JACC. Clinical electrophysiology最新文献

Background: Superior vena cava syndrome (SVC) is an uncommon complication of transvenous leads (TVL). Management often involves removal of the TVL, venoplasty, and stenting in certain situations.

Objectives: This study sought to define the management of lead-related SVC syndrome.

Methods: We identified patients with lead related SVC between 2014 and 2025 at Mayo Clinic sites. Demographic data, information regarding cardiac implantable electronic device, extraction procedure, and venoplasty procedure data were abstracted from the charts for analysis.

Results: A total of 28 leads were present in 14 patients causing SVC syndrome. Median age of the study cohort was 61.0 (Q1-Q3: 45.8-66.8) years, and 50% were female. Median number of leads implanted per patient was 2.0 (Q1-Q3: 1-2) leads, and median age of the leads was 48.0 (Q1-Q3: 31.8-74.0) months. A total of 11 patients (78.6%) underwent extraction procedure, and all of them had complete procedural success without complications. Of the total cohort, 7 underwent venoplasty and 7 underwent stenting. During a median follow-up of 22.1 (Q1-Q3: 9.5-66.3) months, 5 patients (35.7%) had recurrent symptomatic stenosis (2 with index balloon venoplasty and 3 index transvenous lead extraction and venoplasty). Of the 11 patients who underwent extraction, 6 required reimplantation of the device: 2 transvenous, 2 epicardial, 1 subcutaneous, and 1 leadless device implantation.

Conclusions: Effective management of TVL-associated SVC syndrome involves venoplasty with or without transvenous lead extraction, showing good medium-term outcomes. Reimplantation of the device with TVL requires careful consideration, and efforts should be made to consider a leadless device when feasible.

Background: Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) can be ablated from some endocardial sites across the left ventricular myocardium where ventricular activation is later than in the great cardiac vein (anatomical approach). Failure of ablation at the initial target site was common, however, approaches have evolved to improve the outcomes.

Objectives: The goal of this study was to explore predictors of successful anatomical ablation of LVS VAs to elucidate the ablation site selection strategy.

Methods: Forty consecutive patients who underwent successful anatomical ablation of idiopathic LVS VAs with completed endocardial mapping were studied.

Results: The earliest ventricular activation relative to the QRS onset in the endocardium and great cardiac vein was -1 millisecond (-5 to 0 milliseconds) and -24 milliseconds (-29 to -18.25 milliseconds), respectively. Endocardial radiofrequency catheter ablation (E-RFCA) was performed at the shortest distance from the epicardial earliest activation site (EAS) in 36 patients; it was successful in 20 in whom the endocardial earliest ventricular activation was also recorded at the ablation site. That approach failed in 16 patients, and E-RFCA was successful at the junction between the left and right coronary cusps in 3. In 13 of 16 patients with a failed ablation and the remaining 4 patients, E-RFCA was successful at or near the endocardial EAS. Overall, E-RFCA was successful at the endocardial EAS in 37 (93%) of 40 patients.

Conclusions: This study suggests that E-RFCA of LVS VAs through an anatomical approach should first target the endocardial EAS rather than sites anatomically closest to the epicardial EAS.

Background: Pulsed field ablation (PFA) for atrial fibrillation ablation provides a unique challenge for acute lesion evaluation due to reversible myocardial injury. Real-time guidance during ablation would provide reference for lesion location and extent. The second-generation pentaspline PFA catheter improves mapping integration with real-time visualization of catheter shape and previews the estimated ablative electric field.

Objectives: This study sought to evaluate the estimated shape and position of the acute tags relative to low-voltage borders from high-density, postablation maps.

Methods: A multicenter, first-in-human study, NAVIGATE-PF (Feasibility Study on the FARAVIEW Technology), was conducted in 30 atrial fibrillation patients. Tags were placed following each application based on the shape of the estimated electric field. Post ablation, a high-quality, high-density voltage map was created with a high-density mapping catheter. Tags were overlaid on the high-density map and contours were drawn at the border of low voltage (≤0.5mV) and the outer border where at least 2 overlapping tags were placed.

