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Editorial to “An extremely wide QRS complex tachycardia induced by anamorelin” "阿那莫林诱发的极宽 QRS 波群心动过速 "的社论
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-06-04 DOI: 10.1002/joa3.13091
Shujiro Inoue MD, PhD
<p>This is an editorial comment to “An extremely wide QRS complex tachycardia induced by anamorelin.” presented by Shimojo et al.<span><sup>1</sup></span> in the current issue of <i>Journal of Arrhythmia</i>.</p><p>Cancer cachexia is a multifocal syndrome in patients with cancer characterized by reduced muscle mass and malnutrition, causing progressive functional disability and reduced quality of life. Conventional nutritional support cannot completely reverse cancer cachexia, and useful pharmacologic therapies for cachexia management are limited. Since 2021, anamorelin has been licensed for production and marketing in Japan as a pharmacologic therapy for cancer cachexia. Anamorelin functions as a ghrelin-like agonist and may stimulate the secretion of growth hormones and appetite by activating the ghrelin receptor, known as growth hormone release promoting factor receptor type 1a (GHS-R1a). Anamorelin is a drug of interest in the field of cancer cachexia, as several randomized controlled trials have demonstrated efficacy in improving total body weight, lean body mass, quality of life, and appetite in patients with refractory cancer compared with placebo.<span><sup>2, 3</sup></span> In all adverse events or serious adverse events, the investigators reported no significant differences in terms of safety.<span><sup>2, 3</sup></span> However, this drug exhibited serious side effects, such as conduction disturbance, hyperglycemia, diabetes worsening, and hepatic dysfunction; thus, patient selection and posttreatment monitoring are very important.</p><p>Anamorelin generally demonstrates an inhibitory effect on the conduction system because of its Na channel-blocking properties. Therefore, electrocardiographic abnormalities, atrioventricular block, tachycardia, and bradycardia may appear after anamorelin administration. Additionally, anamorelin is contraindicated in patients with heart failure, ischemic heart disease, severe conduction disturbance, and moderate-to-severe hepatic dysfunction. It is administered cautiously to those with a history or risk of QT prolongation and those with conduction disturbances. Periodic electrocardiogram (ECG), pulse, and blood pressure measurements are warranted after anamorelin administration. The mechanism behind anamorelin's proarrhythmic effects remains unknown, but weak binding to sodium channels and L-type calcium channels was revealed.<span><sup>4</sup></span> Decreased sodium current may predispose to sudden cardiac death, as studies on arrhythmia suppression have demonstrated that sodium channel blockers increase the incidence of sudden cardiac death. Sodium channel blockade-induced conduction disturbances may cause reentrant arrhythmias because of excitability gap widening.</p><p>In the current issue of the <i>Journal of Arrhytumia</i>, Shimojo et al. reported a case of drug-induced wide QRS tachycardia by anamorelin.<span><sup>1</sup></span> Healthcare provider should understand the risk of conduction distur
作者声明,他们没有任何可能会影响本文所报道工作的已知竞争性经济利益或个人关系。
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引用次数: 0
Editorial to “Impact of frailty in patients with non-valvular atrial fibrillation undergoing catheter ablation” 接受导管消融术的非瓣膜性心房颤动患者体弱的影响 "的社论。
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-30 DOI: 10.1002/joa3.13074
Sayaka Kurokawa MD, Yasuo Okumura MD
<p>Frail patients with non-valvular atrial fibrillation (NVAF) are a growing population in super-aged societies such as Japan, posing treatment and management challenges. Catheter ablation (CA) for atrial fibrillation (AF) is a widely accepted therapy that has recently been shown to improve symptoms, quality of life, and clinical outcomes compared to medical treatment. However, there is a need for discussion regarding whether CA is a treatment option that can be actively proposed for elderly people, especially frail elderly patients with AF. In this issue of the journal, Soejima et al.<span><sup>1</sup></span> presented new insights into the improvement of frailty after CA in patients with NVAF.</p><p>There are skeptical views on the active indication of CA for AF in the elderly owing to the increased complications,<span><sup>2</sup></span> and there have been concerns particularly negative opinions have been shown in the past for frail patients. In the United States, a retrospective study using Medicare fee-for-service billing codes has been conducted on the prognosis of frail patients who received CA for AF.<span><sup>3</sup></span> Among the 5070 patients who received CA, 1955 were judged to be frail based on the Hospital Frailty Risk Score. The long-term mortality rates (up to 630 days) in a group of patients with a mean age of 74.9 years increased as the frailty risk score increased. Restricted cubic spline regression analysis revealed an adjusted hazard ratio for long-term mortality of 1.065 (95% CI: 1.054–1.077). Another retrospective study using the National Health Insurance Service claims database in Korea examined the therapeutic effects of CA and medication treatment in frail and non-frail elderly patients with AF.<span><sup>4</sup></span> Over a median follow-up of 28 months, the risk of all-cause death and composite outcomes including heart failure admission, stroke/systemic embolism, and sudden cardiac arrest were evaluated. While CA reduced the risk of these outcomes in non-frail patients, it did not show a beneficial effect in frail patients. These findings suggest that clinicians should avoid invasive treatments such as CA when managing frail patients.</p><p>Soejima et al.<span><sup>1</sup></span> conducted sub-analysis of the RYOUMA registry,<span><sup>5</sup></span> a multi-center prospective observational study on perioperative and long-term anticoagulation therapy management of CA in patients with AF in Japan, and yielded different results. They evaluated frailty in elderly patients who received CA for NVAF with a simple 5-item frailty index and analyzed the outcomes of CA for each degree of frailty. Of 3027 patients in the RYOUMA registry,<span><sup>5</sup></span> 203 who completed the 5-item frailty index were analyzed. Among them, 26 patients (12.8%) were frail, 109 patients (53.7%) were pre-frail, and 68 patients (33.5%) were robust. In all groups, the rate of freedom from AF recurrence up to 6 months was relatively good,
在日本等超高龄社会中,非瓣膜性心房颤动(NVAF)的体弱患者越来越多,给治疗和管理带来了挑战。心房颤动(房颤)导管消融术(CA)是一种广为接受的治疗方法,最近的研究表明,与药物治疗相比,CA能改善症状、提高生活质量和临床疗效。然而,对于老年人,尤其是年老体弱的房颤患者,是否可以积极建议使用房颤消融术治疗,还需要进行讨论。在本期杂志中,Soejima 等人1 提出了对 NVAF 患者 CA 治疗后虚弱状况改善的新见解。由于并发症的增加,2 人们对 CA 治疗老年房颤的积极适应症持怀疑态度,尤其是过去对虚弱患者的负面意见。3 在 5070 例接受 CA 治疗的患者中,1955 例根据医院虚弱风险评分被判定为虚弱。一组平均年龄为 74.9 岁的患者的长期死亡率(长达 630 天)随着虚弱风险评分的增加而增加。限制性三次样条回归分析显示,调整后的长期死亡率危险比为 1.065(95% CI:1.054-1.077)。4 在中位随访 28 个月期间,评估了全因死亡风险和包括心力衰竭入院、中风/系统性栓塞和心脏骤停在内的综合结果。虽然 CA 降低了非体弱患者发生这些结果的风险,但对体弱患者并没有显示出有益的影响。Soejima 等人1 对 RYOUMA 登记5 进行了子分析,这是一项关于日本房颤患者 CA 围手术期和长期抗凝治疗管理的多中心前瞻性观察研究,得出了不同的结果。他们采用简单的 5 项虚弱指数评估了接受 CA 治疗的 NVAF 老年患者的虚弱程度,并分析了不同虚弱程度的 CA 治疗结果。在 RYOUMA 登记的 3027 名患者5 中,有 203 人完成了 5 项虚弱指数的分析。其中,26 名患者(12.8%)体弱,109 名患者(53.7%)前期体弱,68 名患者(33.5%)强健。在所有组别中,6 个月内无房颤复发的比率相对较好,虚弱组、虚弱前期组和强壮组的比率分别为 88.5%、91.7% 和 86.8%。该研究的优势在于它证明了在接受 CA 治疗后,虚弱或虚弱前期患者的虚弱程度有所改善。在虚弱组中,21 名患者中分别有 2 人(9.5%)、10 人(47.6%)和 9 人(42.9%)在 CA 术后 6 个月时体格健壮、虚弱前期和虚弱。在虚弱前期组中,86 名患者中分别有 26 人(30.2%)、52 人(60.5%)和 8 人(9.3%)在同一随访时间点表现为体格健壮、虚弱前期和虚弱。CA 治疗后改善虚弱状况的主要因素是体重减轻、行走速度和五项虚弱指数中的疲劳程度得到改善。这一结果表明,CA 甚至可能对体弱的老年 NVAF 患者产生有益的治疗影响,而这一观点之前已被推翻、4 此外,体弱组大出血、心血管事件和心脏事件的发生率分别为 0.3%/人-年、0.5%/人-年和 0.5%/人-年,高于其他两组,三组均未观察到心血管疾病死亡、中风/全身血栓栓塞事件或脑出血病例。不过,需要注意的是,本研究仅对在 RYOUMA 登记处登记的患者中回答了 5 项虚弱指数的少数患者(n = 203)进行了分析。此外,CA 前被判定为虚弱的患者人数很少(26 人),病例数量有限。此外,虚弱包括多种因素。根据所使用的指标,提取的虚弱患者群体可能存在差异,因此在解释结果时需要谨慎。本研究中虚弱组患者的平均年龄和体重均为 75 岁,平均体重为 56 千克,这表明以 5 项虚弱指数判断的虚弱可能提取了一个整体状况相对较好的群体,而不是临床实践中存在问题的超高龄、低体重群体。
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引用次数: 0
Impact of COVID-19 infection among patients hospitalized for conventional pacemaker implantation: Analysis of the Nationwide Inpatient Sample (NIS) 2020 COVID-19感染对传统起搏器植入住院患者的影响:2020年全国住院患者样本(NIS)分析。
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-30 DOI: 10.1002/joa3.13089
Phuuwadith Wattanachayakul MD, Panat Yanpiset MD, Thanathip Suenghataiphorn MD, Thitiphan Srikulmontri MD, Pojsakorn Danpanichkul MD, Pongprueth Rujirachun MD, Natchaya Polpichai MD, Sakditad Saowapa MD, Bruce A. Casipit MD, Kanokphong Suparan MD, Aman Amanullah MD

