06) with bipolar ablation and from 4.9 mm (IQR, 4.4-5.2 mm) to 6.5 mm (IQR, 5.9-6.9 mm; P = .002) with monopolar ablation. On histologic evaluation, lesion borders were clearly demarcated, with vessels and nerves preserved.

Conclusion: A novel large-area focal ablation catheter with the ability for 3D mapping and PFA was able to create dose-dependent deep ventricular lesions durable 1 week after ablation.

Background: The increasing prevalence of atrial fibrillation (AF) requires efforts to understand racial differences in disease distribution and risk factors.

Objective: We aimed to compare associations between risk factors and AF in White Europeans from the UK Biobank and Asians from the Korean National Health Insurance Service-Health Screening (NHIS-HEALS) study.

Methods: This study included participants from the Korean NHIS-HEALS and UK Biobank. After matching for age and sex, 206,704 participants in the Korean NHIS-HEALS and 206,704 participants in the UK Biobank were enrolled in the study. The incidence of AF, its associations with biomarkers, prevalent cardiovascular disease, and population attributable risk by race were examined.

Results: During a median follow-up of 7.1 years in the Korean NHIS-HEALS and 11.9 years in the UK Biobank, those in the UK Biobank showed a higher incidence and risk of AF (3.99 vs 3.41 per 1000 person-years; hazard ratio, 1.20; 95% confidence interval [CI], 1.15-2.25) compared with the population in the Korean NHIS-HEALS. Body mass index (BMI), systolic blood pressure, alcohol, heart failure, myocardial infarction, and stroke were associated with an increased risk of new-onset AF in both cohorts. Higher BMI and smoking were more strongly related to the increased risk of new-onset AF in the UK Biobank compared with the Korean NHIS-HEALS, with a relative risk ratio of 1.21 (95% CI, 1.17-1.25) and 1.12 (95% CI, 1.02-1.21), respectively.

Conclusion: In this first large-scale comparison of White and Asian populations, the cumulative risk for development of AF was higher in the United Kingdom than in Korea. Higher BMI and smoking were associated with a higher risk of AF in the United Kingdom than in Korea.

Background: Pulsed field ablation (PFA) is a promising novel method of atrial ablation, with preclinical data suggesting it to be a viable option for ventricular arrhythmias.

Objective: The objective was to report the feasibility, safety, and clinical efficacy of PFA for ventricular arrhythmias.

Methods: All patients (N = 35) scheduled for ablation of premature ventricular complexes (PVCs; n = 24) or ventricular tachycardia (VT; n = 11) underwent focal PFA by use of a pulsed field generator and irrigated ablation catheters. Procedural and clinical outcomes were evaluated by 3-month Holter monitoring, implantable cardioverter-defibrillator home monitoring, and chart review.

Results: A total of 11 (31%) patients had experienced previously failed radiofrequency ablation. Most PVCs (58%) originated from the outflow tracts, and most VTs were caused by ischemic cardiomyopathy (55%). Average procedure time was 187 ± 59 minutes. Acute procedural success was achieved in 91% of the patients. PFA was delivered combined endocardially and through the cardiac venous system in 25% of the PVC patients. During a mean follow-up of 288 ± 149 days, the success was 75% for PVCs and 45% for VTs. A total of 5 patients were reablated during follow-up (4 VT, 1 PVC). We observed 7 (20%) minor and 2 (6%) major complications including 2 transient conduction system blocks related to pulsed field delivery and 1 stroke and 1 minor stroke.

Conclusion: Focal PFA exhibited satisfactory acute effectiveness for PVC and VT, but favorable clinical effectiveness was retained only in PVC patients. More data are needed to establish lesion durability, safety, and limitations of PFA in ventricular tissue.

Background: Atrial fibrillation (AF) is a relatively prevalent arrhythmia in patients with kidney failure requiring dialysis, who face a high risk of stroke and bleeding, and anticoagulation is a challenging decision. Although direct oral anticoagulants (DOACs) may offer advantages over warfarin K antagonists (VKAs), their use in this patient profile remains unclear.

Objective: We conducted a systematic review and meta-analysis to compare DOACs and VKAs in patients with AF undergoing dialysis.

