Journal of Cardiovascular Electrophysiology最新文献

Background: One of the challenges encountered when extracting transvenous leads with long dwell times is the presence of dense calcifications encasing the leads. This is the most likely reason for failure to advance a laser extraction sheath. The Shockwave intravascular lithotripsy (IVL) device is an angioplasty balloon that delivers intravascular lithotripsy and fractures calcified lesions in the vasculature, approved for use in coronary and arterial angioplasty. It has also been reported as an adjunctive tool in transvenous lead extraction.

Objective: To report the Vanderbilt University Medical Center experience using Shockwave(r) Lithotripsy in the extraction of very old leads.

Methods: We report procedural outcomes in this retrospective single-center series of 24 patients in whom IVL was performed for pretreatment before lead extraction. To use the shockwave balloon, one must have venous access along the path of the leads. In some cases, there was venous access, and in others, a lower-risk lead was extracted first to allow for the passage of the Shockwave balloon. After IVL pretreatment, leads were extracted using conventional laser and, when necessary, mechanical tools.

Results: Forty-nine total leads were extracted, with a median of 2 leads per patient and median dwell time of 16 years with a range of 4-36 years. All transvenous leads were successfully removed, and there were no significant complications. An excimer laser system (Philips, Inc.) was utilized for extraction in all cases, with a median sheath size of 14 Fr. Despite long dwell times, mechanical extraction tools were only required in 6 (12%) of the leads.

Conclusion: Our experience contributes to the growing body of data supporting the use of Shockwave IVL as an adjunctive measure during extraction of calcified leads with long dwell time.

Background: Patients with end-stage renal disease (ESRD) on hemodialysis are at increased risk for bacteremia, which may necessitate transvenous lead extraction (TLE) if a cardiac implantable electronic device (CIED) is present. Most data on outcomes of TLE in ESRD come from small, single-center studies.

Methods: The National Inpatient Sample database was analyzed to identify hospitalizations where patients underwent TLE between 2016 and 2021. Baseline demographics, comorbidities, and outcomes were stratified by history of ESRD.

Results: We identified 98 115 weighted hospitalizations where patients underwent TLE, of which 5005 (5%) had a history of ESRD. Patients with ESRD were younger and had a higher prevalence of comorbidities including congestive heart failure, diabetes, hypertension, and liver dysfunction. Compared to those without ESRD, in-hospital mortality was significantly higher in patients with ESRD undergoing TLE (10.4% vs. 2.5%, p < 0.001). The incidence of vascular complications (including superior vena cava perforation) and cardiogenic shock was also higher in patients with ESRD, as was the length of stay and total hospitalization cost. Even after adjustment for baseline differences, in-hospital mortality after TLE remained significantly higher in patients with ESRD (adjusted odds ratio [ORs] 2.1, 95% confidence interval 1.6-2.7).

Conclusion: In a nationally representative cohort, unadjusted in-hospital mortality among patients with ESRD undergoing TLE is over 10%, and even after adjustment for covariates, patients with ESRD were more than twice as likely to die in the hospital compared to non-ESRD patients undergoing TLE. The increased availability of CIEDs without transvenous hardware may mitigate some of the long-term burden of device implantation in patients with ESRD.

Introduction: Atrial fibrillation (AF) is a common supraventricular tachyarrhythmia associated with an increased risk of stroke and mortality. Catheter ablation using pulmonary vein isolation is a standard treatment for patients refractory to antiarrhythmic drugs, where radiofrequency ablation and cryoablation are the two most commonly used procedures. Although generally safe, esophageal baro- and thermal injuries remain a rare but life-threatening complication due to the close anatomical relationship between the esophagus and the left atrium. Various protective strategies, such as esophageal temperature monitoring and displacement, aim to mitigate this risk, yet their efficacy and safety are still under investigation.

Case presentation: A 72-year-old male with persistent AF underwent cryoablation with an esophageal warming device to prevent esophageal thermal injury. Despite an uneventful procedure, postoperatively, the patient developed severe thoracic pain. Imaging revealed esophageal perforation with active bleeding. Conservative management, including nil per os, antibiotics, and drainage, was initially pursued. However, worsening clinical status necessitated thoracoscopic intervention. Findings included extensive hematoma and inflammation, precluding primary repair. Conservative treatment with enteral nutrition and drainage led to gradual improvement, and the patient was discharged on Day 24. Follow-up confirmed near-complete healing, with no recurrence of AF.

