Journal of Cardiovascular Electrophysiology最新文献

Introduction: Pacing-induced cardiomyopathy in patients with congenital heart disease (CHD) is a cause of significant morbidity. Reports of bundle branch area pacing (BBAP) in this population remain limited.

Methods and results: Eighteen patients with moderate to complex biventricular CHD, as defined by the Bethesda criteria, underwent BBAP attempt with success in 15 (83%). The median age at implant was 17 years (IQR 13, 40). Among the patients with successful BBAP, the median QRSd was 128 ms (IQR 120, 132), and the median V6-RWPT was 72 ms (IQR 58, 80). In the subgroup of patients who underwent successful BBAP for improved synchrony, there was a significant reduction in the QRSd (167 ms [IQR 147 186] vs. 132 ms [IQR 127 135]; p = 0.01). Electrical parameters remained stable over 4-6 months of follow-up apart from threshold, which had a statistically significant but clinically irrelevant rise; this was followed by stabilization (threshold at last follow-up was 0.75 V at 0.4 ms [IQR 0.7 V, 1 V]). Before- and after-pacing ejection fraction (EF) was unchanged in systemic left ventricle (LV) group (LVEF 58% [IQR 48%, 62%] vs. 60% [IQR 54%, 64%]; p = 0.44). There was a non-statistically significant trend towards improvement in the systemic right ventricle (RV) group (RV fractional area change 26.1% [IQR 20.9%, 28.5%] vs. 30.2% [IQR 24.6%, 32.8%]; p = 0.07).

Conclusions: The use of BBAP in patients with moderate to complex biventricular CHD appears to be safe and feasible. The modality delivers good electrical synchrony with lead parameters remaining within normal limits.

Background: Data on atrial fibrillation (AF)/flutter (AFL) recurrence over long-term follow-up after catheter ablation of AF are limited.

Objective: Assess the rate, predictors, and temporal trends of long-term post-ablation AF/AFL recurrence.

Methods: We analyzed consecutive first-time AF catheter ablations between 2008 and 2022 at our center who were captured in our AF ablation registry and outcomes data were supplemented with chart review. Multivariable predictors of any clinically documented AF/AFL after 3-month blanking period were identified with a stepwise-selection multivariable proportional-hazards model in randomly selected 70% data set and validated in remaining 30%.

Results: Among 2905 patients who underwent AF ablation (age 62.9 ± 10.5 years; female 30.5%; persistent 43.6%, long-standing persistent 6.9%; primarily radiofrequency, cryoballoon 18.0%), within 2 years 38.0% had recurrence, and over average 6.1 ± 4.4-years follow-up 53.2% recurred. Multivariable predictors of recurrence (all p < 0.02) included recurrence during blanking period (HR 2.42, 95% CI 2.13-2.74), female sex (1.39, 1.22-1.59), each centimeter increase in LA size (1.34, 1.21-1.49), maximum regional LA fibrosis moderate (1.46, 1.25-1.71) or severe (1.42, 1.14-1.78), every year of AF duration (1.02, 1.00-1.03), and persistent (1.19, 1.03-1.37) or long-standing persistent AF (1.40, 1.10-1.78). Increasing quartiles of risk in the validation set had higher recurrences (compared to Q1; Q2 1.62, 1.19-2.19; Q3 2.58, 1.92-3.46; Q4 4.60, 3.46-6.11; all p < 0.0001).

Conclusion: Over an average 6.1-year follow-up, over half of AF ablation patients had a recurrence of AF/AFL. Independent predictors of recurrence were early recurrence during 3-month blanking period, female sex, increased LA size, moderate/severe maximum regional LA fibrosis, longer AF duration, and non-paroxysmal AF.

