The prevalence rates of heart failure (HF) and hyperpolypharmacy have increased with the aging population. While a negative impact of hyperpolypharmacy on HF clinical outcomes has already been reported, the effects of hyperpolypharmacy on patients with advanced HF with reduced ejection fraction (HFrEF) undergoing cardiac resynchronization therapy (CRT) remain unclear.
Methods
We retrospectively evaluated data from 147 patients with advanced HFrEF who underwent CRT between March 2004 and June 2020. Patients were divided into nonpolypharmacy (<5 medications) and polypharmacy (≥5 medications) groups, as well as nonhyperpolypharmacy (<10 medications) and hyperpolypharmacy (≥10 medications) groups.
Results
The mean age of the study population was 70.6 ± 9.7 years, and 90 patients (67.2%) were male. The median number of medications used was 10 (interquartile range: 7–13, range: 2–24); Kaplan–Meier survival analysis revealed that the hyperpolypharmacy group had a significantly worse long-term survival rate in terms of major adverse cardiovascular events (MACE; p = 0.004) and all-cause mortality (p = 0.005). Long-term survival in terms of MACE and all-cause mortality was not significantly different between the polypharmacy with cardiovascular medication and nonpolypharmacy with cardiovascular medication groups. By contrast, the polypharmacy with noncardiovascular medication group had a significantly worse long-term survival rate in terms of MACE (p = 0.006) and all-cause mortality (p = 0.003) than the nonpolypharmacy with noncardiovascular medication group.
Conclusions
Hyperpolypharmacy was significantly associated with adverse cardiovascular outcomes in patients with advanced HFrEF who underwent CRT. Noncardiovascular polypharmacy may underlie the harmful effects of hyperpolypharmacy.
{"title":"Impact of polypharmacy on clinical outcomes in patients with advanced heart failure undergoing cardiac resynchronization therapy","authors":"Yuma Ono MD, Hidekazu Kondo MD, PhD, Taisuke Harada MD, Kunio Yufu MD, PhD, Hiroki Sato MD, PhD, Kazuki Mitarai MD, Keisuke Yonezu MD, PhD, Katsunori Tawara MD, Hidefumi Akioka MD, PhD, Naohiko Takahashi MD, PhD","doi":"10.1002/joa3.13185","DOIUrl":"10.1002/joa3.13185","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The prevalence rates of heart failure (HF) and hyperpolypharmacy have increased with the aging population. While a negative impact of hyperpolypharmacy on HF clinical outcomes has already been reported, the effects of hyperpolypharmacy on patients with advanced HF with reduced ejection fraction (HFrEF) undergoing cardiac resynchronization therapy (CRT) remain unclear.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We retrospectively evaluated data from 147 patients with advanced HFrEF who underwent CRT between March 2004 and June 2020. Patients were divided into nonpolypharmacy (<5 medications) and polypharmacy (≥5 medications) groups, as well as nonhyperpolypharmacy (<10 medications) and hyperpolypharmacy (≥10 medications) groups.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The mean age of the study population was 70.6 ± 9.7 years, and 90 patients (67.2%) were male. The median number of medications used was 10 (interquartile range: 7–13, range: 2–24); Kaplan–Meier survival analysis revealed that the hyperpolypharmacy group had a significantly worse long-term survival rate in terms of major adverse cardiovascular events (MACE; <i>p</i> = 0.004) and all-cause mortality (<i>p</i> = 0.005). Long-term survival in terms of MACE and all-cause mortality was not significantly different between the polypharmacy with cardiovascular medication and nonpolypharmacy with cardiovascular medication groups. By contrast, the polypharmacy with noncardiovascular medication group had a significantly worse long-term survival rate in terms of MACE (<i>p</i> = 0.006) and all-cause mortality (<i>p</i> = 0.003) than the nonpolypharmacy with noncardiovascular medication group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Hyperpolypharmacy was significantly associated with adverse cardiovascular outcomes in patients with advanced HFrEF who underwent CRT. Noncardiovascular polypharmacy may underlie the harmful effects of hyperpolypharmacy.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"41 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11730717/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143006091","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}
<p>In this issue of the <i>Journal of Arrhythmia</i>, Ishikura et al.<span><sup>1</sup></span> reported a case of persistent atrial fibrillation (AF) with residual endocardial conduction after left atrial posterior wall (LAPW) isolation. Patients with AF have been treated with either sinus rhythm maintenance (rhythm control) or adequate heart rate control (rate control) to improve symptoms. The EAST-AFNET 4 trial<span><sup>2</sup></span> showed that rhythm control is associated with better outcomes, at least in patients with early AF, and that rhythm control should be preferred in such patients. However, in catheter ablation of AF, pulmonary vein isolation (PVI) alone is not effective in maintaining sinus rhythm in some cases, especially in patients with persistent AF. Therefore, several strategies have been investigated in addition to PVI to reduce recurrent AF. Among them, the LAPW isolation has been widely performed with the promise of additional benefits. The LAPW isolation is performed by extending the PVI in lines along the roof and the bottom of the LAPW. However, in the KAPLA study by Kistler et al.,<span><sup>3</sup></span> the addition of LAPW isolation to PVI in patients with persistent AF did not significantly improve freedom from atrial arrhythmias compared with PVI alone. On the other hand, the addition of LAPW isolation was reported to improve outcomes in patients with persistent AF who did not have low-potential regions in the left atrium and in whom atrial arrhythmias were induced by continuous pacing.