Introduction

The cardiac pacemaker is indicated for treating various types of bradyarrhythmia, providing lifelong cardiovascular benefits. Recent data showed that COVID-19 has impacted procedure numbers and led to adverse long-term outcomes in patients with cardiac pacemakers. However, the impact of COVID-19 infection on the in-hospital outcome of patients undergoing conventional pacemaker implantation remains unclear.

Method

Patients aged above 18 years who were hospitalized for conventional pacemaker implantation in the Nationwide In-patient Sample (NIS) 2020 were identified using relevant ICD-10 CM and PCS codes. Multivariable logistic and linear regression models were used to analyze pre-specified outcomes, with the primary outcome being in-patient mortality and secondary outcomes including system-based and procedure-related complications.

Results

Of 108 020 patients hospitalized for conventional pacemaker implantation, 0.71% (765 out of 108 020) had a concurrent diagnosis of COVID-19 infection. Individuals with COVID-19 infection exhibited a lower mean age (73.7 years vs. 75.9 years, p = .027) and a lower female proportion (39.87% vs. 47.60%, p = .062) than those without COVID-19. In the multivariable logistic and linear regression models, adjusted for patient and hospital factors, COVID-19 infection was associated with higher in-hospital mortality (aOR 4.67; 95% CI 2.02 to 10.27, p < .001), extended length of stay (5.23 days vs. 1.04 days, p < .001), and linked with various in-hospital complications, including sepsis, acute respiratory failure, post-procedural pneumothorax, and venous thromboembolism.

Conclusion

Our study suggests that COVID-19 infection is attributed to higher in-hospital mortality, extended hospital stays, and increased adverse in-hospital outcomes in patients undergoing conventional pacemaker implantation.

导言:心脏起搏器适用于治疗各种类型的缓慢性心律失常,可为心血管带来终身益处。最近的数据显示,COVID-19 影响了心脏起搏器患者的手术数量,并导致不良的长期疗效。然而,COVID-19 感染对接受传统心脏起搏器植入术的患者院内预后的影响仍不清楚:方法:使用相关的 ICD-10 CM 和 PCS 编码识别 2020 年全国住院患者样本(NIS)中因常规起搏器植入而住院的 18 岁以上患者。采用多变量逻辑和线性回归模型分析预先指定的结果,主要结果为住院死亡率,次要结果包括系统并发症和手术相关并发症:在 108 020 名住院接受传统起搏器植入手术的患者中,0.71%(108 020 人中有 765 人)同时被诊断感染了 COVID-19。与未感染 COVID-19 的患者相比,感染 COVID-19 的患者平均年龄较低(73.7 岁 vs. 75.9 岁,p = .027),女性比例较低(39.87% vs. 47.60%,p = .062)。在调整了患者和医院因素的多变量逻辑和线性回归模型中,COVID-19 感染与较高的院内死亡率相关(aOR 4.67; 95% CI 2.02 to 10.27, p p 结论:我们的研究表明,COVID-19 感染是导致常规起搏器植入术患者院内死亡率升高、住院时间延长和院内不良预后增加的原因。
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引用次数: 0
Clinical differences between drug-induced type 1 Brugada pattern and syndrome 药物诱发的 1 型 Brugada 模式与综合征之间的临床差异。
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-29 DOI: 10.1002/joa3.13053
Avi Sabbag MD, Gisella Amoroso MD, Orr Tomer MD, Giulio Conte MD, PhD, Roy Beinart MD, Eyal Nof MD, Tardu Özkartal MD, Pierre Ollitrault MD, Mikael Laredo MD, Oholi Tovia-Brodie MD, Estelle Gandjbakhch MD, PhD, Michele de Benedictis MD, Rachel M. A. ter Bekke MD, PhD, Anat Milman MD

Background

Diagnosis of Brugada syndrome (BrS) may be established by exposing a Type 1 Brugada pattern using a sodium channel blocker. Data on the outcomes of different patient populations with drug-induced Type 1 Brugada pattern are limited. The present study reports on the characteristics and outcome of subjects with ajmaline induced Type 1 Brugada pattern.

Methods

A multicenter retrospective study including all consecutive cases of ajmaline-induced Type 1 Brugada pattern from seven centers.

Results

A total of 260 patients (69.9% males, mean age 43.4 ± 13.5) were included. Additional characteristics included history of syncope (n = 56, 21.5%), family history of BrS (n = 58, 22.3%) or sudden cardiac death (n = 47, 18.1%) and ventricular fibrillation (n = 3, 1.2%). Patients were divided into those meeting current diagnostic criteria for drug-induced BrS (DIBrS) and compared to the drug-induced Brugada pattern (DIBrECG). Females were significantly overrepresented in the DIBrS group (n = 50, 40% vs. n = 29, 21.5%, p = .001). A significantly higher prevalence of type 2/3 Brugada ECG at baseline was found in the DIBrECG group (n = 108, 80.8% vs. n = 75, 60% in the DIBrS, p = .026). During a median follow up of three (IQR 1.50–5.32) years, a single event of significant arrhythmia occurred in the DIBrS group.

