A 17-year-old patient presented with frequent palpitations, where the tachycardia was not sustained and could not be induced, making it impossible to pinpoint the earliest activation site using the activation map. However, by utilizing a dual-chamber electrogram-based pace mapping technique, we successfully identified the origin and achieved effective treatment.
Very high-power and short-duration (vHPSD) ablation with QDOT MICRO™ facilitates speedy and safe ablation for pulmonary vein isolation. A brief time interval between ablating two neighboring sites with vHPSD may potentially influence the size and geometry of the lesions. This study evaluates lesion formation when delivering adjacent applications using vHPSD at various inter-lesion times (ILTs).
Radiofrequency applications were conducted by QDOT MICRO™ catheter with 90 W of strength and 4 s duration. Fresh swine heart tissue on the epicardium was ablated with 10 g of the contact force. Lesions were created using a single application (SA) and double applications (DA) of adjacent lesions with a 6 mm distance between them as measured on the 3D mapping system. The DA was performed with various ILTs, 60 s (DA-60 s), 10 s (DA-10 s), 5 s (DA-5 s), and 0 s (DA-0 s).
Out of 90 lesions, 79 were analyzed. Eleven lesions were excluded for one steam pop event, seven out of the target distance, and three divided lesions of two applications. There were no significant differences in surface diameter, cross-sectional diameter, and maximal lesion depth in each application among the groups. The intermediate lesion depth was significantly more profound in groups with shorter and immediate ILT (DA-10, 5, and 0 s) compared to the group with a prolonged ILT between two applications (DA-60 s) (2.99, 3.03, 3.16 mm vs. 2.42 mm, respectively; p < .001).
Two adjacent radiofrequency applications with vHPSD in short ILT may result in deeper lesions in the middle of combined double lesions.
Continuous anticoagulation based on the CHA2DS2-VASc score is recommended to prevent embolism caused by atrial fibrillation (AF), but it does not consider AF episodes. The Apple Watch's continuous heart rhythm monitoring and fast-acting direct oral anticoagulants (DOACs) could enable precise, episode-tailored anticoagulation, reducing bleeding risks while preventing stroke. This study evaluates Apple Watch-guided personalized anticoagulation therapy, adjusting DOAC usage based on real-time AF detection.
This multicenter prospective single-arm study will enroll patients who have maintained sinus rhythm post-ablation and are on DOACs. The target enrollment is 50 patients free of AF for at least 30 days following the initiation of Apple Watch monitoring. If no AF occurs for the first 30 days of monitoring, anticoagulants will be discontinued on day 31. If AF is confirmed after day 31, DOAC administration will be resumed and continued until the end of the observation period. The primary endpoint is the reduction in the total number of days with DOACs from day 31 to day 360 compared to the conventional method of continuing anticoagulation. Secondary endpoints include all-cause mortality, stroke, systemic thromboembolism, bleeding events, and Apple Watch malfunctions.
Enrollment of a total of 50 patients was completed in April 2024. Follow-up of the last enrolled patient will be completed in April 2025 and primary results are expected to be available in late 2025.
The Up to AF trial is the first trial to evaluate Apple Watch-guided personalized anticoagulation therapy. This trial represents a potential advancement in personalized medicine for AF management.
The association between corrected QT (QTc) interval and life-threatening cardiac events in patients with hypertrophic cardiomyopathy (HCM) remains unclear. This study sought to investigate whether the prolonged QTc was associated with HCM-related death in patients with HCM.
We included 445 patients with HCM (mean age 51 ± 16 years, 67% men). The QTc interval was measured at the time of the initial evaluation and the patients were classified into those with and without QTc prolongation, which was defined as a QTc interval >450 ms. HCM-related death was defined as a combined endpoint of sudden death or potentially lethal arrhythmic events, heart failure-related death, and stroke-related death.