<span><sup>4</sup></span> The exact reason for this discrepancy is unknown, but the re-conduction on the LAPW isolation may be part of the cause. When LAPW isolation is performed, transmural conduction block by linear ablation of the left atrial roof and bottom remains challenging, mainly because of epicardial muscle fibers bridging epicardial and endocardial conduction, such as the septopulmonary bundle. Recently, the EnSite X mapping system became available with a new algorithm, the Omnipolar Technology (OT) Near-Field algorithm (Abbott, St. Paul, MN). The algorithm can automatically annotate the highest peak frequency (PF) in local electrograms, resulting in accurate near-field potential annotation.</p><p>In this issue, Ishikura et al.<span><sup>1</sup></span> described that the residual potentials via epicardial connections (ECs) could be eliminated by using PF analysis of the OT Near-Field algorithm. The conventional absolute <i>dV</i>/<i>dt</i> annotation algorithm annotates high-amplitude electrograms. Therefore, the <i>dV</i>/<i>dt</i> algorithm probably may not accurately identify the location of an endocardial residual conduction gap in situations when both endocardial and epicardial electrograms are recorded together. In contrast, the OT Near-Field algorithm using the PF value can identify whether the obtained electrograms are near- or far-field signals. In fact, it has been reported that the OT Near-Field algorithm can d
{"title":"Editorial comment on “Usefulness of peak frequency in electrograms for elimination of left atrial posterior wall residual potentials via epicardial connections”","authors":"Tetsuji Shinohara MD, PhD","doi":"10.1002/joa3.13187","DOIUrl":"10.1002/joa3.13187","url":null,"abstract":"<p>In this issue of the <i>Journal of Arrhythmia</i>, Ishikura et al.<span><sup>1</sup></span> reported a case of persistent atrial fibrillation (AF) with residual endocardial conduction after left atrial posterior wall (LAPW) isolation. Patients with AF have been treated with either sinus rhythm maintenance (rhythm control) or adequate heart rate control (rate control) to improve symptoms. The EAST-AFNET 4 trial<span><sup>2</sup></span> showed that rhythm control is associated with better outcomes, at least in patients with early AF, and that rhythm control should be preferred in such patients. However, in catheter ablation of AF, pulmonary vein isolation (PVI) alone is not effective in maintaining sinus rhythm in some cases, especially in patients with persistent AF. Therefore, several strategies have been investigated in addition to PVI to reduce recurrent AF. Among them, the LAPW isolation has been widely performed with the promise of additional benefits. The LAPW isolation is performed by extending the PVI in lines along the roof and the bottom of the LAPW. However, in the KAPLA study by Kistler et al.,<span><sup>3</sup></span> the addition of LAPW isolation to PVI in patients with persistent AF did not significantly improve freedom from atrial arrhythmias compared with PVI alone. On the other hand, the addition of LAPW isolation was reported to improve outcomes in patients with persistent AF who did not have low-potential regions in the left atrium and in whom atrial arrhythmias were induced by continuous pacing.<span><sup>4</sup></span> The exact reason for this discrepancy is unknown, but the re-conduction on the LAPW isolation may be part of the cause. When LAPW isolation is performed, transmural conduction block by linear ablation of the left atrial roof and bottom remains challenging, mainly because of epicardial muscle fibers bridging epicardial and endocardial conduction, such as the septopulmonary bundle. Recently, the EnSite X mapping system became available with a new algorithm, the Omnipolar Technology (OT) Near-Field algorithm (Abbott, St. Paul, MN). The algorithm can automatically annotate the highest peak frequency (PF) in local electrograms, resulting in accurate near-field potential annotation.</p><p>In this issue, Ishikura et al.<span><sup>1</sup></span> described that the residual potentials via epicardial connections (ECs) could be eliminated by using PF analysis of the OT Near-Field algorithm. The conventional absolute <i>dV</i>/<i>dt</i> annotation algorithm annotates high-amplitude electrograms. Therefore, the <i>dV</i>/<i>dt</i> algorithm probably may not accurately identify the location of an endocardial residual conduction gap in situations when both endocardial and epicardial electrograms are recorded together. In contrast, the OT Near-Field algorithm using the PF value can identify whether the obtained electrograms are near- or far-field signals. In fact, it has been reported that the OT Near-Field algorithm can d","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"41 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11730722/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005950","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}
Carbon dioxide injection through coronary vein puncture can greatly reduce complications from epicardial access. We reported a case of ventricular tachycardia that was successfully ablated by this procedure under ECMO support.
