Heart rhythm最新文献

Background: Prior studies have investigated cardiac anatomy and clinical parameters as predictors for pulmonary vein and non-pulmonary vein triggers.

Objective: We aimed to assess the link between the descending aorta to left inferior pulmonary vein (Dao-LIPV) distance and the occurrence of triggers and drivers in atrial fibrillation (AF) ablation procedures.

Methods: Drug-refractory AF patients who underwent first-time index catheter ablation from January 2010 to December 2019 were retrospectively assembled. The Dao-LIPV distance was measured from preablation pulmonary vein computed tomography. Patients were assigned to groups on the basis of the presence of LIPV triggers or drivers. Multivariate logistic regression was used to identify risk factors.

Results: A total of 886 consecutive patients with drug-refractory AF were studied, and 63 (7.1%) patients were identified to have LIPV triggers or drivers. The Dao-LIPV distance had a better predictive performance (area under the curve, 0.70) compared with persistent AF (area under the curve, 0.57). Multivariate logistic regression analysis showed that Dao-LIPV distance ≤2.5 mm (odds ratio, 3.96; 95% CI, 2.15-7.29; P < .001) and persistent AF (odds ratio, 1.73; 95% CI, 1.02-2.94]; P = .044) were independent predictors for the presence of LIPV triggers or drivers. A risk score model was established to predict the probability of LIPV triggers or drivers with persistent AF (10.2%), Dao-LIPV distance ≤2.5 mm (11.4%), and both (15.0%).

Conclusion: The proximity of the Dao-LIPV was correlated to the presence of LIPV triggers or drivers. We developed a risk score model indicating that persistent AF and Dao-LIPV distances ≤2.5 mm significantly increase the risk of LIPV triggers or drivers, aiding electrophysiologists in preparing for and performing catheter ablation more effectively.

Background: Left bundle branch (LBB) pacing (LBBP) has gained rapid adoption. Evidence for direct LBB capture has varied from 30%-95% depending on the criteria.

Objective: The purpose of this study was to assess the feasibility and efficacy of intraprocedural transthoracic echocardiographic guidance to achieve LBB capture.

Methods: This was a prospective, nonrandomized, case-control study (ClinicalTrials.gov Identifier: NCT05646251). The pectoral region including echocardiographic windows were sterile-draped using Ioban. The lead was placed in the right ventricular septum and sheath orientation adjusted under echocardiography. The lead was advanced under echocardiographic visualization until the tip reached the left ventricular subendocardium. LBB capture was strictly defined: transition from nonselective to selective/left ventricular septal capture; LBB potential with injury current; and Delta (HBP-LBBP) V₆RWPT ≥10.

Results: Thirty patients underwent echocardiography-guided left bundle branch pacing (EC-LBBP) and compared with 30 patients (standard approach): mean age 74.4 ± 10 years; female 45%; hypertension 92%; cardiomyopathy 43%; atrioventricular block/atrioventricular nodal ablation 75%. Total procedural and fluoroscopy durations were similar. Left bundle branch area pacing (LBBAP or left ventricular septal pacing) was successful in all patients in both groups. EC-LBBP was 97% successful in achieving LBB capture vs 70% (P = .02) with LBB potentials (LB-V 23 ± 6 ms) in 95% vs 77% (22 ± 6 ms). Morphology transition confirming LBB capture was seen in 87% vs 67% (P = .02). Lead tip was visualized at the left ventricular subendocardium in 100% of patients in EC-LBBP.

Conclusion: EC-LBBP was 97% successful in achieving LBB capture using strict criteria. LBBP lead was subendocardial in all patients. EC-LBBP is practical, feasible, safe, and highly effective in achieving LBB capture.

Background: Desmoplakin (DSP) variants are associated with left-predominant or biventricular arrhythmogenic cardiomyopathy. Exercise promotes penetrance and sustained ventricular arrhythmias (VA) in right-sided arrhythmogenic right ventricular cardiomyopathy, but its effect is unknown in DSP variant carriers.

Objectives: To assess whether exercise is associated with clinical outcomes among individuals with a pathogenic or likely pathogenic (P/LP) DSP variant.

