Pub Date : 2026-02-01Epub Date: 2025-11-07DOI: 10.1016/j.jacep.2025.09.029
Min Choon Tan MD , Aravinthan Vignarajah MD , Yong Shen Teo MBBS , Nishanthi Vigneswaramoorthy MD , Christopher V. DeSimone MD , Abhishek J. Deshmukh MD , Dan Sorajja MD , Justin Z. Lee MD
Background
Atrial fibrillation (AF) is a common arrhythmia among patients with cardiac amyloidosis. Whereas the success rate of catheter ablation for AF may be lower due to amyloid deposition, the optimal approach to achieving rhythm control in these patients remains controversial.
Objectives
This study aims to assess the 3-year outcomes of catheter ablation for AF vs antiarrhythmic drug (AAD) therapy among patients with AF and cardiac amyloidosis using a multinational data set.
Methods
Using the TriNetX Analytics Research Network, we included patients aged ≥18 years with a diagnosis of AF and amyloidosis between January 1, 2013, and January 1, 2021. Patients were further categorized into 2 groups: those who underwent catheter ablation for AF and those who were initiated on class I or III AAD. Patients with prior catheter ablation or class I /III AAD were excluded. The study outcomes included all-cause mortality and cardiac adverse events during a 3-year study period.
Results
A total of 120 patients in the AF catheter ablation group and 4,749 in the AAD group were identified. After propensity score matching, 118 patients in each group were analyzed. Catheter ablation for AF in cardiac amyloidosis was associated with significantly lower risks of 3-year all-cause mortality (OR: 0.404; 95% CI: 0.182-0.896) and all-cause hospitalization (OR: 0.547; 95% CI: 0.317-0.942). However, no significant differences were observed in the risks of cerebrovascular attack (OR: 1; 95% CI: 0.400-2.500), cardiac arrest (OR: 1; 95% CI: 0.400-2.500), and acute heart failure (OR: 0.688; 95% CI: 0.293-1.617) between the 2 groups.
Conclusions
Catheter ablation for AF in patients with cardiac amyloidosis is associated with improved outcomes in all-cause mortality and hospitalization compared to AAD therapy. Further large-scale studies are needed to validate these potential benefits.
{"title":"Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation in Cardiac Amyloidosis","authors":"Min Choon Tan MD , Aravinthan Vignarajah MD , Yong Shen Teo MBBS , Nishanthi Vigneswaramoorthy MD , Christopher V. DeSimone MD , Abhishek J. Deshmukh MD , Dan Sorajja MD , Justin Z. Lee MD","doi":"10.1016/j.jacep.2025.09.029","DOIUrl":"10.1016/j.jacep.2025.09.029","url":null,"abstract":"<div><h3>Background</h3><div>Atrial fibrillation (AF) is a common arrhythmia among patients with cardiac amyloidosis. Whereas the success rate of catheter ablation for AF may be lower due to amyloid deposition, the optimal approach to achieving rhythm control in these patients remains controversial.</div></div><div><h3>Objectives</h3><div>This study aims to assess the 3-year outcomes of catheter ablation for AF vs antiarrhythmic drug (AAD) therapy among patients with AF and cardiac amyloidosis using a multinational data set.</div></div><div><h3>Methods</h3><div>Using the TriNetX Analytics Research Network, we included patients aged ≥18 years with a diagnosis of AF and amyloidosis between January 1, 2013, and January 1, 2021. Patients were further categorized into 2 groups: those who underwent catheter ablation for AF and those who were initiated on class I or III AAD. Patients with prior catheter ablation or class I /III AAD were excluded. The study outcomes included all-cause mortality and cardiac adverse events during a 3-year study period.</div></div><div><h3>Results</h3><div>A total of 120 patients in the AF catheter ablation group and 4,749 in the AAD group were identified. After propensity score matching, 118 patients in each group were analyzed. Catheter ablation for AF in cardiac amyloidosis was associated with significantly lower risks of 3-year all-cause mortality (OR: 0.404; 95% CI: 0.182-0.896) and all-cause hospitalization (OR: 0.547; 95% CI: 0.317-0.942). However, no significant differences were observed in the risks of cerebrovascular attack (OR: 1; 95% CI: 0.400-2.500), cardiac arrest (OR: 1; 95% CI: 0.400-2.500), and acute heart failure (OR: 0.688; 95% CI: 0.293-1.617) between the 2 groups.</div></div><div><h3>Conclusions</h3><div>Catheter ablation for AF in patients with cardiac amyloidosis is associated with improved outcomes in all-cause mortality and hospitalization compared to AAD therapy. Further large-scale studies are needed to validate these potential benefits.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":"12 2","pages":"Pages 325-331"},"PeriodicalIF":7.7,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145458260","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01Epub Date: 2025-11-20DOI: 10.1016/j.jacep.2025.09.042
Michael W. Lim MBBS , Geoffrey R. Wong MBBS, PhD , Troy W. Watts BSc , Souvik K. Das MBBS , Youlin Koh MBBS , Sohaib A. Virk MBBS , Danlu Liang MBBS , Paul B. Sparks MBBS, PhD , Joseph B. Morton MBBS, PhD , Geoffrey Lee MBBS, PhD , Peter M. Kistler MBBS, PhD , Jonathan M. Kalman MBBS, PhD
Background
Atrial substrate is characterized by regions of reduced bipolar voltage (BV), conduction velocity slowing, and complex potentials. It is thought to reflect the myocardial tissue loss and interstitial fibrosis that typifies atrial remodeling. Whether this remodeling results in regional changes in left atrial wall thickness (LAWT) is unclear.
