JACC. Clinical electrophysiology最新文献

Background: Percutaneous epicardial access has been increasingly adopted in clinical practice, particularly for ventricular tachycardia ablation. "Dry" epicardial puncture (Dry-EPI) carries a considerable risk of access-related complications, even with modified techniques. Pericardial carbon dioxide insufflation (EpiCO₂) has emerged as a promising alternative, potentially enhancing safety by increasing anatomical clearance between pericardial layers.

Objectives: This study compared the safety and efficacy of EpiCO₂ vs traditional Dry-EPI techniques through systematic review, meta-analysis, and meta-regression.

Methods: PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane databases were searched using medical subject heading terms "epicardial access," "carbon dioxide insufflation," "complications," and similar key words. Random-effects meta-analyses of proportions and means, subgroup analyses, and meta-regressions were conducted.

Results: One hundred nineteen studies (8,784 procedures) were included; most (95.0%) were of moderate or high quality. Ventricular tachycardia ablation was the main access indication (n = 7,178). EpiCO₂ was used in 493 procedures (5.6%) and Dry-EPI in 8,291 (94.4%). Among 5,786 Dry-EPI cases with specified needle type, 5,184 (89.6%) used a large-bore needle and 602 (10.4%) a micropuncture needle. EpiCO₂ was associated with significantly fewer complications requiring surgery compared with Dry-EPI (0.24% [95% CI: 0.00-0.93] vs 1.55% [95% CI: 1.27-1.86], P < 0.010), large-bore needle (0.24% [95% CI: 0.00%-0.93%] vs 1.58% [95% CI: 1.23-1.97], P < 0.010), and micropuncture (0.24 [95% CI: 0.00-0.93] vs 1.66% [95% CI: 0.60-3.17], P = 0.020). Inadvertent ventricular puncture was also lower with EpiCO₂ compared with Dry-EPI (0.28% [95% CI: 0.00-1.00] vs 3.17% [95% CI: 2.36-4.10], P < 0.010).

Conclusions: Compared with Dry-EPI, EpiCO₂ was associated with significantly lower risk of inadvertent ventricular puncture and complications requiring surgery, supporting broader clinical adoption.

Background: The diagnosis of carotid sinus syndrome requires the reproduction of spontaneous symptoms during carotid sinus massage (CSM) alongside clinical features indicative of a reflex mechanism. In contrast, the significance of asymptomatic asystolic carotid sinus hypersensitivity (CSH) remains uncertain, as it is frequently observed in older adults without syncope.

Objectives: This study aimed to evaluate the correlation between asymptomatic asystolic CSH and spontaneous events documented via implantable loop recorder (ILR).

Methods: In this study, 92 reflex syncope patients with an asymptomatic pause >3 seconds during CSM (average 4.9 ± 1.7 seconds) received an ILR and were followed for a median of 23.1 months. The control group consisted of reflex syncope patients with negative CSM drawn from a historical ILR population and matched with the propensity score method to the CSH group based on clinical variables.

Results: During the observation period, 38 (41.3%) CSH patients had recurrence of syncope, which was associated with asystole of 8.0 seconds (95% CI: 5.3-13.5 seconds) in 29 (76.3%) cases. Although the actuarial rate of total syncope recurrence in CSH group was similar to that in the control group (HR: 1.22; P = 0.40), CSH patients showed a higher rate of asystolic syncope (HR: 2.13; P = 0.011) and asystolic pauses (HR: 2.06; P = 0.009).

Conclusions: Patients with asymptomatic asystolic CSH were more likely to experience spontaneous asystolic syncope than those without CSH. Among CSH patients who experienced a recurrence of syncope documented by an ILR, the positive predictive value of an asystolic pause detected during CSM was 76.3%.

Background: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for paroxysmal atrial fibrillation (PAF), but outcome data beyond 10 years are limited.

Objectives: This study sought to evaluate 20-year outcomes of PVI for PAF.

Methods: From 2003 to 2004, patients with symptomatic, drug-refractory PAF underwent PVI with radiofrequency current, confirmed by the double-lasso technique. Freedom from atrial fibrillation/atrial tachycardias (ATs) after multiple procedures was assessed in all patients. Very late AT recurrences were defined as recurrence >10 years after last ablation. Long-term cardiovascular outcomes were analyzed over 2 decades.

Results: A total of 154 patients (median age 76 years [Q1-Q3: 66-83 years], 26% female) were included with a median follow-up duration of 19.3 years (Q1-Q3: 15.9 years to not available). Multiple procedural success was 25% after 20 years and a mean of 2 ± 1 ablation procedures, with 24% of patients on antiarrhythmic drugs. The progression rate from PAF to persistent atrial fibrillation was 13% (n = 20 of 154). Very late AT recurrences were associated with high PVI durability of 83%. Long-term outcomes included 7 (4.5%) thromboembolic events, 3 (1.9%) cardiopulmonary resuscitations, 3 (1.9%) acute coronary syndromes and 1 (0.6%) major bleeding, and 19 (12%) deaths (42% cancer, 26% unknown, 16% cardiovascular). Oral anticoagulation was discontinued in 48% (n = 75 of 154) of patients, with 73% (n = 55 of 75) of these patients in stable sinus rhythm at the last follow-up.

Conclusions: During 20 years post-PVI, 25% of patients maintained stable sinus rhythm, including multiple ablation procedures and antiarrhythmic drugs. Despite being at risk for stroke, half of the patients were off anticoagulation, with the majority being "PVI responders" in stable sinus rhythm. The low stroke rate during long-term follow-up may indicate a potential beneficial effect of PVI; however, confirmation in larger studies is necessary.

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).