JACC. Clinical electrophysiology最新文献

Background: Left atrial appendage occlusion (LAAO) has emerged as an effective stroke- prevention strategy for selected patients with nonvalvular atrial fibrillation (NVAF). However, LAAO outcomes data in patients with hypertrophic cardiomyopathy (HCM), rheumatic heart disease (RHD), or cardiac amyloidosis (CA), are limited.

Objectives: This study aimed to compare the safety and efficacy of LAAO in patients with NVAF, with and without comorbid HCM, RHD, or CA.

Methods: Using OptumLabs Data Warehouse, a retrospective cohort of adult patients undergoing LAAO (2015-2023) was analyzed. Outcomes included mortality, stroke/transient ischemic attack (TIA), and bleeding, with multivariable Cox models and subgroup analyses.

Results: A total of 14,755 patients (mean age 76.5 ± 7.0, 43.7% female, median follow-up 1.4 [0.8-2.4] years) were included. Compared with patients with AF, patients AF + RHD had high risk of nongastrointestinal/intracranial bleeding events (HR: 1.24; 95% CI: 1.04-1.49; P = 0.02), whereas AF + CA showed higher risk of composite endpoint (mortality, stroke/TIA, bleeding) (HR: 1.63; 95% CI: 1.17-2.27; P = 0.004), stroke/TIA (HR: 2.00; 95% CI; 1.13-3.54; P = 0.02), and gastrointestinal bleeding (HR: 2.50; 95% CI: 1.14-5.47; P = 0.02). There were no significant differences in clinical outcomes between patients with AF alone and those with AF + HCM.

Conclusions: Patients with AF and either RHD or CA experienced higher bleeding rates following LAAO compared with those without these conditions, despite similar stroke/TIA rates in AF + RHD, suggesting a higher inherent bleeding risk and possibly further supporting a role of LAAO. Importantly, there was no difference in outcomes between patients with AF and HCM vs those without. Because of the small sample size, the results in HCM and CA cohorts are mainly hypothesis generating.

Background: Patients undergoing orthotopic transcatheter tricuspid valve replacement (TTVR) frequently present with a cardiac implantable electronic device (CIED) lead traversing the tricuspid valve.

Objectives: This study sought to investigate the clinical, procedural, and lead-related outcomes of orthotopic TTVR in patients with transvalvular CIED leads.

Methods: All consecutive patients enrolled in the multicenter TRIPLACE (Global Multicenter Registry on Transcatheter Tricuspid Valve Replacement) registry (NCT06033274) were included for analysis. Patients were stratified based on the presence of a CIED lead traversing the tricuspid valve. Changes in lead function parameters were assessed after TTVR in a subset of these patients who had pacemaker lead parameter data recorded. Lead failure was defined as structural or electrical malfunction requiring new lead or CIED insertion.

Results: Among 395 patients, 104 (26.3%) had transvalvular CIED leads. Procedural success, symptomatic improvement, and 30-day mortality were comparable between those with and without CIED. Patients with CIED leads had lower rates of mild or less residual tricuspid regurgitation (82.6% vs 91.4%; P < 0.041) and higher rates of moderate or greater paravalvular leak (17.1% vs 7.1%; P < 0.017). Lead failure occurred in 5.8% over a median follow-up time of 183 days, with modest changes in pacing thresholds. No significant increase in adverse events or mortality was observed at 30 days.

Conclusions: Orthotopic TTVR in patients with transvalvular CIED leads can be safely and effectively performed with low rates of lead failure. Significant paravalvular leak and residual tricuspid regurgitation is more common with a jailed lead. These patients require close CIED follow-up with alternative pacing strategies in place, particularly when pacing dependent. (Global Multicenter Registry on Transcatheter TRIcuspid Valve RePLACEment [TRIPLACE]; NCT06033274).

Background: Supraventricular tachycardia (SVT) is a common type of arrythmia leading to patient distress and substantial health care utilization. Although the mechanistic underpinnings of SVT are well elucidated, the etiologies remain unknown.

Objectives: This study aimed to determine to what extent SVT may be heritable using a classical biometrical twin study design.

Methods: Monozygotic and same-sex dizygotic twin pairs born in Denmark, in which one or both members were diagnosed with SVT between 1977 and 2024, were identified through the Danish Twin Registry and the Danish National Patient Registry. The risk in the co-twin following the index-twin's diagnosis was estimated by using Cox proportional hazards models. Heritability of SVT was assessed by using probandwise concordance rates and biometrical models.

Results: Of 32,324 twin pairs (12,006 monozygotic and 20,318 dizygotic pairs), at least one SVT diagnosis was identified in 663 twin pairs. After an SVT diagnosis in the index-twin, the risk of SVT was significantly higher in monozygotic co-twins compared with dizygotic co-twins (HR: 3.61; 95% CI: 1.35-9.63; P = 0.01), which remained significant after adjusting for age and sex (HR: 3.3; 95% CI: 1.24-8.89; P = 0.01). The probandwise concordance rate was significantly higher in monozygotic twins compared with dizygotic twins (9% vs 3%; P < 0.001). Biometrical models indicated that 35% of SVT risk could be attributed to genetics and 65% to unique environmental components.

Conclusions: Based on a large nationwide population of monozygotic and same-sex dizygotic twins, this is the first study to quantify the genetic and environmental contributions to SVT.

Atrial fibrillation ablation trials have significantly evolved over the past 3 decades, especially recently with the introduction of pulsed field ablation. Efficacy endpoint definitions are inconsistent among clinical trials, leaving the readers (ie, physicians, patients, payers, and regulators) to determine which values are most meaningful and how to compare results across various technologies. This review highlights differences in study design, atrial arrhythmia monitoring methods, and endpoint definitions of key pulsed field ablation trials and discusses the challenges of making cross-trial comparisons. Ultimately, a coordinated effort by physician-researchers, in collaboration with industry partners and regulatory agencies, could establish consensus-driven benchmarks for clinical success, recurrence thresholds, and quality-of-life measures. Such harmonization would enhance the reliability of cross-trial comparisons and support faster, better informed decision-making in both clinical and policy settings.

The treatment of atrial fibrillation (AF) is compounded by its common coexistence with depression. Autonomic dysfunction has been described in both conditions, which may represent a shared target for treatment. A narrative review was conducted to synthesize the literature surrounding depression, AF, autonomic dysfunction characterized using heart rate variability, and antidepressant medication. Invasive autonomic modulation in AF has been studied as part of catheter ablation for AF. Changes in autonomic indices after catheter ablation have been associated with improved quality of life and reduced anxiety scores in the short term. Treating depression in AF using clinically available selective serotonin reuptake inhibitor antidepressants may reduce excessive changes in heart rate variability and possibly autonomic dysfunction seen in AF. These agents may also improve compliance with lifestyle changes that are critical in the management of AF. These agents have a good safety track record in the coronary artery disease and heart failure populations but have not been systemically studied in arrhythmia likely secondary to concurrent administration of class III antiarrhythmic medications. However, effects on QT interval vary within this drug class and are not as large as those exerted by tricyclic antidepressants. Additionally, behavioral treatment of depression in AF has been shown to reduce symptom perception and health care utilization despite stable AF burden. In conclusion, effective treatment of depression may have direct benefits on AF treatment via autonomic modulation and indirect benefits via enhanced risk factor management and reduced symptom perception.