{"title":"Carbon dioxide insufflation to facilitate epicardial access in ECMO-supported ventricular tachycardia ablation","authors":"Tetsuro Takase MD, Kouki Yoshikawa BS, Tasuku Morimoto BS, Kent Kamiya BS, Yoshio Furukawa MD","doi":"10.1002/joa3.13188","DOIUrl":"10.1002/joa3.13188","url":null,"abstract":"<p>Carbon dioxide injection through coronary vein puncture can greatly reduce complications from epicardial access. We reported a case of ventricular tachycardia that was successfully ablated by this procedure under ECMO support.\u0000 <figure>\u0000 <div><picture>\u0000 <source></source></picture><p></p>\u0000 </div>\u0000 </figure></p>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"41 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11730983/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005996","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}
Junctional ectopic tachycardia (JET) is not amenable to catheter ablation, with amiodarone currently recognized as a recommended therapy for managing JET. However, treating JET presents significant challenges, particularly in patients experiencing hemodynamic instability postsurgery. This study evaluates the feasibility of ivabradine in managing JET following pediatric cardiac surgery, addressing several pertinent concerns.1
Accurately diagnosing JET through body surface electrocardiograms alone remains challenging. The authors attempted to rule out atrioventricular nodal reentrant tachycardia by confirming the presence of atrioventricular dissociation or persistent tachycardia following adenosine-induced atrioventricular nodal block.1 However, other arrhythmias, such as infra-atrial reentrant tachycardia, must also be considered. As these require ventricular overdrive pacing for differential diagnosis, a definitive diagnosis of JET necessitates an electrophysiological study.2
In this study, ivabradine was co-administered with amiodarone in patients with JET and hemodynamic instability.1 As intravenous administration of amiodarone can result in hypotension,3 ivabradine alone may be particularly suitable for patients with hemodynamic compromise due to its minimal impact on hemodynamics.
The clinical implications of co-administering a beta-blocker were not discussed in the study.1 Ivabradine is generally indicated for sinus tachycardia and is refractory to the maximum dosage of beta-blockers. Experimental evidence suggests that ivabradine's efficacy in suppressing the atrioventricular node is reduced under conditions of heightened sympathetic activity.4 Therefore, concurrent administration of a beta-blocker could be practical to maximize the therapeutic impact of ivabradine.
The authors declare no conflicts of interest.
{"title":"Clinical implication of ivabradine-incorporated medical therapy for junctional ectopic tachycardia following pediatric cardiac surgery","authors":"Naoya Kataoka MD, Teruhiko Imamura MD","doi":"10.1002/joa3.13190","DOIUrl":"10.1002/joa3.13190","url":null,"abstract":"<p>Junctional ectopic tachycardia (JET) is not amenable to catheter ablation, with amiodarone currently recognized as a recommended therapy for managing JET. However, treating JET presents significant challenges, particularly in patients experiencing hemodynamic instability postsurgery. This study evaluates the feasibility of ivabradine in managing JET following pediatric cardiac surgery, addressing several pertinent concerns.<span><sup>1</sup></span></p><p>Accurately diagnosing JET through body surface electrocardiograms alone remains challenging. The authors attempted to rule out atrioventricular nodal reentrant tachycardia by confirming the presence of atrioventricular dissociation or persistent tachycardia following adenosine-induced atrioventricular nodal block.<span><sup>1</sup></span> However, other arrhythmias, such as infra-atrial reentrant tachycardia, must also be considered. As these require ventricular overdrive pacing for differential diagnosis, a definitive diagnosis of JET necessitates an electrophysiological study.<span><sup>2</sup></span></p><p>In this study, ivabradine was co-administered with amiodarone in patients with JET and hemodynamic instability.<span><sup>1</sup></span> As intravenous administration of amiodarone can result in hypotension,<span><sup>3</sup></span> ivabradine alone may be particularly suitable for patients with hemodynamic compromise due to its minimal impact on hemodynamics.</p><p>The clinical implications of co-administering a beta-blocker were not discussed in the study.<span><sup>1</sup></span> Ivabradine is generally indicated for sinus tachycardia and is refractory to the maximum dosage of beta-blockers. Experimental evidence suggests that ivabradine's efficacy in suppressing the atrioventricular node is reduced under conditions of heightened sympathetic activity.<span><sup>4</sup></span> Therefore, concurrent administration of a beta-blocker could be practical to maximize the therapeutic impact of ivabradine.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"41 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11730708/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143006004","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}
Left atrial posterior wall (LAPW) residual potentials via epicardial connections during LAPW isolation are often low-frequency continuous potentials. Accurate annotation of these residual potentials by three-dimensional electroanatomical mapping systems is challenging and can be misleading. Herein, we present a case of successful LAPW isolation using peak frequency analysis.