Results: All 30 patients were successfully treated with the second-generation PFA catheter. For the 15 patients included in the acute tags analysis, the region of acute electrical isolation correlated with the estimated ablative electric field. Post-procedural processing of the distance between the tag and low-voltage border was -0.58 mm (Q1-Q3: -2.9 to 2.17 mm) where a negative number indicates the tag is smaller than the low-voltage border.

Conclusions: The second-generation pentaspline PFA catheter, with dynamic shape visualization and preview of anticipated electric field, resulted in alignment with postablation voltage mapping. (Feasibility Study on the FARAVIEW Technology [NAVIGATE-PF]; NCT06175234).

Background: About one-third of patients with heart failure with reduced ejection fraction remain nonresponders to guideline-directed cardiac resynchronization therapy. An algorithm for age prediction using an artificial intelligence-enabled electrocardiography (AI-ECG) has been proposed as a marker of a patient's "biological" age.

Objectives: This study aimed to evaluate the utility of the preimplantation AI-ECG age in predicting survival post cardiac resynchronization therapy with defibrillator (CRT-D).

Methods: We retrospectively reviewed records of patients who underwent CRT-D at the Mayo Clinic between January 1, 2001 and September 30, 2022. All patients with left ventricular ejection fraction ≤35%, QRS duration ≥120 milliseconds, and CRT-D were included. The primary endpoint was all-cause mortality. From preimplantation ECGs, chronological age and AI-ECG age were obtained using the Mayo Clinic AI-ECG age algorithm. The δage was calculated as the patient's AI-ECG age minus the chronological age. Survival analyses were conducted.

Results: A total of 464 patients were included. Patients with δage < 0 were chronologically older with a greater incidence of hypertension, coronary artery disease, hyperlipidemia, and peripheral vascular disease (P < 0.05). In multivariable analyses, with δage as a continuous variable, a lower δage correlated with longer survival post implantation (time ratio: 0.96; P = 0.007). Other markers of prolonged survival included a lower chronological age, nonischemic cardiomyopathy, absence of advanced chronic kidney disease, and hypertension. As a categorical variable, δage >5.1 years portended shorter survival than a δage between -5.1 and 5.1 years (time ratio: 0.62; P = 0.017).

Conclusions: Preimplantation AI-ECG-derived δage is an independent predictor of survival post-CRT-D. The lower the AI-ECG age compared to the chronological age, the longer the post-CRT-D survival, possibly reflective of a lower "biologic" age.

Background: Premature ventricular complexes with a QRS morphology almost identical to the sinus rhythm (PVC-iSR) are scarce and have been insufficiently investigated.

Objectives: The purpose of this study was to explore the electrophysiology characteristics, true origin, and ablation strategy for PVC-iSR.

Methods: Among 3,804 patients referred for PVC ablation, 20 patients with PVC-iSR were identified. Detailed mapping, ablation, and analysis were performed.

Results: The earliest activation site (EAS) of PVC-iSR consistently recorded a sharp Purkinje potential with a Purkinje-ventricular interval of 46.65 ± 4.43 milliseconds. By targeting the EAS of PVC-iSR, successful ablation was achieved without incurring atrioventricular block or bundle branch block in 17 of 20 cases. These findings indicate that PVC-iSR may originate from a discrete branch of the His bundle or proximal left bundle branch (LBB); we labeled this "His-LBB twig." His-LBB twig was located anterosuperior to the His-LBB trunk and underneath the right coronary cusp (RCC). The distance was 8.96 ± 2.32 mm between the EAS and left-sided His bundle, and 5.55 ± 2.31 mm between EAS and RCC. Ablation was successful in the RCC in 45%, beneath the RCC in 40%, and aborted for high risk of atrioventricular nodal injury in 15% of patients, with the distance between the EAS and RCC being shortest, moderate, and longest, respectively. The R/S index >1.0 in lead II was a good predictor of successful ablation in RCC.

Conclusions: PVC-iSR was caused by a His-LBB twig that could be successfully ablated in or underneath the RCC without injury to the conduction system.