Conclusion

Less than half of subjects with ajmaline-induced Brugada pattern met current criteria for BrS. These individuals had very low rate of adverse outcomes during a follow up of 3 years, irrespective of the indication for the test or eligibility for the BrS diagnosis.

背景:使用钠通道阻滞剂暴露出 1 型 Brugada 模式,即可确诊为 Brugada 综合征(BrS)。有关药物诱发 1 型 Brugada 模式的不同患者群体的预后数据十分有限。本研究报告了阿扎马林诱导的 1 型 Brugada 模式受试者的特征和预后:多中心回顾性研究,包括来自七个中心的所有阿扎马林诱导的 1 型 Brugada 模式连续病例:结果:共纳入 260 例患者(69.9% 为男性,平均年龄为 43.4±13.5 岁)。其他特征包括晕厥史(56人,21.5%)、BRS家族史(58人,22.3%)或心脏性猝死(47人,18.1%)和心室颤动(3人,1.2%)。患者被分为符合当前药物诱发BRS(DIBrS)诊断标准的患者,并与药物诱发Brugada模式(DIBrECG)进行比较。女性在 DIBrS 组中的比例明显偏高(n = 50,40% vs. n = 29,21.5%,p = .001)。DIBrECG 组基线 2/3 型 Brugada ECG 患病率明显更高(n = 108,80.8%;DIBrS 组 n = 75,60%,p = .026)。在中位随访三年(IQR 1.50-5.32)期间,DIBrS组发生了一起明显的心律失常事件:结论:不到一半的阿扎马林诱发 Brugada 模式受试者符合当前的 BrS 标准。结论:只有不到一半的阿司马林诱导的 Brugada 模式患者符合当前的 BrS 诊断标准,这些患者在 3 年的随访期间不良后果发生率非常低,与测试指征或 BrS 诊断资格无关。
{"title":"Clinical differences between drug-induced type 1 Brugada pattern and syndrome","authors":"Avi Sabbag MD,&nbsp;Gisella Amoroso MD,&nbsp;Orr Tomer MD,&nbsp;Giulio Conte MD, PhD,&nbsp;Roy Beinart MD,&nbsp;Eyal Nof MD,&nbsp;Tardu Özkartal MD,&nbsp;Pierre Ollitrault MD,&nbsp;Mikael Laredo MD,&nbsp;Oholi Tovia-Brodie MD,&nbsp;Estelle Gandjbakhch MD, PhD,&nbsp;Michele de Benedictis MD,&nbsp;Rachel M. A. ter Bekke MD, PhD,&nbsp;Anat Milman MD","doi":"10.1002/joa3.13053","DOIUrl":"10.1002/joa3.13053","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Diagnosis of Brugada syndrome (BrS) may be established by exposing a Type 1 Brugada pattern using a sodium channel blocker. Data on the outcomes of different patient populations with drug-induced Type 1 Brugada pattern are limited. The present study reports on the characteristics and outcome of subjects with ajmaline induced Type 1 Brugada pattern.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A multicenter retrospective study including all consecutive cases of ajmaline-induced Type 1 Brugada pattern from seven centers.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 260 patients (69.9% males, mean age 43.4 ± 13.5) were included. Additional characteristics included history of syncope (<i>n</i> = 56, 21.5%), family history of BrS (<i>n</i> = 58, 22.3%) or sudden cardiac death (<i>n</i> = 47, 18.1%) and ventricular fibrillation (<i>n</i> = 3, 1.2%). Patients were divided into those meeting current diagnostic criteria for drug-induced BrS (DIBrS) and compared to the drug-induced Brugada pattern (DIBrECG). Females were significantly overrepresented in the DIBrS group (<i>n</i> = 50, 40% vs. <i>n</i> = 29, 21.5%, <i>p</i> = .001). A significantly higher prevalence of type 2/3 Brugada ECG at baseline was found in the DIBrECG group (<i>n</i> = 108, 80.8% vs. <i>n</i> = 75, 60% in the DIBrS, <i>p</i> = .026). During a median follow up of three (IQR 1.50–5.32) years, a single event of significant arrhythmia occurred in the DIBrS group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Less than half of subjects with ajmaline-induced Brugada pattern met current criteria for BrS. These individuals had very low rate of adverse outcomes during a follow up of 3 years, irrespective of the indication for the test or eligibility for the BrS diagnosis.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 4","pages":"982-990"},"PeriodicalIF":2.2,"publicationDate":"2024-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11317691/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975742","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Editorial to “Revitalizing brain perfusion: Unveiling advancements through rhythm control strategies in atrial fibrillation—A systematic review” 振兴脑灌注:通过心房颤动的节律控制策略揭示进展--系统综述 "的编辑。
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-28 DOI: 10.1002/joa3.13085
Yoshimori An MD, PhD
<p>This is an editorial comment on the article presented by Rasti et al.<span><sup>1</sup></span> as a systematic review focusing on published data regarding the impact of rhythm control therapy for atrial fibrillation (AF) on brain perfusion.</p><p>AF is one of the most common cardiac arrhythmias that increases the risk of stroke and death. As the prevalence of AF increases with age, it has been exhibiting an upward trend globally, with a worldwide prevalence ranging between 3 and 6 million individuals—which is projected to reach 6–16 million by 2050.<span><sup>2</sup></span> Dementia is a condition that leads to a loss of cognitive function, affecting daily life activities. Alzheimer's disease and vascular dementia represent the two main subvarieties of dementia. Studies have shown that AF is independently associated with cognitive decline. The proposed pathophysiological mechanisms include silent ischemic or hemorrhagic cerebral microinfarction, or impaired cerebral blood flow. Recently, it has been shown that AF is associated with a risk of dementia, independent of clinical stroke.<span><sup>3</sup></span> Brain perfusion may be reduced in patients with AF, which may contribute to cognitive impairment. Theoretically, rhythm control therapy including catheter ablation (CA) may positively affect brain perfusion in patients with AF, because the restoration of the sinus rhythm may increase cardiac output. However, the evidence supporting this notion is not yet well established, and research on this topic is ongoing.</p><p>In a recent issue of <i>Journal of Arrhythmia</i>, Rasti et al. presented a systematic review on the topic that included articles from Scopus, PubMed, Cochrane Reviews, ProQuest, and EBSCOhost databases, searched from their respective inceptions until April 30, 2023.<span><sup>1</sup></span> A total of 10 studies (436 patients with AF) that met their criteria were reviewed. They found that restoring the sinus rhythm enhanced brain perfusion in 8 of the 10 studies. The authors therefore concluded that successful control of the AF rhythm enhances brain perfusion and mitigates cognitive decline. They reviewed published data on the subject and provided valuable information for physicians. Their conclusions are promising and helpful but must be interpreted cautiously. A wide variety of methods exist for both achieving rhythm control and measuring the outcomes. One of the studies reviewed used a pharmacological approach (amiodarone), six used electrical cardioversion, and three used CA (pulmonary vein isolation by radiofrequency ablation or cryoballoon and atrioventricular node ablation after pacemaker implantation). The maintenance rate of sinus rhythm differs depending on the method used to control it, thus exerting a range of effects on brain perfusion outcomes. Regarding the outcome measures, the methods used to evaluate brain perfusion can be categorized as direct and indirect. In seven of the 10 studies included in the review ar