{"title":"Usefulness of peak frequency in Electrograms for elimination of left atrial Posterior Wall residual potentials via Epicardial connections","authors":"Masahiro Ishikura MD, Yoshiaki Kawase MD, Hiroki Kamiya MD, Taiji Miyake MD, Hitoshi Matsuo MD","doi":"10.1002/joa3.13183","DOIUrl":"10.1002/joa3.13183","url":null,"abstract":"<p>Left atrial posterior wall (LAPW) residual potentials via epicardial connections during LAPW isolation are often low-frequency continuous potentials. Accurate annotation of these residual potentials by three-dimensional electroanatomical mapping systems is challenging and can be misleading. Herein, we present a case of successful LAPW isolation using peak frequency analysis.\u0000 <figure>\u0000 <div><picture>\u0000 <source></source></picture><p></p>\u0000 </div>\u0000 </figure></p>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"41 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11730724/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005800","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}
Sharath Kumar MD, Sachin Yalagudri MD, Daljeet Saggu MD, M. Mansoor MD, Vijaya K. Tourani MD, Calambur Narasimhan MD
Objectives
We present a case series of patients with granulomatous myocarditis presenting as atrial arrhythmias accompanied by lymphadenopathy.
Background
Atrial myocarditis (AM) may be the cause of atrial fibrillation (AF) in patients without risk factors.
Methods
Patients with atrial fibrillation without risk factors underwent 18F-Fluorodeoxyglucose positron emission tomography (18F-FDG-PET). We performed biopsy of lymph nodes or myocardium in patients with atrial uptake of 18F-FDG-PET.
Results
AM was observed in 15 patients. The median age of the patients was 42 years and left ventricular ejection fraction (LVEF) at presentation was 45%. All patients had AF, atrial flutter was noted in 4 patients (26.7%) and 2 patients (13.3%) had atrioventricular nodal reentrant tachycardia (AVNRT). 18F-FDG-PET uptake was noted in the atria in all patients and in the ventricles in 3 patients (20%). Cardiac sarcoidosis was the diagnosis in 12 patients (80%) while 3 patients (20%) had tuberculosis. The median CHA2DS2 VASc score was 1. Four patients (26.7%) presented with ischemic stroke. All patients were treated with disease-specific therapy in addition to antiarrhythmic medications. Over a median follow up of 26 months, a significant improvement in clinical status commensurate with a decline in atrial uptake was noted. A non-significant improvement in LVEF to 56% with disease-specific therapy was observed. (p = 0.09).
Conclusion
Atrial fibrillation with granulomatous lymphadenopathy may be a presenting feature of AM. The risk of stroke is high in these individuals. AM should be suspected in young individuals presenting with atrial fibrillation and stroke without conventional risk factors.
{"title":"Atrial arrhythmias with mediastinal lymphadenopathy presentation of isolated atrial myocarditis","authors":"Sharath Kumar MD, Sachin Yalagudri MD, Daljeet Saggu MD, M. Mansoor MD, Vijaya K. Tourani MD, Calambur Narasimhan MD","doi":"10.1002/joa3.13181","DOIUrl":"10.1002/joa3.13181","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>We present a case series of patients with granulomatous myocarditis presenting as atrial arrhythmias accompanied by lymphadenopathy.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Atrial myocarditis (AM) may be the cause of atrial fibrillation (AF) in patients without risk factors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Patients with atrial fibrillation without risk factors underwent 18F-Fluorodeoxyglucose positron emission tomography (18F-FDG-PET). We performed biopsy of lymph nodes or myocardium in patients with atrial uptake of 18F-FDG-PET.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>AM was observed in 15 patients. The median age of the patients was 42 years and left ventricular ejection fraction (LVEF) at presentation was 45%. All patients had AF, atrial flutter was noted in 4 patients (26.7%) and 2 patients (13.3%) had atrioventricular nodal reentrant tachycardia (AVNRT). 18F-FDG-PET uptake was noted in the atria in all patients and in the ventricles in 3 patients (20%). Cardiac sarcoidosis was the diagnosis in 12 patients (80%) while 3 patients (20%) had tuberculosis. The median CHA2DS2 VASc score was 1. Four patients (26.7%) presented with ischemic stroke. All patients were treated with disease-specific therapy in addition to antiarrhythmic medications. Over a median follow up of 26 months, a significant improvement in clinical status commensurate with a decline in atrial uptake was noted. A non-significant improvement in LVEF to 56% with disease-specific therapy was observed. (<i>p</i> = 0.09).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Atrial fibrillation with granulomatous lymphadenopathy may be a presenting feature of AM. The risk of stroke is high in these individuals. AM should be suspected in young individuals presenting with atrial fibrillation and stroke without conventional risk factors.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"41 1","pages":""},"PeriodicalIF":2.2,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11730979/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005938","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}
Pulsed field ablation (PFA) is a form of nonthermal energy that has been recently introduced for pulmonary vein isolation (PVI). A multi-electrode pentaspline catheter for delivery of PFA guided by fluoroscopy has become widely available for clinical use.