Methods: Adults with P/LP DSP variants were interviewed about physical activity from age 10. Endurance athletes were defined based on a mean exercise dose >24 metabolic equivalent hours/week (METhr/wk) of moderate to vigorous intensity exercise. Lifetime survival free from VA (ventricular tachycardia/fibrillation or appropriate ICD therapy), clinical heart failure (HF) (presentation to the emergency department or hospitalization with HF), and myocardial injury events characteristic of DSP-cardiomyopathy (symptoms, elevated troponin, imaging with non-obstructive coronaries) were examined with the Kaplan-Meier method and Cox regression models.

Results: Participants (N=100, 66% female, age 36 ± 15 years) were active with a median 28.4 METhr/wk (IQR 14.8-46) of pre-baseline evaluation exercise, and just 8 individuals continued athlete level exercise post-baseline evaluation. In multivariable analyses, endurance athletes (60%) had no worse survival free from VA [HR 1.00 (95% CI 0.5-1.98)] or clinical HF [HR 0.86 (95% CI 0.36-2.05)] but their risk for myocardial injury was elevated [HR 2.37 (95% CI 1.11-5.05)]. Furthermore, myocardial injury episodes were strongly associated with an elevated risk of both VA [HR 7.86 (95% CI 3.56-17.33)] and clinical HF [HR 10.28 (95% CI 2.95-35.83)] thereafter.

Conclusions: Endurance exercise may promote progression of DSP-cardiomyopathy by increasing risk of myocardial injury episodes, but the effect on VA and clinical HF is less clear. This study informs shared decision-making exercise and sports participation discussions.

Left bundle branch block (LBBB) causes immediate electrical and mechanical dyssynchrony of the left ventricle (LV) and gradual structural damages in the Purkinje cells and myocardium. Mechanical dyssynchrony reduces the LV ejection fraction (EF) instantly, but only to ≈55% in an otherwise normal heart. Because of the heart's in-built functional redundancy, a patient with LBBB does not always notice the heart's reduced efficiency straightaway. After a variable period of time (which could be from days to decades), the patient may become symptomatic with heart failure (HF), which classifies as HF with preserved EF ≥50% (HFpEF). The LVEF drops further because of continuous adverse remodeling and inefficient cardiac contraction. The patient transits to HF with moderately reduced EF 35%-50% (HFmrEF) and then reduced EF ≤35% (HFrEF) over 5-21 years. Cardiac resynchronization therapy (CRT) is currently only indicated in guidelines for HFrEF and LBBB. LBBB shortens the median survival of patients with HFmrEF by 5.5 years. Randomized controlled trials have shown that CRT improves echocardiographic indices for HFmrEF with LBBB. CRT in HFpEF with LBBB is a promising but underexplored/underused therapy. There have been anecdotal reports that CRT produced symptom relief in patients debilitated by HFpEF with LBBB, who constitute ≈6% of all patients with HF and an adequate pool of potential randomized controlled trial participants. Conduction system pacing in the form of left bundle branch area pacing is an emerging pacing strategy that might reverse and forestall the deleterious effects of LBBB.

Background: Early recurrence of atrial tachyarrhythmia (ERAT) is common after catheter ablation of atrial fibrillation (AF). The specific clinical and arrhythmia characteristics of ERAT influencing late recurrence risk in persistent AF are unclear. In addition, the impact of different ablation strategies on the incidence and prognostic significance of ERAT remains unknown.

Objective: This study aimed to assess the incidence, characteristics, and prognostic impact of ERAT in patients with persistent AF undergoing pulmonary vein isolation alone or pulmonary vein isolation with posterior wall isolation.

Methods: Trial participants monitored by implantable cardiac devices or twice-daily electrocardiogram transmissions were included. Atrial arrhythmia recurrences lasting ≥30 seconds were classified as ERAT (within 3 months after ablation) or late recurrence (between 3 and 12 months).