Methods: PubMed, Embase, and Cochrane Central databases were analyzed. The outcomes analyzed were total stroke (a composite of ischemic and hemorrhagic stroke), ischemic stroke, all-cause death, cardiovascular death, myocardial infarction, major bleeding, clinically relevant non-major bleeding and gastrointestinal bleeding. Risk ratios (RRs) with 95% confidence intervals were calculated using a random effects model. R software (version 4.3.2) was used for statistical analyses. Heterogeneity was assessed with I² statistics.

Results: The final analysis included 486 patients from 4 RCT studies. The median follow-up ranged from 5.8 to 18 months. Although a reduction in total stroke was observed in the group receiving DOACs (RR 0.40; 95% CI 0.17 - 0.92; p=0.031; I2 =0%), no significant difference was found between the groups for ischemic stroke (RR 0.42; 95% CI 0.17 - 1.04; p=0.062; I2 =0%). Additionally, a statistically significant reduction in major bleeding was noted in the DOAC group (RR 0.64; 95% CI 0.41 - 0.98; p=0.044; I² = 0%). However, no significant differences were observed between the groups for all-cause death (RR 0.88; 95% CI 0.57 - 1.35; p=0.567; I2 =47%), cardiovascular death (RR 1.13; 95% CI 0.60 - 2.10; p=0.700; I2 =0%), or clinically relevant non-major bleeding (RR 1.11; 95% CI 0.67 - 1.84; p=0.669; I² = 0%).

Conclusion: In this meta-analysis, DOACs were associated with a lower risk of total stroke and major bleeding. However, DOACs and VKA groups exhibited similar rates of ischemic stroke, all-cause and cardiovascular death, clinically relevant non-major bleeding and gastrointestinal bleeding.

Background and objective: Limited evidence supports apixaban's use for atrial fibrillation (Af) in severe chronic kidney disease (CKD) or end-stage kidney disease (ESKD) patients, where warfarin is often contraindicated.

Methods: Using TriNetX data (2017-2023), we compared apixaban and warfarin in chronic Af patients after stage 5-CKD or ESKD. Propensity score matching (PSM) and Cox multivariate analysis were applied to reduce bias. Only exclusive users were included to prevent switching influence. Subdistribution hazard ratios (SHRs) and 95% CI for outcomes (cerebrovascular events, bleeding, and mortality) were adjusted for competing risks. Subgroup analyses considered sex, age, and dialysis status. We also compared apixaban doses to evaluate dose-related effects.

Results: After 1:1 PSM, our analysis included 1364 cases per group. The apixaban group showed significant advantages over the warfarin group in effectiveness (cerebral infarction: SHR=0.72, 95% CI=0.60-0.85; hemorrhagic stroke: SHR=0.42, 95% CI=0.28-0.63; cerebrovascular events: SHR=0.69, 95% CI=0.59-0.81), bleeding safety (gastrointestinal bleeding: SHR=0.77, 95% CI=0.61-0.97; blood transfusion: SHR=0.73, 95% CI=0.61-0.87; bleeding-related outcomes: SHR=0.75, 95% CI=0.64-0.87), and all composite outcomes (SHR=0.69, 95% CI=0.61-0.78). Subgroup analyses showed consistent improvements across gender, age, and dialysis status. Warfarin's time in therapeutic range was 44.4%. Sensitivity analysis still lacks sufficient evidence to determine whether the 5 mg or 2.5 mg dose of apixaban is superior.

Conclusions: This large cohort study highlights the lower risks of cerebrovascular events and bleeding associated with apixaban in patients with stage 5 CKD or those undergoing hemodialysis. However, the optimal dosage of apixaban requires further investigation in future studies.

There is no consensus on the most efficient ablation strategy for patients with persistent atrial fibrillation (PerAF). This study aimed to conduct a systematic review and network meta-analysis (NMA) to evaluate the effectiveness of different ablation strategies for PerAF. The primary efficacy outcome was the recurrence of any atrial arrhythmia after a single ablation procedure during the follow-up period. The primary safety outcome of interest was any reported complication related to the procedure. The secondary outcome was the procedure time. Fifty-two studies with 9048 patients were included in this NMA. The studies were conducted between 2004 and 2024, and 22 different ablation strategies were identified. Pulmonary vein isolation + posterior wall box isolation + extra-pulmonary vein isolation was the most effective ablation therapy for PerAF. Most additional substrate modification ablation strategies do not show significant additional benefits. There were no significant differences in the incidence of procedure-related complications between the different ablation strategies. Pulmonary vein isolation combined with additional ablation sites increases the duration of the procedure.