Methods and Results
In this study, we aimed to assess whether the addition of electroanatomical mapping (EAM) for confirmation of PVI in the acute phase can increase the efficacy of the procedure in terms of arrhythmia recurrences. A total of 51 patients with atrial fibrillation (AF) scheduled for first time PVI were included in the study. Participants were assigned to receive PVI using fluoroscopy guidance only (Fluoro-only group: 31 patients) or additional validation with EAM (EAM group: 20 patients). Endpoints included arrhythmia recurrence and procedural characteristics. During a 11.2 ± 1.3 months follow-up period, arrhythmia recurrences did not statistically differ between groups (16.1% vs. 20%, p .72). Procedure time was longer in the EAM group (86.5 ± 11.4 vs. 78.4 ± 9.3 min, p .008). EAM revealed 5 nonisolated PVs that were re-ablated using the same catheter. Four patients of the cohort underwent a redo-procedure during the follow-up period. In all 4 cases, at least one reconnected PV was identified.
Conclusion
In a cohort of patients with AF undergoing first time PVI using a pentaspline PFA catheter, PVI validation with EAM did not lead to significantly different arrhythmia recurrence rates compared to PVI without EAM. In the acute phase, the rate of nonisolated PVs was low.
简介：脉冲场消融（PFA）是一种最近被引入肺静脉隔离（PVI）的非热能形式。一种多电极pentaspline导管在透视引导下输送PFA已广泛应用于临床。方法和结果：在本研究中，我们旨在评估在急性期增加电解剖定位（EAM）来确认PVI是否可以提高心律失常复发的疗效。研究共纳入51例首次行PVI的心房颤动（AF）患者。参与者被分配到仅在透视指导下接受PVI（仅氟组：31例患者）或额外的EAM验证（EAM组：20例患者）。终点包括心律失常复发和手术特征。在11.2±1.3个月的随访期间，两组患者心律失常复发率无统计学差异（16.1% vs. 20%, p .72）。EAM组手术时间更长（86.5±11.4 min vs. 78.4±9.3 min, p .008）。EAM发现5例未分离的pv使用同一导管再次消融。该队列中的4例患者在随访期间接受了再手术。在所有4例中，至少发现了一个重新连接的PV。结论：在一组使用pentaspline PFA导管进行首次PVI的房颤患者中，与不使用EAM的PVI相比，EAM的PVI验证并没有导致心律失常复发率的显著差异。急性期非分离性pv发生率低。
{"title":"Investigating the role of electroanatomical mapping in single-shot pulsed field catheter ablation","authors":"Ourania Kariki MD, Panagiotis Mililis MD, Athanasios Saplaouras MD, Theodoros Efremidis MD, Anastasios Chatziantoniou MD, Ioannis Panagiotopoulos MD, Stylianos Dragasis MD, Konstantinos P. Letsas MD, PhD, FEHRA, Michael Efremidis MD, PhD","doi":"10.1002/joa3.13180","DOIUrl":"10.1002/joa3.13180","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Pulsed field ablation (PFA) is a form of nonthermal energy that has been recently introduced for pulmonary vein isolation (PVI). A multi-electrode pentaspline catheter for delivery of PFA guided by fluoroscopy has become widely available for clinical use.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods and Results</h3>\u0000 \u0000 <p>In this study, we aimed to assess whether the addition of electroanatomical mapping (EAM) for confirmation of PVI in the acute phase can increase the efficacy of the procedure in terms of arrhythmia recurrences. A total of 51 patients with atrial fibrillation (AF) scheduled for first time PVI were included in the study. Participants were assigned to receive PVI using fluoroscopy guidance only (Fluoro-only group: 31 patients) or additional validation with EAM (EAM group: 20 patients). Endpoints included arrhythmia recurrence and procedural characteristics. During a 11.2 ± 1.3 months follow-up period, arrhythmia recurrences did not statistically differ between groups (16.1% vs. 20%, <i>p</i> .72). Procedure time was longer in the EAM group (86.5 ± 11.4 vs. 78.4 ± 9.3 min, <i>p</i> .008). EAM revealed 5 nonisolated PVs that were re-ablated using the same catheter. Four patients of the cohort underwent a redo-procedure during the follow-up period. In all 4 cases, at least one reconnected PV was identified.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>In a cohort of patients with AF undergoing first time PVI using a pentaspline PFA catheter, PVI validation with EAM did not lead to significantly different arrhythmia recurrence rates compared to PVI without EAM. In the acute phase, the rate of nonisolated PVs was low.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 6","pages":"1374-1378"},"PeriodicalIF":2.2,"publicationDate":"2024-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11632236/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142818064","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}