Condensed abstract: This observational single-center evaluation included 2905 consecutive AF first-time catheter ablation patients between 2008 and 2022 (age 62.9 ± 10.5 years; female 30.5%; persistent 43.6%, long-standing persistent 6.9%; mostly radiofrequency, cryoballoon 18.0%; follow-up 6.1 ± 4.4 years). A multivariable model developed in 70% data set predicted late (> 3 months) AF/flutter recurrences in remaining 30%. Predictors included recurrence during blanking period (HR 2.42, 95% CI 2.13-2.74), female sex (1.39, 1.22-1.59), each cm increase in LA size (1.34, 1.21-1.49), maximum regional LA fibrosis moderate (1.46, 1.25-1.71) or severe (1.42, 1.14-1.78), every year of AF duration (1.02, 1.00-1.03), and persistent (1.19, 1.03-1.37) or long-standing persistent AF (1.40, 1.10-1.78).

Background: Pulsed field ablation (PFA) is a novel, non-thermal ablation modality to achieve pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). For the pentaspline catheter, eight applications per pulmonary vein (PV) are considered standard, with four in basket configuration and four in flower configuration. The objective of the study is to investigate whether pentaspline PFA using 16 applications per PV is associated with an improved outcome compared with the standard procedure.

Methods: The prospective study included a total of 292 patients with AF. According to the number of applications per PV, patients were assigned to group PFA-8 (8 applications per PV; 4x basket configuration, 4x flower configuration; n = 130) or group PFA-16 (16 applications per PV; 6x basket, 10x flower; n = 162). The primary endpoint was freedom from atrial arrhythmia (AA), i.e. AF, atrial flutter, and atrial tachycardia, after a follow-up period of 1 year, as assessed by Holter monitoring after 3 and 12 months, respectively.

Results: Freedom from AA was significantly higher in group PFA-16 than in group PFA-8 (73.9% vs. 62.3%; p < 0.05). Subgroup analysis showed greater effectiveness in the PFA-16 group than in the PFA-8 group (66.1% vs. 45.3%; p < 0.05) in patients with persistent AF, while freedom from AA was similar in both groups in patients with paroxysmal AF (78.8% in PFA-16 vs. 75.7% in PFA-8; p = ns). Serious adverse events were observed in 8 (2.7%) patients, with no differences between the two groups.

Conclusion: PVI using 16 PFA applications per PV may improve clinical outcome in patients with persistent AF.

Introduction: Tachycardia-induced cardiomyopathy (TICM) is a reversible cause of left ventricular (LV) systolic dysfunction. We evaluated LV endocardial electroanatomic mapping (EAM) to characterize electrical remodeling in TICM caused by atrial tachyarrhythmias.

Methods and results: Patients undergoing radiofrequency catheter ablation of persistent atrial tachyarrhythmias were included. Detailed LV endocardial EAM was performed in 23 patients with LV dysfunction (LV ejection fraction [EF] < 40%) and 29 with normal LVEF (reference group). Electrogram voltage and the extent of voltage abnormalities were analyzed. Patients with LV dysfunction and normalized LVEF after ablation were diagnosed with TICM. Twenty-three patients met the TICM criteria. Compared to the reference group, TICM patients had a lower LV endocardial bipolar (median 2.7 mV [IQR 1.2-5.6 mV] vs. 3.9 mV [IQR 1.7-7.0 mV]; p < 0.01) and unipolar voltage (median 12.6 mV [IQR 9.1 - 16.3 mV] vs. 15.2 mV[IQR 12.0-20.1 mV]; p < 0.01) in both the global and regional LV. No extensive macroscopic scar, but small localized abnormal unipolar voltage areas (median 4.6 cm²) were found in most TICM patients, mainly in the basal inferolateral LV, and wall thinning was more common in those basal LV areas. A low bipolar voltage without abnormal potentials was found in most patients with TICM but was more diffusely distributed with multiple small areas (median 5.1 cm²). There was no significant difference in LV activation time between groups.