房颤是最常见的心律失常之一,会增加中风和死亡的风险。心房颤动是最常见的心律失常之一,会增加中风和死亡的风险。随着年龄的增长,心房颤动的患病率呈上升趋势,全球患病率在 300 万到 600 万之间,预计到 2050 年将达到 600 万到 1600 万。阿尔茨海默病和血管性痴呆是痴呆症的两大分支。研究表明,房颤与认知功能衰退有独立关联。提出的病理生理机制包括无声缺血性或出血性脑微梗塞,或脑血流受损。最近的研究表明,房颤与痴呆风险相关,与临床中风无关。3 房颤患者的脑血流灌注可能减少,从而导致认知功能障碍。从理论上讲,包括导管消融(CA)在内的节律控制治疗可能会对房颤患者的脑灌注产生积极影响,因为恢复窦性心律可能会增加心输出量。在最近一期的《心律失常杂志》(Journal of Arrhythmia)上,Rasti 等人发表了一篇关于该主题的系统性综述,其中包括 Scopus、PubMed、Cochrane Reviews、ProQuest 和 EBSCOhost 数据库中的文章,检索时间从各自数据库建立之初到 2023 年 4 月 30 日为止1。他们发现,在这 10 项研究中,有 8 项研究发现恢复窦性心律能增强脑灌注。因此,作者得出结论,成功控制房颤节律可增强脑灌注,缓解认知能力下降。他们回顾了已发表的相关数据,为医生提供了有价值的信息。他们的结论很有希望,也很有帮助,但必须谨慎解读。实现心律控制和测量结果的方法多种多样。其中一项研究采用了药物治疗方法(胺碘酮),六项研究采用了心脏电复律方法,三项研究采用了 CA 方法(通过射频消融或冷冻球囊进行肺静脉隔离,起搏器植入后进行房室结消融)。控制窦性心律的方法不同,窦性心律的维持率也不同,因此对脑灌注结果的影响也不同。关于结果测量,评估脑灌注的方法可分为直接和间接两种。在综述文章收录的 10 项研究中,有 7 项使用直接方法测量脑血流量(CBF),其量化为单位时间内通过脑组织的血液量(通常以毫升/100 克脑组织/分钟表示)。其他三项研究使用的是间接方法,包括脑组织氧饱和度(SctO2;两项研究)和组织血红蛋白指数(THI;一项研究)。在解释本综述中每项研究的结果时,应认识到结果测量的差异。在他们的综述文章中调查的 10 项研究中,有 4 项在房颤节律控制前后对认知功能进行了评估。其中两项研究报告称心律控制对认知功能有积极影响,而另外两项研究则称有消极影响。这两项有积极效果的研究采用的方法是通过射频消融或冷冻球囊进行肺静脉隔离,以及在植入起搏器后进行房室结消融。另外两项结果为阴性的研究则使用了电复律。值得注意的是,这四项研究评估认知功能的方法和时间也不尽相同。关于 CA 对认知功能的影响,应考虑到围术期脑栓塞和消融过程中麻醉的影响。认知功能测试的结果因患者接受 CA 评估的时间而异。同时,亚急性期(如 CA 术后 3 个月内)的亚临床脑栓塞可能会加重认知功能障碍。此外,最近有报道称,节律控制对痴呆的影响因疾病亚型而异。最近的一项荟萃分析表明,与非 CA 组相比,接受 CA 的患者罹患阿尔茨海默病的风险较低(危险比为 0.78 [95% 保密区间:0.66-0.92];p &lt; .001)。
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引用次数: 0
Editorial to “Uncoupling endocardial bundles coupled by an epicardial bundle in the left atrium and pulmonary veins” 左心房和肺静脉中由心外膜束耦合的心内膜束解除耦合 "的社论。
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-27 DOI: 10.1002/joa3.13066
Masao Takemoto MD, PhD, Yoshibumi Antoku MD, PhD, Takuya Tsuchihashi MD, PhD
<p>The recent decades have seen rapid developments in the treatment of atrial fibrillation (AF) patients, especially for the use of three-dimensional (3D) electro-anatomical mapping systems. To prevent initiating and maintaining AF, a complete pulmonary vein (PV) isolation (PVI) should be a target of the AF treatment. A recent report has revealed that approximately 10% of patients with AF exhibit epicardial connections (ECs) within the complete PVI lines, potentially contributing to AF recurrence.<span><sup>1</sup></span> Thus, with ablation techniques, various isolation lines and focal targets using electric and anatomic approaches are deployed.</p><p>The atrial architecture is highly complex. It not only exhibits 3D arrangements of circumferentially and longitudinally orientated muscle bundles but also sudden transitions in the fiber architecture from the endocardial to epicardial layers.<span><sup>2</sup></span> Such transitions may promote the unique pathological conduction properties associated with the development of atrial arrhythmias.<span><sup>2</sup></span> Epicardial myofibers/bundles,<span><sup>3</sup></span> such as the septopulmonary bundle, Marshal bundle, Bachmann bundle, and intercaval bundles, play a role in connecting the PV(s) and atrium on the epicardial side. These myofibers/bundles are anatomically inherited<span><sup>3</sup></span> and predominantly situated near the right- and left-sided PV carinas.<span><sup>1</sup></span></p><p>A recent report has demonstrated that the left atrial (LA) wall thickness (LAWT) plays a crucial role in the recurrence of AF in patients undergoing ablation therapy.<span><sup>4</sup></span> The LAWT varies from 1.5 to 6.5 mm<sup>3</sup>. Consequently, the definition of ECs may encompass true ECs preexisting prior to the PVI, alongside false ECs formed after the PVI as residual epicardial-sided conduction related to a nontransmural lesion creation because of a thicker LAWT. While some ECs may result from the former between the right- or left-sided PV carina and atrium, others could arise from the latter. Notably, the septopulmonary bundle's thickness makes it prone to a nontransmural lesion creation,<span><sup>3</sup></span> potentially leading to ECs between the left PVs and LA.</p><p>A previous report demonstrated that the double-Lasso technique using conventional circular mapping catheters did miss the nonisolation of the PV carina after a successful PVI, which was an independent predictor of AF recurrence after the PVI.<span><sup>5</sup></span> More recently, it was revealed that ECs were mainly located on the carina, and employing a conventional circular mapping catheter missed 25% of ECs in comparison to a multi-electrode mapping catheter (MEMC).<span><sup>1</sup></span> This MEMC with two-dimensional surfaces can take high-density cardiac mapping in a whole new direction and could potentially enhance the detection of ECs, even considering their small size, as opposed to circular mapping o
近几十年来,心房颤动(房颤)患者的治疗取得了飞速发展,尤其是三维(3D)电子解剖图系统的使用。为防止房颤的发生和维持,完全的肺静脉(PV)隔离(PVI)应成为房颤治疗的目标。最近的一份报告显示,约有 10% 的房颤患者在完整的 PVI 线路内表现出心外膜连接(EC),这有可能导致房颤复发1。心房结构非常复杂,不仅表现为周向和纵向肌束的三维排列,还表现为纤维结构从心内膜层到心外膜层的突然转变。2 心外膜肌纤维/肌束3 如隔肺束、Marshal 束、Bachmann 束和腔间束起着连接心外膜侧 PV 和心房的作用。这些肌纤维/束在解剖学上具有遗传性3 ,主要位于右侧和左侧上腔静脉附近。1A 最近的报告显示,左心房壁厚度(LAWT)对接受消融治疗的患者房颤复发起着至关重要的作用4。因此,心电图的定义可能包括 PVI 之前就存在的真性心电图,以及 PVI 之后形成的假性心电图,即由于 LAWT 较厚而产生的与非横隔病变相关的残余心外膜侧传导。前者可能导致右侧或左侧 PV 心尖和心房之间出现一些 EC,而后者则可能导致其他 EC。值得注意的是,隔肺束的厚度使其容易产生非跨壁病变,3 可能导致左侧 PV 和 LA 之间的 EC。先前的一份报告显示,使用传统圆形绘图导管的双拉索技术在成功进行 PVI 后确实会错过 PV 心尖的非隔离,而这是 PVI 后房颤复发的独立预测因素。1 这种具有二维表面的 MEMC 可以将高密度心脏测图带入一个全新的方向,与圆形测图或消融导管的点评估相比,即使考虑到心电图的小尺寸,也有可能提高心电图的检测率。1 因此,正如本手稿所述,在房颤消融过程中使用 MEMC 进行 LA 和 PV 映射和起搏似乎是一种有效且可行的方法,可帮助 EC 患者成功实现 PVI。Kobayashi 等人的这篇手稿描述了一个有趣的病例,即在未完成 LA 室顶跨膜传导阻滞的情况下,成功消除了左侧 PV 后心尖和 LA 室顶之间的心外膜束(=隔肺束)。在第二张图中,他们可以漂亮地同时显示出心外膜在心尖上的延迟传导和心内膜在左侧PV心尖后方的断裂,这表明左侧PV心尖后方和LA心尖之间的心外膜束(=隔肺束)耦合的心内膜束解除了耦合(补充影片2)。2 此外,在他们绘制的第二张图中,左侧后部 PV 心尖处的心内膜突起部位显示了左侧后部 PV 心尖处的分段式高频电位(图 3A-C 中的白色箭头)。他们的结论是,这些特征性的分馏和高频电位可能是沿后壁隔离的心内膜突破点的标记。需要进一步研究来确定接受消融治疗的EC患者的房颤处理方法。
{"title":"Editorial to “Uncoupling endocardial bundles coupled by an epicardial bundle in the left atrium and pulmonary veins”","authors":"Masao Takemoto MD, PhD,&nbsp;Yoshibumi Antoku MD, PhD,&nbsp;Takuya Tsuchihashi MD, PhD","doi":"10.1002/joa3.13066","DOIUrl":"10.1002/joa3.13066","url":null,"abstract":"&lt;p&gt;The recent decades have seen rapid developments in the treatment of atrial fibrillation (AF) patients, especially for the use of three-dimensional (3D) electro-anatomical mapping systems. To prevent initiating and maintaining AF, a complete pulmonary vein (PV) isolation (PVI) should be a target of the AF treatment. A recent report has revealed that approximately 10% of patients with AF exhibit epicardial connections (ECs) within the complete PVI lines, potentially contributing to AF recurrence.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Thus, with ablation techniques, various isolation lines and focal targets using electric and anatomic approaches are deployed.&lt;/p&gt;&lt;p&gt;The atrial architecture is highly complex. It not only exhibits 3D arrangements of circumferentially and longitudinally orientated muscle bundles but also sudden transitions in the fiber architecture from the endocardial to epicardial layers.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Such transitions may promote the unique pathological conduction properties associated with the development of atrial arrhythmias.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Epicardial myofibers/bundles,&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; such as the septopulmonary bundle, Marshal bundle, Bachmann bundle, and intercaval bundles, play a role in connecting the PV(s) and atrium on the epicardial side. These myofibers/bundles are anatomically inherited&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; and predominantly situated near the right- and left-sided PV carinas.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;A recent report has demonstrated that the left atrial (LA) wall thickness (LAWT) plays a crucial role in the recurrence of AF in patients undergoing ablation therapy.