Objectives
This study sought to determine whether computed tomography (CT)–derived LAWT is associated with regional atrial substrate in atrial fibrillation (AF) patients.
Methods
High-density electroanatomic maps of the left atrium (LA) were created in a cohort of adult patients undergoing index AF ablation. LAWT derived from the preprocedure CT utilizing automated postprocessing software was correlated with electrical markers of atrial substrate in the overall LA and at 6 predefined atrial regions.
Results
The study included 77 patients. In multiple linear regression analyses incorporating mean LAWT, age, body mass index, AF type, and LA volume, mean LAWT was an independent predictor of mean BV (β = 1.34; P < 0.001) and conduction velocity (β = 25.63; P = 0.005) as well as an independent predictor of the percentage of low voltage (β = −30.80; P < 0.001) and conduction slowing/block (β = −31.69; P = 0.013) points. Regional mean LAWT was an independent predictor of regional mean BV across all 6 predefined LA segments (anterior/posterior/roof/inferior/septal/lateral). Regional mean LAWT of the anterior (β = −5.42; P = 0.033) and roof (β = −3.17; P = 0.021) segments were also independent predictors of the percentage of complex potentials in the corresponding segments.
Conclusions
CT-derived LAWT is a promising noninvasive marker of LA substrate.
背景：心房底物的特征是双极电压（BV）降低、传导速度减慢和复杂电位。它被认为反映了心房重构的心肌组织损失和间质纤维化。这种重构是否会导致左房壁厚度（LAWT）的局部改变尚不清楚。目的：本研究旨在确定计算机断层扫描（CT）衍生的LAWT是否与房颤（AF）患者的区域性心房底物相关。方法：在一组接受指数心房颤动消融的成年患者中建立左心房高密度电解剖图。利用自动后处理软件从术前CT获得的LAWT与整个LA和6个预定义心房区域的心房底物电标记相关。结果：共纳入77例患者。在纳入平均LAWT、年龄、体重指数、AF类型和LA容积的多元线性回归分析中，平均LAWT是平均BV （β = 1.34, P < 0.001）和传导速度（β = 25.63, P = 0.005）的独立预测因子，也是低电压百分比（β = -30.80, P < 0.001）和传导减慢/阻滞（β = -31.69, P = 0.013）点的独立预测因子。区域平均LAWT是所有6个预定义LA节段（前/后/顶/下/中隔/外侧）区域平均BV的独立预测因子。前节段（β = -5.42; P = 0.033）和顶节段（β = -3.17; P = 0.021）的区域平均LAWT也是相应节段复杂电位百分比的独立预测因子。结论：ct衍生的LAWT是一种很有前途的无创LA底物标志物。
{"title":"Left Atrial Wall Thickness as a Marker of Atrial Substrate in Patients With Atrial Fibrillation","authors":"Michael W. Lim MBBS , Geoffrey R. Wong MBBS, PhD , Troy W. Watts BSc , Souvik K. Das MBBS , Youlin Koh MBBS , Sohaib A. Virk MBBS , Danlu Liang MBBS , Paul B. Sparks MBBS, PhD , Joseph B. Morton MBBS, PhD , Geoffrey Lee MBBS, PhD , Peter M. Kistler MBBS, PhD , Jonathan M. Kalman MBBS, PhD","doi":"10.1016/j.jacep.2025.09.042","DOIUrl":"10.1016/j.jacep.2025.09.042","url":null,"abstract":"<div><h3>Background</h3><div>Atrial substrate is characterized by regions of reduced bipolar voltage (BV), conduction velocity slowing, and complex potentials. It is thought to reflect the myocardial tissue loss and interstitial fibrosis that typifies atrial remodeling. Whether this remodeling results in regional changes in left atrial wall thickness (LAWT) is unclear.</div></div><div><h3>Objectives</h3><div>This study sought to determine whether computed tomography (CT)–derived LAWT is associated with regional atrial substrate in atrial fibrillation (AF) patients.</div></div><div><h3>Methods</h3><div>High-density electroanatomic maps of the left atrium (LA) were created in a cohort of adult patients undergoing index AF ablation. LAWT derived from the preprocedure CT utilizing automated postprocessing software was correlated with electrical markers of atrial substrate in the overall LA and at 6 predefined atrial regions.