<p>Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with an increased risk of stroke, heart failure, dementia, and mortality. Pulmonary vein isolation (PVI) is an effective rhythm control strategy for treating AF.<span><sup>1</sup></span> Safe and effective treatments for PVI have been established with cryoballoon and radiofrequency ablation, both of which use thermal energy in the myocardium. Meanwhile, pulsed field ablation (PFA), a novel ablation technology that uses non-thermal energy, provides electrical pulses to cause non-thermal irreversible electroporation and induce cardiac cell death.</p><p>In this issue of the <i>Journal of arrhythmia</i>, Kariki et al.<span><sup>1</sup></span> compared the arrhythmia recurrence and procedural characteristics of PFA for AF between the electroanatomical mapping (EAM) and fluoroscopy groups. Fifty-one patients with AF who underwent PVI for the first time were included in their study (fluoro-only group, 31 patients; EAM group, 20 patients). PVI was performed using the FARAPULSE™ PFA system (Boston Scientific, Natick, MA, USA). In the EAM group, the ablation catheter was exchanged with a multipolar mapping catheter (Advisor™ HD Grid catheter [Abbott Laboratories, Abbott Park, Ill, USA]) after PVI, and the EAM of the left atrium was subsequently generated. As a result of the acute procedures, the procedure time was significantly longer in the EAM group than in the fluoroscopy-only group, whereas there was no significant difference in the fluoroscopy time between the two groups. During a mean follow-up period of 11.2 months, PVI with EAM did not lead to significantly different arrhythmia recurrence rates compared with PVI without EAM. No complications were observed in either of the groups.</p><p>In their study, EAM was performed only after fluoroscopy-guided PFA and not before ablation in the EAM group. Obtaining an EAM with a mapping catheter preoperatively is useful for understanding the pulmonary vein (PV) and left atrial anatomy, which may support the learning curve for PV identification and increase the certainty of catheter manipulation, especially for young fellows and residents. Perhaps the acquisition of EAM prior to ablation, in addition to post-mapping, may have influenced the procedure outcomes differently, despite the small number of samples in the current study. A recent non-randomized study with 197 patients undergoing first PVI using the same PFA catheter at a tertiary referral center reported the same efficacy of recurrence-free rate after a 12-month follow-up between the pre- and post-mapping group (<i>n</i> = 127) and non-mapping group (<i>n</i> = 70), and the median procedure duration, left atrial dwell time, and fluoroscopic time were significantly shorter in the non-mapping group than in the mapping group.<span><sup>2</sup></span> These findings suggest that the creation of a preoperative EAM is unnecessary. Similarly, the current study demonstrated several po
{"title":"Editorial to “investigating the role of electroanatomical mapping in single-shot pulsed field catheter ablation”","authors":"Yoshiaki Mizutani MD, PhD, Satoshi Yanagisawa MD, PhD, Yasuya Inden MD, PhD","doi":"10.1002/joa3.13184","DOIUrl":"10.1002/joa3.13184","url":null,"abstract":"<p>Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with an increased risk of stroke, heart failure, dementia, and mortality. Pulmonary vein isolation (PVI) is an effective rhythm control strategy for treating AF.<span><sup>1</sup></span> Safe and effective treatments for PVI have been established with cryoballoon and radiofrequency ablation, both of which use thermal energy in the myocardium. Meanwhile, pulsed field ablation (PFA), a novel ablation technology that uses non-thermal energy, provides electrical pulses to cause non-thermal irreversible electroporation and induce cardiac cell death.</p><p>In this issue of the <i>Journal of arrhythmia</i>, Kariki et al.<span><sup>1</sup></span> compared the arrhythmia recurrence and procedural characteristics of PFA for AF between the electroanatomical mapping (EAM) and fluoroscopy groups. Fifty-one patients with AF who underwent PVI for the first time were included in their study (fluoro-only group, 31 patients; EAM group, 20 patients). PVI was performed using the FARAPULSE™ PFA system (Boston Scientific, Natick, MA, USA). In the EAM group, the ablation catheter was exchanged with a multipolar mapping catheter (Advisor™ HD Grid catheter [Abbott Laboratories, Abbott Park, Ill, USA]) after PVI, and the EAM of the left atrium was subsequently generated. As a result of the acute procedures, the procedure time was significantly longer in the EAM group than in the fluoroscopy-only group, whereas there was no significant difference in the fluoroscopy time between the two groups. During a mean follow-up period of 11.2 months, PVI with EAM did not lead to significantly different arrhythmia recurrence rates compared with PVI without EAM. No complications were observed in either of the groups.