Results: Of the 282 included patients, ERAT occurred in 124 (44.0%). ERAT portended an increased incidence of late recurrence (68.5% vs 32.9%; hazard ratio, 3.36; 95% confidence interval, 2.35-4.79) and significantly higher post-blanking period AF burden (median, 0.66% [interquartile range, 0-8.35%] vs 0% [0-0.55%]). The hazard ratio for late recurrence was 2.34 (1.48-3.71), 2.89 (1.63-5.12), and 6.00 (3.86-9.32) when the latest ERAT occurred in the first, second, and third month, respectively. Late recurrence risk was particularly elevated in patients with high-burden, frequent, or symptomatic ERAT. Ablation strategy did not affect the incidence, burden, arrhythmia characteristics, or prognostic significance of ERAT.

Conclusion: ERAT after radiofrequency ablation of persistent AF is an independent predictor of late recurrence and increased post-blanking period AF burden. An individualized assessment of early recurrences is warranted to critically evaluate their clinical significance.

Background: Pacing-induced cardiomyopathy (PICM) is a frequent complication of right ventricular pacing that often requires re-operation for biventricular or conduction system pacing. Better methods for predicting PICM may inform initial pacing strategy and follow-up monitoring.

Objective: To determine if the spatial ventricular gradient (SVG), a vectorcardiographic marker of ventricular electrical and mechanical heterogeneity, is associated with subsequent development of PICM.

Methods: Retrospective study of patients with pacemakers implanted between 2003 and 2012 at the Hospital of the University of Pennsylvania. Baseline demographic, echocardiographic and electrocardiographic parameters, including SVG magnitude, elevation, and azimuth, were measured from standard 12-lead electrocardiograms. Adjusted Cox proportional hazards modeling was used to assess the associations between SVG and the risk of PICM over follow-up.

Results: Among 203 patients with a median age of 74 years, 54% male, and a median baseline LVEF of 65%, 44 patients (22%) developed PICM during follow-up. In unadjusted Cox regression, male sex, native QRS duration among patients without bundle branch block, and both native and paced mean adjusted SVG azimuth predicted future PICM. After multivariable adjustment, higher tertile (tertile 3 vs tertiles 1-2) of mean adjusted SVG azimuth before (HR_adj = 1.95, P = 0.047) and immediately after (HR_adj 2.55, P=0.003) pacemaker implantation remained significant predictors of PICM.

Conclusion: Assessment of the SVG both before and immediately after pacemaker implantation can help identify patients at elevated risk for PICM, and may identify a cohort of patients who would be better served with initial biventricular or conduction system pacing.

Background: Electrocardiographic imaging (ECGi) is a non-invasive technique for ventricular tachycardia (VT) ablation planning. However, it is limited to reconstructing epicardial surface activation. In-silico pace mapping combines a personalized computational model with clinical electrocardiograms (ECGs) to generate a virtual 3D pace map.

Objective: To compare the ability of ECGi and in-silico pace mapping to determine the site of ventricular pacing.

Methods: ECGi recordings were collected during left ventricle (LV) (endocardial: N=5, epicardial: N=1), septal (N=3) and right ventricle (RV) apical pacing (N=15) along with computed tomography (CT). Personalized CT-based ventricular-torso computational models were created and aligned with the 252 ECGi vest electrodes. Ventricles were paced at 1000 random sites, and corresponding body surface potentials (BSPs) and ECGs were computed. In-silico pace maps were then reconstructed by correlating all simulated ECGs or BSPs with the corresponding paced clinical signals. The distance (d) between the pacing electrode (ground truth) and the location with the strongest correlation was determined; for ECGi, the site with earliest activation time was used.

Results: In-silico pace mapping consistently outperformed ECGi in locating the pacing origin, with the best results when all BSPs were used. During LV pacing, spatial accuracy of in-silico pacing mapping was 9.5mm with BSPs and 12.2mm when using ECGs, compared to 30.8mm when using ECGi. During RV pacing, d = 26.1mm (BSPs), 30.9mm (ECGs) and 29.1mm (ECGi).

Conclusion: In-silico pace mapping is more accurate than ECGi in detecting paced activation. Performance was optimal when all BSPs were used and reduced during RV apical pacing.