</div></div><div><h3>Results</h3><div>The study included 77 patients. In multiple linear regression analyses incorporating mean LAWT, age, body mass index, AF type, and LA volume, mean LAWT was an independent predictor of mean BV (β = 1.34; <em>P</em> < 0.001) and conduction velocity (β = 25.63; <em>P</em> = 0.005) as well as an independent predictor of the percentage of low voltage (β = −30.80; <em>P</em> < 0.001) and conduction slowing/block (β = −31.69; <em>P</em> = 0.013) points. Regional mean LAWT was an independent predictor of regional mean BV across all 6 predefined LA segments (anterior/posterior/roof/inferior/septal/lateral). Regional mean LAWT of the anterior (β = −5.42; <em>P</em> = 0.033) and roof (β = −3.17; <em>P</em> = 0.021) segments were also independent predictors of the percentage of complex potentials in the corresponding segments.</div></div><div><h3>Conclusions</h3><div>CT-derived LAWT is a promising noninvasive marker of LA substrate.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":"12 2","pages":"Pages 332-342"},"PeriodicalIF":7.7,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145564069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01Epub Date: 2025-11-24DOI: 10.1016/j.jacep.2025.10.006
Astrid B.M. Heymans MD , Rutger R. van de Leur MD, PhD , Ping Wang PhD , Esther González-López MD, PhD , Max F.G.H.M. Venner MD , Nina J. Beelen MD , Steven A. Muller MD , Nerea Mora-Ayestarán MD , Noemi Ramos MD , Isa M.E. Faassen MD , Sophie L.V.M. Stroeks MD , Miriam Soria RN , Saskia N. van der Crabben MD, PhD , Rachel M.A. ter Bekke MD, PhD , René van Es MD, PhD , Kevin Vernooy MD, PhD , Anneline S.J.M. te Riele MD, PhD , Pablo García-Pavía MD, PhD , Stephane R.B. Heymans MD, PhD , Job A.J. Verdonschot MD, PhD
Background
Titin truncating variants (TTNtvs) are the leading genetic cause of dilated cardiomyopathy (DCM). Although recommended, routine genetic testing is frequently not performed owing to resource constraints.
Objectives
This study sought to identify electrocardiography (ECG) parameters predictive of an underlying TTNtv in DCM patients, comparing conventional ECG analysis with an ECG-based deep neural network (DNN) to identify patients that would benefit most from targeted genetic testing.
Methods
This retrospective multinational study compared baseline ECGs from 99 DCM patients with (likely) pathogenic TTNtv with 318 gene-elusive DCM patients. Conventional ECG parameters (eg, QRS duration) were extracted. The DNN was trained to compress ECGs into 21 explainable factors, summarizing relevant ECG features. Discriminative performances of both created models, built using LASSO regularization for variable selection to fit logistic regression model, were compared (eg, C-statistics).
Results
TTNtv patients were younger (50.5 vs 56.9 years; P < 0.001), predominantly male (69.7 vs 54.7%; P = 0.008), and had lower left ventricular ejection fraction (28.0% vs 35.0%; P < 0.001) compared with gene-elusive patients. Conventional ECG analysis identified shorter QRS duration (P < 0.001), prolonged PR interval (P < 0.001), and a trend toward reduced QRS voltage (P = 0.098) as TTNtv characteristics. In the DNN model, factors F1 (inferolateral T wave inversion) and F9 (anterior T-wave inversion), among others, were associated with TTNtv. The conventional and DNN models showed good predictive performance for TTNtv (C-statistics: conventional 0.83, DNN 0.86; P = 0.197).
Conclusions
Conventional ECG and DNN analyses demonstrated similar good predictive performance in distinguishing TTNtv from gene-elusive DCM patients, emphasizing their potential as clinical tools to guide targeted genetic testing.