</p><p>In their study, EAM was performed only after fluoroscopy-guided PFA and not before ablation in the EAM group. Obtaining an EAM with a mapping catheter preoperatively is useful for understanding the pulmonary vein (PV) and left atrial anatomy, which may support the learning curve for PV identification and increase the certainty of catheter manipulation, especially for young fellows and residents. Perhaps the acquisition of EAM prior to ablation, in addition to post-mapping, may have influenced the procedure outcomes differently, despite the small number of samples in the current study. A recent non-randomized study with 197 patients undergoing first PVI using the same PFA catheter at a tertiary referral center reported the same efficacy of recurrence-free rate after a 12-month follow-up between the pre- and post-mapping group (<i>n</i> = 127) and non-mapping group (<i>n</i> = 70), and the median procedure duration, left atrial dwell time, and fluoroscopic time were significantly shorter in the non-mapping group than in the mapping group.<span><sup>2</sup></span> These findings suggest that the creation of a preoperative EAM is unnecessary. Similarly, the current study demonstrated several po","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 6","pages":"1379-1380"},"PeriodicalIF":2.2,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11632240/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142818023","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}
Optimization of fluoroscopic image quality for reducing radiation exposure in cryoballoon pulmonary vein isolation (CB-PVI) has not yet been fully investigated. Therefore, we tried to compare the radiation doses among three different X-ray system settings.
Methods
Consecutive 148 patients scheduled for their first CB-PVI were prospectively enrolled: low dose with the use of an anti-scatter grid for the first 51 patients (LD + G group), low dose without an anti-scatter grid for the subsequent 46 patients (LD-G group), and ultralow dose (ULD group) with an anti-scatter grid for the remaining 51 patients. We compared the radiation doses required to complete CB-PVI procedures among the groups. There were 27 patients for whom CB-PVI was performed without cine acquisition, but with fluoroscopy only, and the radiation doses were also compared.
Results
The median procedure time and fluoroscopy time were 119 and 35.5 min, respectively, with no significant differences among the groups. The median cumulative air Kerma (AK) decreased in both the LD-G group (71.8 mGy, p < .001) and the ULD group (73.0 mGy, p < .001), compared to the LD + G group (145.0 mGy). Among 27 patients who underwent CB-PVI without cine acquisition, the median cumulative AK further decreased in both the LD-G group (31.4 mGy, p < .05) and the ULD group (22.7 mGy, p < .01), compared to the LD + G group (64.6 mGy).
Conclusion
Using an ULD X-ray setting and avoiding cine acquisition, we can reduce radiation exposure, while ensuring the necessary fluoroscopy time for the CB-PVI procedure.
背景与目的：在低温球囊肺静脉隔离术（CB-PVI）中，减少辐射暴露的透视图像质量优化尚未得到充分的研究。因此，我们试图比较三种不同x射线系统设置下的辐射剂量。方法：连续148例计划进行首次CB-PVI的患者被前瞻性纳入：前51例患者低剂量使用抗散射网格（LD + G组），随后46例患者低剂量不使用抗散射网格（LD-G组），其余51例患者超低剂量（ULD组）使用抗散射网格。我们比较了各组间完成CB-PVI手术所需的辐射剂量。27例患者行CB-PVI检查，未行胶片采集，仅行透视检查，并比较辐射剂量。结果：中位手术时间和透视时间分别为119和35.5 min，组间差异无统计学意义。LD-G组中位累积空气Kerma （AK）均降低（71.8 mGy, p p p p p）。结论：使用ULD x线设置和避免电影采集，我们可以减少辐射暴露，同时确保CB-PVI手术所需的透视时间。
{"title":"Achieving reduced radiation exposure with maintained fluoroscopy effectiveness using ultralow-dose settings in cryoballoon ablation","authors":"Takashi Kaneshiro M.D., Sadahiro Murota M.D., Takeshi Nehashi M.D., Minoru Nodera M.D., Shinya Yamada M.D., Masamitsu Ikeda R.T., Yasuchika Takeishi M.D.","doi":"10.1002/joa3.13179","DOIUrl":"10.1002/joa3.13179","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background and Aims</h3>\u0000 \u0000 <p>Optimization of fluoroscopic image quality for reducing radiation exposure in cryoballoon pulmonary vein isolation (CB-PVI) has not yet been fully investigated. Therefore, we tried to compare the radiation doses among three different X-ray system settings.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Consecutive 148 patients scheduled for their first CB-PVI were prospectively enrolled: low dose with the use of an anti-scatter grid for the first 51 patients (LD + G group), low dose without an anti-scatter grid for the subsequent 46 patients (LD-G group), and ultralow dose (ULD group) with an anti-scatter grid for the remaining 51 patients. We compared the radiation doses required to complete CB-PVI procedures among the groups. There were 27 patients for whom CB-PVI was performed without cine acquisition, but with fluoroscopy only, and the radiation doses were also compared.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The median procedure time and fluoroscopy time were 119 and 35.5 min, respectively, with no significant differences among the groups. The median cumulative air Kerma (AK) decreased in both the LD-G group (71.8 mGy, <i>p</i> < .001) and the ULD group (73.0 mGy, <i>p</i> < .001), compared to the LD + G group (145.0 mGy). Among 27 patients who underwent CB-PVI without cine acquisition, the median cumulative AK further decreased in both the LD-G group (31.4 mGy, <i>p</i> < .05) and the ULD group (22.7 mGy, <i>p</i> < .01), compared to the LD + G group (64.6 mGy).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Using an ULD X-ray setting and avoiding cine acquisition, we can reduce radiation exposure, while ensuring the necessary fluoroscopy time for the CB-PVI procedure.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 6","pages":"1400-1407"},"PeriodicalIF":2.2,"publicationDate":"2024-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11632245/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142818081","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}
