JACC. Clinical electrophysiology最新文献

Background: Pulsed field energy is an increasingly adopted technology for ablation of atrial fibrillation (AF). Although clinical data on pulsed field ablation (PFA) is positive, data on ischemic cerebral lesions (ICLs) after PFA is limited. Because the individual PFA systems differ substantially in pulse characteristics, cerebral safety should be studied separately for each system.

Objectives: This study sought to assess the incidence of ICLs after PFA for AF using a variable-loop circular catheter.

Methods: The study was designed as a prospective, observational, cohort, single-center study. In patients with nonparoxysmal AF, pulmonary vein and left atrial posterior wall isolation were performed. National Institutes of Health Stroke Scale scores were assessed within 24 hours post ablation. Brain magnetic resonance imaging (1.5T, diffusion-weighted imaging included) was conducted 1 day before and 24 hours after the procedure to detect acute ICL. The study initially aimed to enroll 40 patients but was terminated early because of safety concerns.

Results: Twenty-one patients were enrolled (age 66.1 ± 9.0 years, 38% women, all with nonparoxysmal AF). ICLs occurred in 14 (66.7%) patients, with a median of 2 (IQR: 0, 3) lesions per patient, and a median cumulative lesion burden of 10.5 mm (6.3, 19.3). Most ICLs (28; 55.8%) were localized in the posterior territory. One patient experienced a transient ischemic attack, and 1 patient suffered a major peri-procedural stroke (National Institutes of Health Stroke Scale = 6; modified Rankin scale = 3 at the day 30 clinical follow-up).

Conclusions: PFA using a variable-loop circular catheter was associated with a high rate of ICLs. More than half of the lesions were in the posterior cerebrovascular territory. (Cerebral Safety After Pulsed-Field Ablation of Atrial Fibrillation; NCT06786988).

Background: Isolated nonischemic left ventricular scar (NILVS), identified by cardiac magnetic resonance, is an increasing finding in athletes and may be the substrate for life-threatening arrhythmias. Clinical significance in asymptomatic athletes is yet to be investigated.

Objectives: This study sought to describe the clinico-genetic profile and follow-up of asymptomatic athletes diagnosed with NILVS through preparticipation screening.

Methods: We evaluated 40 athletes (90% males, 44 [range:33-52] years) including 9 elites, with isolated NILVS involving at least 2 segments, no previous major arrhythmic events, with available genetic testing and >1 year of follow-up. Data regarding electrocardiography, echocardiography, 24-hour Holter, exercise testing, and genetic analysis were collected. Follow-up assessed therapy, sport participation, and outcome.

Results: Electrocardiogram abnormalities were present in 48%, and all showed premature ventricular beats at exercise testing, mostly with right bundle branch/superior axis morphology. Left ventricular ejection fraction was normal or mildly reduced. Genetic testing or family screening was positive in 9 (23%). Athletes without familial/genetic background were older and declared higher cumulative years of sports activity. Over a median follow-up time of 23 months, 84% continued noncompetitive sport, mostly (73%) on beta-blocker therapy. Two major arrhythmic events occurred (resuscitated cardiac arrest and sustained ventricular tachycardia), both in athletes with a positive family history for NILVS, but negative genetic testing, and both during noncompetitive exercise.

Conclusions: NILVS in asymptomatic athletes may carry arrhythmic risk even in the absence of previous symptoms or left ventricular dysfunction. Athletes with NILVS and no gene mutations/family history are older and with a higher past exercise volume.

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.