背景：Titin截断变异（ttntv）是扩张型心肌病（DCM）的主要遗传原因。虽然建议进行常规基因检测，但由于资源限制，通常不进行常规基因检测。目的：本研究旨在确定预测DCM患者潜在TTNtv的心电图（ECG）参数，将传统ECG分析与基于ECG的深度神经网络（DNN）进行比较，以确定从靶向基因检测中获益最多的患者。方法：这项回顾性多国研究比较了99例（可能）致病性TTNtv的DCM患者和318例基因难以捉摸的DCM患者的基线心电图。提取常规心电图参数（如QRS持续时间）。训练DNN将心电图压缩为21个可解释因素，总结相关心电图特征。采用LASSO正则化变量选择拟合逻辑回归模型，比较两种模型的判别性能（如C-statistics）。结果：TTNtv患者较年轻（50.5 vs 56.9岁，P < 0.001），以男性为主（69.7 vs 54.7%, P = 0.008），与基因不明的患者相比，左心室射血分数较低（28.0% vs 35.0%, P < 0.001）。常规心电图分析发现，TTNtv特征为QRS持续时间缩短（P < 0.001）， PR间期延长（P < 0.001）， QRS电压降低趋势（P = 0.098）。在DNN模型中，因子F1（内外侧T波反转）和因子F9（前侧T波反转）等与TTNtv相关。传统模型和DNN模型对TTNtv的预测性能较好（C-statistics：传统模型0.83，DNN模型0.86;P = 0.197）。结论：传统心电图和DNN分析在区分TTNtv和基因难以捉摸的DCM患者方面表现出相似的良好预测效果，强调了它们作为指导靶向基因检测的临床工具的潜力。
{"title":"Detection of Titin-Associated Electrocardiography Features in Dilated Cardiomyopathy Using Conventional and Deep Neural Network Analysis","authors":"Astrid B.M. Heymans MD , Rutger R. van de Leur MD, PhD , Ping Wang PhD , Esther González-López MD, PhD , Max F.G.H.M. Venner MD , Nina J. Beelen MD , Steven A. Muller MD , Nerea Mora-Ayestarán MD , Noemi Ramos MD , Isa M.E. Faassen MD , Sophie L.V.M. Stroeks MD , Miriam Soria RN , Saskia N. van der Crabben MD, PhD , Rachel M.A. ter Bekke MD, PhD , René van Es MD, PhD , Kevin Vernooy MD, PhD , Anneline S.J.M. te Riele MD, PhD , Pablo García-Pavía MD, PhD , Stephane R.B. Heymans MD, PhD , Job A.J. Verdonschot MD, PhD","doi":"10.1016/j.jacep.2025.10.006","DOIUrl":"10.1016/j.jacep.2025.10.006","url":null,"abstract":"<div><h3>Background</h3><div>Titin truncating variants (TTNtvs) are the leading genetic cause of dilated cardiomyopathy (DCM). Although recommended, routine genetic testing is frequently not performed owing to resource constraints.</div></div><div><h3>Objectives</h3><div>This study sought to identify electrocardiography (ECG) parameters predictive of an underlying TTNtv in DCM patients, comparing conventional ECG analysis with an ECG-based deep neural network (DNN) to identify patients that would benefit most from targeted genetic testing.</div></div><div><h3>Methods</h3><div>This retrospective multinational study compared baseline ECGs from 99 DCM patients with (likely) pathogenic TTNtv with 318 gene-elusive DCM patients. Conventional ECG parameters (eg, QRS duration) were extracted. The DNN was trained to compress ECGs into 21 explainable factors, summarizing relevant ECG features. Discriminative performances of both created models, built using LASSO regularization for variable selection to fit logistic regression model, were compared (eg, C-statistics).</div></div><div><h3>Results</h3><div>TTNtv patients were younger (50.5 vs 56.9 years; <em>P</em> < 0.001), predominantly male (69.7 vs 54.7%; <em>P</em> = 0.008), and had lower left ventricular ejection fraction (28.0% vs 35.0%; <em>P</em> < 0.001) compared with gene-elusive patients. Conventional ECG analysis identified shorter QRS duration (<em>P</em> < 0.001), prolonged PR interval (<em>P</em> < 0.001), and a trend toward reduced QRS voltage (<em>P</em> = 0.098) as TTNtv characteristics. In the DNN model, factors F1 (inferolateral T wave inversion) and F9 (anterior T-wave inversion), among others, were associated with TTNtv. The conventional and DNN models showed good predictive performance for TTNtv (C-statistics: conventional 0.83, DNN 0.86; <em>P</em> = 0.197).</div></div><div><h3>Conclusions</h3><div>Conventional ECG and DNN analyses demonstrated similar good predictive performance in distinguishing TTNtv from gene-elusive DCM patients, emphasizing their potential as clinical tools to guide targeted genetic testing.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":"12 2","pages":"Pages 363-374"},"PeriodicalIF":7.7,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145603577","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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