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; The LAWT varies from 1.5 to 6.5 mm&lt;sup&gt;3&lt;/sup&gt;. Consequently, the definition of ECs may encompass true ECs preexisting prior to the PVI, alongside false ECs formed after the PVI as residual epicardial-sided conduction related to a nontransmural lesion creation because of a thicker LAWT. While some ECs may result from the former between the right- or left-sided PV carina and atrium, others could arise from the latter. Notably, the septopulmonary bundle's thickness makes it prone to a nontransmural lesion creation,&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; potentially leading to ECs between the left PVs and LA.&lt;/p&gt;&lt;p&gt;A previous report demonstrated that the double-Lasso technique using conventional circular mapping catheters did miss the nonisolation of the PV carina after a successful PVI, which was an independent predictor of AF recurrence after the PVI.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; More recently, it was revealed that ECs were mainly located on the carina, and employing a conventional circular mapping catheter missed 25% of ECs in comparison to a multi-electrode mapping catheter (MEMC).&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; This MEMC with two-dimensional surfaces can take high-density cardiac mapping in a whole new direction and could potentially enhance the detection of ECs, even considering their small size, as opposed to circular mapping o","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 4","pages":"788-789"},"PeriodicalIF":2.2,"publicationDate":"2024-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11317674/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975747","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Editorial to “Associations of the fibrosis-4 index with left atrial low-voltage areas and arrhythmia recurrence after catheter ablation: Cardio-hepatic interaction in patients with atrial fibrillation”: Fibrosis is a cause or an outcome! 纤维化-4 指数与左心房低电压区和导管消融术后心律失常复发的关系 "的社论:心房颤动患者的心肝相互作用 "的社论:纤维化是原因还是结果?
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-26 DOI: 10.1002/joa3.13084
Ugur Canpolat MD
<p>In the current issue of the <i>Journal of Arrhythmia</i>, Yamada et al.<span><sup>1</sup></span> retrospectively assessed the association of left atrial (LA) low-voltage area (LVA) on electroanatomic mapping (bipolar voltage amplitude of <0.5 mV) with fibrosis index-4 (FIB4), an indicator of liver fibrosis, during radiofrequency (RF)-based first pulmonary vein isolation (PVI) at step 1 (<i>n</i> = 214) and tested the role of FIB4 ≥1.3 (cut-off value for liver fibrosis) on atrial fibrillation (AF) recurrence after cryoballoon (CB)-based first PVI (<i>n</i> = 129). The FIB-4 index was strongly correlated with quantitative LA LVA (<i>r</i> = .642, <i>p</i> < .001). The FIB-4 index ≥1.3 was also a significant predictor of the presence of LA LVA (OR: 2.508, <i>p</i> = .039) after adjusting for age, female gender, diabetes, non-paroxysmal AF, and the LA diameter. Type IV collagen 7S, a marker of liver fibrosis, was also higher in the high FIB4 index group than in the low FIB4 index group. Post-blanking period AF recurrence rate was 13.1% in the cryoablation group (20.2% in the high FIB4 group vs. 5.0% in the low FIB4 group, <i>p</i> = .017). The FIB-4 index ≥1.3, an indirect indicator of LA LVA, is also an important predictor of AF recurrence in the cryoablation group (OR: 3.796, <i>p</i> = .037) after adjusting for the female gender, and non-paroxysmal AF.</p><p>AF has a complex multifactorial pathophysiology. Several risk factors interplay a role in electrical, structural, and contractile atrial remodeling and subsequent occurrence and maintenance of AF. The latest consensus document recommended early catheter ablation for AF to prevent both the recurrence and progression of the disease and AF-related hospitalizations. PVI is the cornerstone of all catheter ablation procedures in paroxysmal and persistent AF. The PVI can be achieved using various thermal and non-thermal energy tools including RF, CB, laser balloon, hot balloon, and pulsed-field ablation. Despite successful PVI, AF recurrence is still a significant problem. The atrial LVA (atrial substrate) plays a significant role in the recurrence of AF. However, there were conflicting data about the impact of atrial LVA ablation (substrate modification) in addition to PVI on AF recurrence after catheter ablation. Furthermore, there is a bidirectional relationship between atrial LVA and AF. Atrial LVA may be the cause and/or outcome of AF. A recent expert consensus statement on catheter and surgical ablation of AF recommended that ablation of atrial LVAs may only be reasonable during persistent AF ablation.<span><sup>2</sup></span> Thus, non-invasive pre-procedural predictors of atrial LVA and/or AF recurrence are important in selecting the appropriate tool (CB or RF or others) and approach (PVI alone or PVI plus) for AF catheter ablation.</p><p>Metabolic dysfunction is a common pathophysiological pathway in various disease processes, particularly in heart-liver interaction. Fatty liver dis
因此,他们建议,在没有明显肝病的情况下出现肝脏僵硬或纤维化的房颤患者应进行亚临床静脉充血评估。基于生物标记物的肝纤维化评估算法的主要诟病在于缺乏准确的调整分析。Yamada等人1的研究中计算出的FIB-4指数在预测心房低密度变异和房颤复发方面也有局限性,因为该算法本身包括了年龄等房颤和心房重塑的重要预测因素。虽然研究人群有脂肪肝的危险因素,但欧洲肝病研究协会的无创检测指南建议用瞬态弹性成像筛查有代谢功能障碍和中高 FIB-4 指数的晚期肝病患者。在缺乏此类无创成像检测结果的情况下,仅凭FIB-4指数无法确定房颤患者肝脏和心房纤维化的潜在机制。在 Yamada 等人的研究1 中,FIB-4 指数较高的患者血清 BNP 水平较高,这对明确其潜在机制也很重要。在 Yamada 等人的研究1 中,作为肝纤维化和心房 LVA 指标的 FIB-4 指数较高可能是由静脉充血和随后的充血性肝病引起的,而非纤维化机制。因此,通过影像学检查(脂肪变性和/或僵化)对肝脏进行评估,以及通过详细的超声心动图检查对心室舒张功能进行评估,可能会突出显示较高的 FIB-4 指数与心房 LVA 和房颤复发之间的关联。要得出结论,对肝脏和心脏进行全面成像至关重要。如果不突出 FIB-4 指数较高的根本原因,我们就无法对患者进行适当的管理。我们应建议在没有明显肝病和房颤的情况下,对肝纤维化患者进行亚临床舒张功能障碍评估和治疗。此外,对于与脂肪肝相关的肝纤维化和房颤患者,应调整生活方式并控制代谢综合征的成分。在这两种情况下,肝纤维化和心房纤维化的存在似乎是心房低密度变性和房颤复发的标志(结果)而非原因。
{"title":"Editorial to “Associations of the fibrosis-4 index with left atrial low-voltage areas and arrhythmia recurrence after catheter ablation: Cardio-hepatic interaction in patients with atrial fibrillation”: Fibrosis is a cause or an outcome!","authors":"Ugur Canpolat MD","doi":"10.1002/joa3.13084","DOIUrl":"10.1002/joa3.13084","url":null,"abstract":"&lt;p&gt;In the current issue of the &lt;i&gt;Journal of Arrhythmia&lt;/i&gt;, Yamada et al.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; retrospectively assessed the association of left atrial (LA) low-voltage area (LVA) on electroanatomic mapping (bipolar voltage amplitude of &lt;0.5 mV) with fibrosis index-4 (FIB4), an indicator of liver fibrosis, during radiofrequency (RF)-based first pulmonary vein isolation (PVI) at step 1 (&lt;i&gt;n&lt;/i&gt; = 214) and tested the role of FIB4 ≥1.3 (cut-off value for liver fibrosis) on atrial fibrillation (AF) recurrence after cryoballoon (CB)-based first PVI (&lt;i&gt;n&lt;/i&gt; = 129). The FIB-4 index was strongly correlated with quantitative LA LVA (&lt;i&gt;r&lt;/i&gt; = .642, &lt;i&gt;p&lt;/i&gt; &lt; .001). The FIB-4 index ≥1.3 was also a significant predictor of the presence of LA LVA (OR: 2.508, &lt;i&gt;p&lt;/i&gt; = .039) after adjusting for age, female gender, diabetes, non-paroxysmal AF, and the LA diameter. Type IV collagen 7S, a marker of liver fibrosis, was also higher in the high FIB4 index group than in the low FIB4 index group. Post-blanking period AF recurrence rate was 13.1% in the cryoablation group (20.2% in the high FIB4 group vs. 5.0% in the low FIB4 group, &lt;i&gt;p&lt;/i&gt; = .017). The FIB-4 index ≥1.3, an indirect indicator of LA LVA, is also an important predictor of AF recurrence in the cryoablation group (OR: 3.796, &lt;i&gt;p&lt;/i&gt; = .037) after adjusting for the female gender, and non-paroxysmal AF.