Direct oral anticoagulants (DOACs) are preferred for stroke prevention in nonvalvular atrial fibrillation (NVAF); however, warfarin is still used. This study examined why physicians may choose warfarin over DOACs and the associated safety outcomes in patients with NVAF.
Methods
We conducted a new-user, active-comparator cohort study in newly diagnosed patients with NVAF to assess safety outcomes after the introduction of DOACs in Japan.
Results
The median observation period was 1120 days; 1428 patients started anticoagulation therapy with warfarin and 1551 with DOACs. Warfarin was chosen for patients with lower creatinine clearance and left ventricular ejection fractions and those using aspirin and verapamil. The unadjusted risk of major bleeding was considerably higher in the warfarin group but was nonsignificant after adjusting for variables associated with the choice of warfarin, in addition to age and sex. The risk of death was higher in the warfarin group, even after adjustments for relevant variables. However, high-risk subgroups, including those with older ages and multiple comorbidities, such as renal impairment, for whom warfarin was more likely to be selected, had severely compromised prognoses with either anticoagulant. The risk of stroke/systemic embolism was not significantly different between the two groups.
Conclusions
Warfarin is often chosen for older patients with multiple comorbidities characterized by reduced renal function, which is associated with a higher risk of major bleeding and mortality. These high-risk patients seem to have a poor prognosis regardless of the type of anticoagulant used. Thus, safe anticoagulant therapy remains a challenge for such patients.
{"title":"Factors related to the choice of warfarin for treating newly diagnosed nonvalvular atrial fibrillation are associated with safety outcomes during anticoagulation: A new-user, active-comparator, retrospective cohort study","authors":"Yoshiko Takagi BA, MSc, Shinichiro Ueda MD, PhD","doi":"10.1002/joa3.13160","DOIUrl":"10.1002/joa3.13160","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Direct oral anticoagulants (DOACs) are preferred for stroke prevention in nonvalvular atrial fibrillation (NVAF); however, warfarin is still used. This study examined why physicians may choose warfarin over DOACs and the associated safety outcomes in patients with NVAF.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a new-user, active-comparator cohort study in newly diagnosed patients with NVAF to assess safety outcomes after the introduction of DOACs in Japan.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The median observation period was 1120 days; 1428 patients started anticoagulation therapy with warfarin and 1551 with DOACs. Warfarin was chosen for patients with lower creatinine clearance and left ventricular ejection fractions and those using aspirin and verapamil. The unadjusted risk of major bleeding was considerably higher in the warfarin group but was nonsignificant after adjusting for variables associated with the choice of warfarin, in addition to age and sex. The risk of death was higher in the warfarin group, even after adjustments for relevant variables. However, high-risk subgroups, including those with older ages and multiple comorbidities, such as renal impairment, for whom warfarin was more likely to be selected, had severely compromised prognoses with either anticoagulant. The risk of stroke/systemic embolism was not significantly different between the two groups.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Warfarin is often chosen for older patients with multiple comorbidities characterized by reduced renal function, which is associated with a higher risk of major bleeding and mortality. These high-risk patients seem to have a poor prognosis regardless of the type of anticoagulant used. Thus, safe anticoagulant therapy remains a challenge for such patients.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15174,"journal":{"name":"Journal of Arrhythmia","volume":"40 6","pages":"1408-1424"},"PeriodicalIF":2.2,"publicationDate":"2024-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11632260/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142818044","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}
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