Conclusion: Detailed LV endocardial EAM reveals diffuse voltage reduction and localized abnormal voltage areas in TICM, particularly in the basal inferolateral wall, even in the absence of persistent LV systolic dysfunction after maintenance of sinus rhythm.

Introduction: Multifocal ectopic Purkinje-related premature contractions (MEPPC) is a syndrome caused by gain-of-function SCN5A variants, characterized by multifocal ventricular ectopy and dilated cardiomyopathy (DCM).

Methods and results: We report a case of a 63-year-old woman with longstanding DCM and a high burden of multifocal premature ventricular contractions arising from the His-Purkinje system, refractory to multiple antiarrhythmic drugs and associated with progressive heart failure. Genetic testing identified the pathogenic SCN5A R814W variant. Quinidine resulted in complete suppression of ventricular ectopy, marked improvement in left ventricular function, and clinical recovery.

Conclusion: This case supports the role of a rare SCN5A variant in MEPPC and the efficacy of quinidine.

Introduction: While very high-power short-duration (vHPSD) ablation has been shown to be safe and effective for ablation of atrial fibrillation, the utility of vHPSD ablation for targeting premature ventricular complexes (PVCs) remains unclear. We aimed to describe our experience of PVC ablation using vHPSD ablation targeting areas with suboptimal catheter contact.

Methods and results: We included 8 patients (mean age 66.5 ± 11.3 years, 77% female gender, mean LV ejection fraction 52.8 ± 8.2%, baseline PVC burden 23.3 ± 10.1% [range 9-41%]) with PVCs originating from intracavitary structures [LV papillary muscle(s) (n = 7), RV papillary muscle (n = 1)] which were successfully eliminated with vHPSD ablation using a temperature-controlled ablation catheter (QDOT-MICRO; Biosense Webster, Irvine, California, USA) with lesions delivered at 90 W for 4 seconds using QMODE+ mode. Mean QMODE+ lesions delivered in each patient was 28 ± 15.1 with a mean total QMODE+ RF time of 112 ± 60.4 seconds. There were no procedural complications. Durable PVC suppression was confirmed on post-ablation monitoring in all patients (mean post-ablation PVC burden < 1% [range 0-2.3%]).

Conclusion: Ablation with vHPSD using a temperature-controlled radiofrequency ablation catheter can be safe and effective for PVC ablation in regions with poor catheter stability such as RV and LV papillary muscles.

Background: Atrial tachycardias (AT) after radiofrequency ablation (RFA) of atrial fibrillation (AF) may utilize Bachmann's bundle (BB). Due to their epicardial location, these ATs remain poorly understood.

Objective: To describe the electrophysiologic and anatomic basis of BB-related ATs.

Methods: The region of BB was defined as the anterior left atrium (LA) immediately outside the right superior pulmonary vein. A BB-dependent AT was defined as an arrhythmia that originated from (focal) or involved the BB region (reentrant).

Results: Among 1611 patients with persistent AF undergoing ablation, 32 patients (2%) (age 69 ± 9, male n = 22, LA size 47 ± 6 mm, ejection fraction 55 ± 13%) with BB ATs were included. Twenty-nine (91%) had undergone prior ablation for persistent AF (average, 2.0 ± 1.3 procedures). The mechanism of BB ATs was focal (n = 7, 22%) or macro-reentry (n = 25, 78%). RFA eliminated all focal and ultimately reentrant ATs in 15 of the 32 patients; RFA was required at the right atrial (RA) projections of BB among eight of the latter patients. The electrogram at the successful site was devoid of local voltage in four patients. In nine patients with redo procedure, recurrent BB-AT was found in five (56%). After 2.3 ± 1.4 years of follow-up, 22 of the 32 patients (69%) remained free of atrial arrhythmias.

Conclusion: The region of the BB bundle may be responsible for focal and reentrant tachycardias following RFA of persistent AF. Given its epicardial location, sequential ablation from the LA and RA may be required, even at sites that might be devoid of local voltage.