&lt;/p&gt;&lt;p&gt;AF has a complex multifactorial pathophysiology. Several risk factors interplay a role in electrical, structural, and contractile atrial remodeling and subsequent occurrence and maintenance of AF. The latest consensus document recommended early catheter ablation for AF to prevent both the recurrence and progression of the disease and AF-related hospitalizations. PVI is the cornerstone of all catheter ablation procedures in paroxysmal and persistent AF. The PVI can be achieved using various thermal and non-thermal energy tools including RF, CB, laser balloon, hot balloon, and pulsed-field ablation. Despite successful PVI, AF recurrence is still a significant problem. The atrial LVA (atrial substrate) plays a significant role in the recurrence of AF. However, there were conflicting data about the impact of atrial LVA ablation (substrate modification) in addition to PVI on AF recurrence after catheter ablation. Furthermore, there is a bidirectional relationship between atrial LVA and AF. Atrial LVA may be the cause and/or outcome of AF. A recent expert consensus statement on catheter and surgical ablation of AF recommended that ablation of atrial LVAs may only be reasonable during persistent AF ablation.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Thus, non-invasive pre-procedural predictors of atrial LVA and/or AF recurrence are important in selecting the appropriate tool (CB or RF or others) and approach (PVI alone or PVI plus) for AF catheter ablation.&lt;/p&gt;&lt;p&gt;Metabolic dysfunction is a common pathophysiological pathway in various disease processes, particularly in heart-liver interaction. Fatty liver dis","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 4","pages":"796-797"},"PeriodicalIF":2.2,"publicationDate":"2024-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11317706/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141977630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Editorial to “Ischemic stroke associated with high grade pedunculated device related thrombosis following left atrial appendage closure” 为 "左心房阑尾闭合术后高位梗阻性器械相关血栓引起的缺血性中风 "撰写的社论。
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-25 DOI: 10.1002/joa3.13086
Wei-Ta Chen MD, PhD.
<p>In this issue, Chatani Ryuki presented a case entitled “Ischemic stroke associated with high grade pedunculated device related thrombosis following left atrial appendage closure.”<span><sup>1</sup></span> The authors presented a case with atrial fibrillation and stroke despite on oral anticoagulation therapy (OAC). They performed left atrial appendage closure (LAAC) with Watchman (Boston Scientific) and discontinued OAC. However, device related thrombus (DRT) was noted at 314 days after LAAC. DRT was successfully resolved by OAC and OAC was kept as long-term medication. In the presented case, the post-LAAC drug regimen and the happening of DRT deserve more discussion.</p><p>LAAC was considered a reasonable alternative option to OAC in atrial fibrillation. In 2015, the first LAAC device (Watchman, Boston Scientific) was approved by Food and Drug Administration of United states. After that, patients with atrial fibrillation and CHA2DS2-VAS score higher than<span><sup>2</sup></span> have an option to take LAAC if they have contraindications for OAC. In the consensus statements about LAAC from major societies (Heart Rhythm Society, Asia-Pacific Heart Rhythm Society and European Heart Rhythm Association), all listed LAAC in patients contraindicated to OAC as Class I indication. Based on the current available evidences, there is almost no doubt that LAAC should be taken if one is unable to take long-term OAC.</p><p>However, there are some uncertainty in the other indications of LAAC. Can LAAC replace OAC even in patients without contraindication to OAC? This is one of most often discussed questions. The role of OAC for stroke prevention in atrial fibrillation has long been established based on many large-scale clinical trials. On the other hand, trials comparing LAAC and OAC were much less. PRAGUE-17 trial is the current largest prospective trial comparing LAAC and OAC.<span><sup>2</sup></span> It enrolled 402 patients with 50% receiving LAAC and 50% taking OAC. After 1 year, the stroke rate and bleeding rate were similar in both groups. However, after 4 years, the LAAC group was with lower composite risk rates (including stroke, transient ischemic attack, systemic embolism, bleeding, and cardiovascular death) than the OAC group. While the stroke rate is similar in both groups, the major difference of composite risk came from the lower rate of non-procedural bleeding risk of LAAC group.</p><p>Based on this finding, LAAC may offer patients a benefit at reduction of bleeding, rather than at a stronger protection from stroke than OAC. Such finding echoes the suggestion from the consensus statements of the societies. Due to the lack of stronger protection of LAAC, OAC is still the main suggestion for patients with high CHA2DS2-VAS score. For those with high bleeding risk, LAAC may be a reasonable alternative to OAC.</p><p>To extend the concept, it affects the choice of drugs after LAAC, especially for those had stroke despite on OAC. For patients with c
在本期杂志中,Chatani Ryuki 介绍了一例题为 "左心房阑尾闭合术后高位梗阻性器械相关血栓形成引起的缺血性中风 "1 的病例。他们使用 Watchman(波士顿科学公司)进行了左心房阑尾闭合术(LAAC),并停用了 OAC。然而,在 LAAC 术后 314 天,发现了与设备相关的血栓(DRT)。OAC 成功解决了 DRT,并将 OAC 作为长期用药。在本病例中,LAAC 后的用药方案和 DRT 的发生值得进一步讨论。2015 年,美国食品和药物管理局批准了首个 LAAC 设备(波士顿科学公司的 Watchman)。此后,心房颤动且 CHA2DS2-VAS 评分高于 2 分的患者如果有 OAC 禁忌症,可以选择服用 LAAC。在主要学会(心脏节律学会、亚太心脏节律学会和欧洲心脏节律协会)关于 LAAC 的共识声明中,均将 OAC 禁忌患者的 LAAC 列为 I 类适应症。根据目前现有的证据,如果不能长期服用 OAC,几乎毫无疑问应该服用 LAAC,但 LAAC 的其他适应症还存在一些不确定性。即使是没有 OAC 禁忌症的患者,LAAC 是否也能替代 OAC?这是最经常讨论的问题之一。OAC 在预防心房颤动患者卒中方面的作用早已在许多大规模临床试验中得到证实。另一方面,比较 LAAC 和 OAC 的试验要少得多。PRAGUE-17 试验是目前最大的比较 LAAC 和 OAC 的前瞻性试验。1 年后,两组患者的中风率和出血率相似。但 4 年后,LAAC 组的综合风险率(包括中风、短暂性脑缺血发作、全身性栓塞、出血和心血管死亡)低于 OAC 组。虽然两组的中风率相似,但综合风险的主要差异来自 LAAC 组较低的非手术出血风险率。这一发现与各学会共识声明中的建议不谋而合。由于 LAAC 缺乏更强的保护作用,对于 CHA2DS2-VAS 评分较高的患者,OAC 仍是主要建议。对于出血风险较高的患者,LAAC 可能是 OAC 的合理替代方案。为了扩展这一概念,LAAC 会影响患者在 LAAC 后的药物选择,尤其是那些在使用 OAC 后仍发生卒中的患者。对于 OAC 禁忌症患者,LAAC 后应使用短期抗血小板治疗。使用抗血小板的目的是避免在 LAAC 内皮化之前形成血栓。换句话说,预防中风主要靠闭塞的左心房阑尾,而非 LAAC 后的药物。然而,对于使用 OAC 但仍中风的患者,LAAC 后的药物并没有明确的提示。对于这部分患者,OAC 无法提供足够的中风保护。然而,证据并未证明 LAAC 在预防中风方面比 OAC 更有效。因此,对于使用 OAC 的中风患者,仅使用 LAAC 可能还不够。虽然缺乏直接证据,但对于使用 OAC 的卒中患者,即使在 LAAC 后仍继续使用 OAC 也是合理且合乎逻辑的处理方法。在 LAAC 314 天后,患者再次发生缺血性卒中,并发生了 DRT。如果患者在 LAAC 后长期服用 OAC,情况可能完全不同。Amulet IDE 试验和瑞士 APERO 试验均显示,Amulet(雅培)和 Watchman(波士顿科学公司)的 DRT 发生率相似3,4 但是,在不同类型的 LAAC 中,DRT 的时机可能不同。在 Amulet 中,大多数 DRT 发生在早期(植入后 45 天)。而在 Watchman,大多数 DRT 发生在 45 天之后。本病例使用的是 Watchman FLX,在植入后 314 天出现 DRT。最后,2023 年 2 月,一项倾向评分匹配研究比较了 LAAC 和 OAC,结果显示 LAAC 组死亡率和中风/系统性栓塞发生率较低。5 LAAC 组在植入后早期出血风险较高,但从植入后第六周开始出血风险降低。根据这项研究的结果,LAAC 的适应症可能会进一步扩大,在更多情况下取代 OAC。
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引用次数: 0
Safety and feasibility of atrial fibrillation ablation after left atrial appendage closure: A single-center experience of the left atrial appendage closure first strategy 左心房阑尾关闭术后心房颤动消融的安全性和可行性:左心房阑尾封闭第一策略的单中心经验
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-23 DOI: 10.1002/joa3.13073
Ryuki Chatani MD, Shunsuke Kubo MD, Hiroshi Tasaka MD, Atsushi Sakata MD, Mitsuru Yoshino MD, Takeshi Maruo MD, Kazushige Kadota MD, PhD