Prolonged QTc interval was found in 120 patients (26.4%) at the time of enrollment. Over a median (IQR) follow-up period of 8.1 (4.6–11.9) years, a total of 67 patients (15.1%) experienced HCM-related deaths including 57 (12.8%) with the endpoint of sudden death or potentially lethal arrhythmic events. In a multivariable analysis that included prolonged QTc interval and the risk factors for life-threatening events, prolonged QTc interval was independently associated with an HCM-related death (adjusted hazard ratio [HR]: 1.91; 95% confidence interval [CI]: 1.16–3.16; p = .011) and this trend also persisted for the combined endpoint of sudden death or potentially lethal arrhythmic events (adjusted HR: 2.01: 95% CI: 1.17–3.46; p = .012).
In this cohort of patients with HCM, QTc prolongation may be associated with HCM-related death, including the endpoint of sudden death or potentially lethal arrhythmic events.
Much data informing sex differences in atrial fibrillation (AF) comes from Western cohorts. In this analysis, we describe sex differences in Kerala, India, using the Kerala-AF registry—the largest AF registry from the Indian subcontinent.
Patients aged ≥18 years were recruited from 53 hospitals across Kerala. Patients were compared for demographics, treatments, and 12-month outcomes, including major adverse cardiovascular events (MACE) and bleeding.
Male patients were more likely to have a smoking and/or alcohol history and had more ischaemic heart disease (46.2% vs. 25.5%; p < 0.001). Female patients had more valvular AF (35.1% vs. 18.0%; p < 0.001), and more use of calcium-channel blockers (23.3% vs. 16.5%; p < 0.001) or digoxin (39.6% vs. 28.5%; p < 0.001). Almost one in four patients were not anticoagulated despite raised CHA2DS2-VASc scores. 12-month MACE outcomes did not differ by sex (male: 30.2% vs. female: 29.4%; p = 0.685), though bleeding events were more common in male patients (2.4% vs. 1.3%; p = −0.038), driven by minor bleeding (1.2% vs. 0.5%).
In this large AF cohort from India, male patients had a higher prevalence of ischaemic heart disease, smoking, and alcohol use, while female patients had a higher prevalence of valvular heart disease. MACE did not differ by sex, though bleeding was more common in males. Almost a quarter of patients were not anticoagulated despite raised thromboembolic risk.
Recent data showed an association between malnutrition and increased all-cause mortality and thromboembolic risk in patients with atrial fibrillation (AF). However, the impact of malnutrition on the clinical outcomes for patients undergoing catheter ablation for AF is still debated. Our study aimed to examine this relationship using all existing available data.
We conducted a systematic review of MEDLINE and EMBASE databases from inception to April 2024, analyzing the association between malnutrition, assessed by the Geriatric Nutritional Risk Index (GNRI), and the risk of AF recurrence in patients who underwent catheter ablation for AF, compared to those without malnutrition. Relative Risk (RR) or hazard ratio (HR) and 95% CIs were retrieved from each study and combined using the generic inverse variance method.
We included 3 cohort studies with 1697 participants undergoing AF ablation (10.9%) who had malnutrition indicated by GNRI score below 98. Patients with malnutrition had a higher risk of AF recurrence following catheter ablation for AF compared to those without malnutrition (Pooled RR = 2.74, 95% CI 1.36–5.51, I2 = 67%, p = .005).
Our pooled analysis indicates that malnourished patients undergoing catheter ablation for AF have an increased risk of AF recurrence compared to non-malnourished patients.
With the cases of mechanical valves, especially double mitral and aortic valves, ablation at the left ventricle is very challenging. This case report used equipments that are readily available in the Electrophysiology laboratory, which can make the access feasible.
Catheter ablation for atrial fibrillation (AF) in patients with systolic heart failure is a well-established therapeutic procedure. However, predicting the degree of improvement in left ventricular ejection fraction (LVEF) following catheter ablation remains challenging. Ling and colleagues recently applied the ANTWERP score, a novel predictive tool, to estimate postablation LVEF improvement in an Asian cohort.1 They determined a specific ANTWERP score cutoff to identify “responders” — patients who are likely to experience significant LVEF enhancement after ablation. Nonetheless, several concerns warrant attention.
