JACC. Clinical electrophysiology最新文献

Background: Atrial fibrillation (AF) is characterized by a heterogeneous presentation of symptoms. AF ablation reduces symptom burden. However, persistent symptoms following AF ablation are common independently of AF recurrence.

Objectives: This study sought to perform a cluster analysis to identify clinically relevant AF subphenotypes based on persistent symptoms following AF ablation and evaluate their associations with clinical characteristics and AF recurrence.

Methods: Patients were instructed to perform smartphone app-based simultaneous symptom and photoplethysmography heart rhythm monitoring 3 times daily for 1 week at the 3-month follow-up after AF ablation. A two-step cluster analysis including 7 categorical symptoms variables was performed in symptomatic patients.

Results: In total, half of all patients (n = 313 of 614 [51%]) reported symptoms. Five symptom clusters were identified: nonspecified symptoms (n = 52 [17%]), AF with sparse symptoms (n = 93 [30%]), palpitations (n = 47 [15%]), fatigue with comorbidities (n = 63 [20%]), and sinus rhythm with severe symptoms (n = 58 [19%]). Frequency (P < 0.001) and pattern (P < 0.001) of symptom reporting as well as AF recurrence (P < 0.001), AF load (P < 0.001), AF pattern (P = 0.002 and P = 0.005), and symptom-rhythm correlation (P < 0.001) differed between clusters. Furthermore, age (P < 0.01), N-terminal pro-B-type natriuretic peptide levels (P < 0.01), CHA₂DS₂-VA (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke, vascular disease, and age 65-74 years) score (P < 0.001), and left atrial volume index (P = 0.01) differed between clusters.

Conclusions: Half of all patients report symptoms after AF ablation. Using cluster analysis, 5 symptom-based AF subphenotypes were identified, each with distinct clinical characteristics, biomarker profiles, AF recurrence, AF pattern, AF and symptom burden, and symptom-rhythm correlation. Symptom clusters empowered by digital health may facilitate individualized AF management strategies following AF ablation.

Background: Ventricular tachycardia (VT) storm is associated with substantial risk of in-hospital mortality. There are limited data on which patients are at highest risk and the optimal timing of catheter ablation for VT.

Objectives: This study sought to identify predictors of in-hospital mortality among patients with VT storm, develop a mortality risk score, and evaluate the impact of ablation timing across risk strata.

Methods: Retrospective analysis of patients admitted with VT storm at 6 high-volume tertiary care centers between 2015 and 2024. Multivariable logistic regression was used to identify independent predictors of acute in-hospital mortality. A weighted clinical risk score-the CHAMPS (cerebrovascular accident, hypoxia, admission diagnosis, malnutrition, vasopressors, sepsis) score-was developed from these predictors. Mortality rates were compared across risk strata and by timing of VT ablation.

Results: A total of 1,675 patients met inclusion criteria and 363 (22%) died during the index hospitalization. Independent predictors of mortality included acute cerebrovascular accident (OR: 3.9), hypoxia resulting in intubation (OR: 3.8), an admission diagnosis other than VT (OR: 4.1), severe malnutrition (OR: 1.4), multiple vasopressor agents (OR: 1.8), and sepsis or fever (OR: 5.0). Using the proportionally weighted CHAMPS score, mortality was 6.6% in low-risk patients, 26.7% in moderate-risk patients, and 60.7% in high-risk patients. VT ablation was performed in 59% of patients and early ablation performed within 7 days of developing VT storm was protective against in hospital mortality (OR: 0.01), independent of CHAMPS score.

Conclusions: VT storm is associated with high risk of acute in-hospital mortality and the CHAMPS score identifies patients at highest risk. Early catheter ablation is associated with significantly improved survival across risk categories.

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.