Background

Patients with atrial fibrillation (AF) who are not suitable for long-term anticoagulant therapy undergo percutaneous left atrial appendage closure (LAAC). The safety and feasibility of left atrial catheter ablation (CA) procedures after LAAC remain unclear. This study aimed to clarify the feasibility and safety of CA after LAAC, including in the early phase within 180 days.

Methods

Characteristics and clinical outcomes of 46 patients with AF who had undergone both CA and LAAC within 2 years (mean age, 72 years; 29 men) were compared between those who had undergone CA-first (31 patients) and LAAC-first (15 patients).

Results

The mean CHA₂DS₂-VASc and HAS-BLED scores were 4.8 and 3.3 points, respectively. The LAAC-first strategy was often used in patients with prior major bleeding and LAA thrombosis or sludge. In the LAAC-first group, the mean duration between both procedures was 212 days, and all LAAC-first patients, including seven patients in the early phase, could undergo CA without LAAC device-related complications; moreover, no cardiovascular adverse events were reported after both procedures (mean periods: 420 days). After CA post-LAAC, no device-related adverse events (device-related thrombosis, new peri-device leak appearance, peri-device leak increase, or device dislodgement) were observed, whereas, after LAAC post-CA, 3 new peri-device leak appearance events and 1 peri-device leak increase event were observed, especially patients who underwent LAAC in the early phase post-CA.