The clinical utility of the ANTWERP score for assessing catheter ablation candidacy in AF patients remains ambiguous. For instance, recent studies have introduced a novel classification for response to cardiac resynchronization therapy (CRT). Following CRT initiation, patients exhibiting early LVEF stabilization demonstrate superior clinical outcomes compared to those with subsequent LVEF decline.2 Notably, an LVEF increase is not a requisite for classifying responders to CRT. Similarly, in the context of AF catheter ablation, LVEF improvement may be limited in patients with a history of myocardial infarction. Nevertheless, ablation remains indicated in such cases to prevent heart failure exacerbation. Furthermore, catheter ablation may also be indicated to reduce AF burden, potentially leading to LVEF improvement, regardless of the ANTWERP score. Thus, ablation could be justified in patients with reduced LVEF irrespective of their ANTWERP score.
The ANTWERP score does not appear to predict AF recurrence postablation effectively.1 In their study, nonresponders experience early AF recurrence, whereas responders are more likely to encounter recurrence beyond 1 year postprocedure. Nonresponders with elevated ANTWERP scores frequently exhibited larger left atria and pulmonary veins, which may facilitate reconnection gaps. In contrast, late-phase AF recurrence in responders may stem from nonpulmonary vein foci.3 Did the authors collect data regarding the specific origins of AF recurrence? Tailoring the therapeutic approach for AF catheter ablation may benefit from stratification by ANTWERP score.
Authors declare no conflict of interests for this article.
Quality of life (QOL) is reduced in patients with atrial fibrillation (AF). However, data regarding the association between sleep quality, one of the major components of QOL, and AF are insufficient. This cross-sectional study aimed to elucidate whether sleep quality is reduced in patients with AF.
We recruited 2054 consecutive outpatients (64 ± 10 years, 1089 men) who had regularly presented to 26 clinics affiliated with the Tamagawa Medical Association, Tokyo, Japan. The patients were divided into paroxysmal AF (PaAF), persistent or permanent AF (PeAF), and non-AF groups. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). The global PSQI score was calculated according to the answer to each question, and poor sleep quality was defined as a global PSQI score ≥6 points. Logistic regression analysis was used to obtain odds ratio for poor sleep quality in the PaAF and PeAF groups, relative to the non-AF group.
The PaAF group showed significantly increased odds ratio for poor sleep quality (1.49, 95% confidence interval 1.02–2.17), after adjusting for multiple potential confounders. In contrast, no significant odds ratio for poor sleep quality was observed in the PeAF group (1.09, 95% confidence interval 0.70–1.71). Among the PSQI components, poor subjective sleep quality and sleep disturbances were the main determinants of poor sleep quality in the PaAF group.
Sleep quality was found to be reduced in patients with PaAF, and this may be attributed to poor subjective sleep quality and sleep disturbances.
A novel contact force (CF) sensing catheter with a mesh-shaped irrigation tip (TactiFlexTM SE, Abbott), is expected to provide safe and effective radiofrequency ablation. Our previous study revealed that the TactiFlex catheter needs a higher power for pulmonary vein isolation (PVI) due to the long tip length. This study aimed to examine the feasibility and safety of a 50 W ablation with the TactiFlex for PVI of atrial fibrillation (AF).
A PVI was performed in 100 AF patients using TactiFlex catheters with a 50 W setting, 5-20 g CF, and 15–20 s ablation time. The primary outcomes included a successful PVI, the incidence of first-pass isolations (FPIs), the presence of PV conduction gaps, and the incidence of complications.
FPIs were achieved for 82/100 (82%) right pulmonary veins (RPVs) and 87/100 (87%) left PVs (LPVs). Among the unsuccessful RPV FPIs, residual carina potentials were observed in 16/18 cases (89%), PV gaps in 1/18 cases (5.5%), and both carina and PV gaps in 1/18 cases (5.5%). Similarly, among the unsuccessful LPV FPIs, residual carina potentials were observed in 11/13 cases (84.6%), PV gaps in 1/13 cases (7.7%), and both carina and PV gaps in 1/13 cases (7.7%). Periesophageal nerve injury occurred in 1/100 cases (1%), and no cardiac tamponade occurred. The overall AF-free rate at one-year was 81.7%.
The 50 W ablation with the TactiFlex demonstrated a high rate of an FPI, low incidence of PV gaps, and proved to be a safe and effective approach for the initial PVI of AF.
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