Conclusion

Based on single-center experience, left atrial CA in the presence of an LAAC device implanted including the early phase was safe and feasible.

不适合接受长期抗凝治疗的心房颤动(房颤)患者会接受经皮左心房阑尾关闭术(LAAC)。LAAC 后进行左心房导管消融术(CA)的安全性和可行性仍不清楚。这项研究旨在明确 LAAC 后 CA 的可行性和安全性,包括在 180 天内的早期阶段。研究人员比较了 46 名在 2 年内同时接受 CA 和 LAAC 的房颤患者(平均年龄 72 岁,29 名男性)的特征和临床结果,先接受 CA 的患者(31 名)和先接受 LAAC 的患者(15 名)的特征和临床结果。LAAC-first策略通常用于既往有大出血和LAA血栓或淤血的患者。在LAAC-first组中,两次手术之间的平均间隔时间为212天,所有LAAC-first患者,包括早期阶段的7名患者,均可接受CA,且未出现LAAC装置相关并发症;此外,两次手术后均未报告心血管不良事件(平均间隔时间:420天)。在LAAC术后进行CA后,未观察到与器械相关的不良事件(与器械相关的血栓形成、新的器械周围渗漏出现、器械周围渗漏增加或器械脱落),而在LAAC术后进行CA后,观察到3例新的器械周围渗漏出现事件和1例器械周围渗漏增加事件,尤其是在LAAC术后早期阶段接受LAAC的患者。
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引用次数: 0
Editorial to “Notched P-wave on digital electrocardiogram predicts the recurrence of atrial fibrillation in patients who have undergone catheter ablation” "数字心电图上的缺口 P 波可预测接受导管消融术的患者心房颤动的复发 "的社论
IF 2.2 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-05-23 DOI: 10.1002/joa3.13067
Satoshi Yanagisawa MD, PhD, Yasuya Inden MD, PhD, Toyoaki Murohara MD, PhD
<p>In the current issue of the <i>Journal of Arrhythmia</i>, Okuyama et al.<span><sup>1</sup></span> retrospectively investigated the prognostic value of notched P-wave on electrocardiogram (ECG) automatically evaluated in a specific analyzer system in patients with one or more cardiovascular risk undergoing catheter ablation for atrial fibrillation (AF). Among 100 patients selected from the two previous cohort studies, 28 had recurrence, and the notched P-wave with a distance of ≥20 ms in lead II was documented in 26 patients. The presence of the notched P-wave was independently associated with recurrence after ablation in multivariate analysis.</p><p>P-wave morphology assessment on ECG is an old clinical tool; however, it is also essential for the diagnosis and treatment in clinical practice. P-wave morphology is characterized by several components: (a) the origin of the sinus or atypical rhythm forming the right atrial (RA) depolarization vector; (b) the left atrial (LA) breakthrough and strength of interatrial conduction pathways, which defines the LA depolarization vector; and (c) the size of atrial chambers and structural abnormalities in atrium, requiring time duration of the depolarization process.<span><sup>2</sup></span> An abnormal P-wave morphology, reported to be associated with AF and ischemic stroke incidence, includes P-wave duration, advanced interatrial block, P terminal force in lead V1, and P-wave axis and amplitude.<span><sup>3</sup></span> Specifically, P-wave morphology in inferior leads can estimate the extent of interatrial block and the conduction capacity of the atrial septal pathways. The P-wave morphology in lead II consists of the former part activated from the RA and the latter from the LA, with the two components separating as the interatrial block emerges progressively. This partial interatrial block type is thought to be caused by damage in Bachmann's bundle or decreased interatrial impulse propagation in the upper and posterior parts of the interatrial septum and represents a prolonged notch interval between the two components with the valley on ECG, which the authors have tested for prognosis in this study.</p><p>One limitation when assessing ECG parameters manually is the variability and inaccuracy of the measurement. Additionally, despite the magnification of the digital recordings, the short duration or amplitude of P-waves can be difficult to measure. Therefore, automatic calculation using an ECG analyzer system is desirable to resolve the above-mentioned issues, reducing human effort and unintended variations.<span><sup>4</sup></span> This is because the difference in the notched interval presented in figure 1 in this article is too small to distinguish the distance and components with the valley from the visual appearance of the surface ECG. However, the utility of this analysis may be limited to M-shape patterns of P-waves with two positive components, and it is unclear whether this algorithm can be adap
在本期《心律失常杂志》(Journal of Arrhythmia)上,Okuyama 等人1 回顾性研究了在接受心房颤动(房颤)导管消融术的具有一种或多种心血管风险的患者中,由特定分析系统自动评估的心电图(ECG)上的缺口 P 波的预后价值。从之前的两项队列研究中选出的 100 名患者中,有 28 名患者复发,26 名患者的第 II 导联出现了距离≥20 毫秒的缺口 P 波。在多变量分析中,缺口 P 波的存在与消融后复发独立相关。P 波形态的特征由以下几个部分组成:(a) 形成右心房(RA)除极矢量的窦性心律或非典型心律的起源;(b) 左心房(LA)的突破和心房间传导通路的强度,这定义了 LA 除极矢量;(c) 心房腔的大小和心房结构的异常,要求除极过程的时间长度。据报道,P 波形态异常与房颤和缺血性中风发病率有关,包括 P 波持续时间、晚期房室间阻滞、V1 导联的 P 波末端力以及 P 波轴和振幅。第 II 导联的 P 波形态由前者从 RA 处激活和后者从 LA 处激活两部分组成,随着房室间阻滞的逐渐出现,两部分逐渐分离。这种部分心房间阻滞类型被认为是由巴赫曼束受损或心房间隔上部和后部的心房间冲动传播减弱引起的,在心电图上表现为两个波谷成分之间的缺口间期延长,作者在本研究中对此进行了预后测试。此外,尽管数字记录可以放大,但 P 波的持续时间短或振幅大也很难测量。因此,最好使用心电图分析仪系统进行自动计算,以解决上述问题,减少人力和意外变化。4 这是因为本文图 1 中显示的切迹间隔差异太小,无法从表面心电图的视觉外观上区分与谷的距离和成分。然而,这种分析的实用性可能仅限于具有两个阳性成分的 P 波的 M 型模式,目前还不清楚这种算法是否适用于下导联出现双相(阳性/阴性)或阴性 P 波形态的晚期房室传导阻滞。这种异常 P 波代表心房间传导逐渐受损,可能是由于巴赫曼束传导中断和 LA 通过下导联靠近冠状窦腔逆行激活造成的,冠状窦腔的激活通常持续到最后。鉴于作者在研究方法中指出没有患者出现负性 P 波,研究人群可能包括轻度至中度传导受损和心脏重塑的患者,可能排除了重度重塑和传导障碍的患者。我们的经验是,无论随后肺静脉(PV)-LA 传导是否重新连接,P 波持续时间从消融前到消融后都明显缩短了 10 毫秒。我们推测,成功隔离 PV 后的隔离区可能是 P 波的重要组成部分。此外,在消融后,P 波的切迹形态发生了显著变化,表现为延迟或新出现的切迹,这可能与 PV 电位的重新连接和传导延迟有关。因此,强烈建议在消融前而不是消融后评估 P 波形态。本研究中的 40 名患者可能是持续性房颤,因此在术前评估窦性心律时的 P 波的机会可能有限。2尽管存在上述局限性,但本研究提出了一个重要的视角,即在机械性和结构性心房重塑之前描述早期电重塑的特征,从而对接受导管消融术治疗房颤的患者进行分层。
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Journal of Arrhythmia
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