Conclusion: Severe esophageal complications post-cryoablation remain rare but pose significant morbidity. In this case, overinflation of the esophageal warming device likely contributed to barotraumatic injury, worsening of esophageal fragility, leading to a major perforation with extensive mediastinitis. While protective devices aim to reduce ETI, their potential risks must be carefully considered. Optimal patient selection and refined protective strategies are crucial to enhancing procedural safety.

Introduction: Slow pathway radiofrequency ablation is an effective treatment for atrioventricular nodal re-entrant tachycardia (AVNRT) but has been reported in some series to result in late atrioventricular block. We examined our local experience with a retrospective review.

Methods: A retrospective review of all patients undergoing slow pathway ablation at our institution from 1993 through to 2021 was undertaken, with long-term outcomes reported till the end of 2022. Outcomes assessed included late atrioventricular block, and rhythm control.

Results: We identified a total of 1290 procedures performed on 1256 patients over the 28-year period. Mean patient age at the time of the procedure was 48.5 years (range 13 to 93 years). A total of 1234 patients were followed up, whilst 22 were lost to follow-up. Mean follow up was 12.6 years (range 1 to 29 years). Of this cohort 9 patients subsequently developed atrioventricular block and proceeded to pacemaker implantation, for an incidence of 0.58 per 1000 patient years. Overall long-term rhythm controlled was achieved in 1221 (97%) patients.

Conclusions: We report what we believe to be the largest single centre experience, with the longest follow-up for slow pathway ablation, for AVNRT. We observed a low rate of late atrioventricular block that was not clearly higher than the spontaneous rate of heart block, yet still achieving good rhythm control. We believe our data supports radiofrequency slow pathway modification as effective and safe therapy for atrioventricular nodal re-entrant tachycardia.

Background: Ventricular tachycardia (VT) is a life-threatening arrhythmia that requires both relatively rapid and accurate detection in intensive care units (ICUs). Continuous monitoring systems play a crucial role in detecting them. However, previous studies have reported that nearly 9 out of 10 arrhythmia alarms in ICUs tend to be false positives, which usually transpire to a well-documented phenomenon called "alarm fatigue" that leads to desensitization, delayed responses, and increased cognitive burden on healthcare providers.

Methods: We developed a deep learning based, one-dimensional convolutional neural network (1D-CNN) to classify VT alarms using multiple raw waveform inputs, including two electrocardiogram (ECG) leads, photoplethysmogram (PPG) and arterial blood pressure (ABP) signals. The model was trained using the publicly available VTaC Arrhythmia Benchmark Dataset. We used the 10-second waveform segments that preceded each VT alarm, pre-processed and then used them to train the machine learning model to correctly classify the VT alarm.

Results: On the test set, the model achieved an area under the receiver operating characteristic curve of 0.901, overall accuracy of 83.22%, F1-score of 73.3%, sensitivity of 77.53%, specificity of 85.63%, and positive predictive value of 69.57%. The model successfully detected over three-quarters of them while significantly reducing false positive rates for the detection of VT.

Conclusions: This study demonstrates that a deep learning based 1D-CNN model using short segments of raw waveform data can achieve robust performance in distinguishing true and false VT alarms.

Introduction: Atrioventricular node (AVN) ablation after pacemaker implantation is a rate control option for patients with symptomatic atrial fibrillation (AF) when rhythm control with anti-arrhythmic drug therapy and/or ablation with pulmonary vein isolation fails. This study investigated the long-term risk of hospitalization and mortality after AVN ablation using nationwide and population-based registries.

Methods: All AVN ablations between 2015 and 2021 were identified in the National Danish Ablation Database, and hospitalizations were found in the Danish National Patient Registry. Hospitalizations were compared before and after AVN ablation.

Results: We studied 571 patients who underwent AVN ablation. The mean age was 74.5 ± 8.8 years, and 53% were male. The success rate of the ablations was 98.4% without any major procedure-related complications. Median follow-up time was 2.7 years (IQR: 1.2; 4.6). The annual cardiac hospitalizations decreased from incidence rate (IR) of 2.3 per person-year (95% CI: 2.2; 2.6) before ablation to IR of 0.5 per person-year (95% CI: 0.4; 0.6) after ablation. The IR ratio was 0.38 (95% CI: 0.35; 0.41) and more significant for AF admissions. The overall clinical outcomes were independent for implanted pacing system and clinical patient characteristics. After 2 years of follow-up, mortality was 14.2%, but was associated with high patient age, advanced pacing systems, and substantial cardiac and non-cardiac comorbidities.

Conclusion: AVN ablation is associated with an over four-fold reduction of cardiac hospitalization. This procedure has a high success rate and very low risk of complications.

Background: Atrial fibrosis is an important substrate for atrial fibrillation (AF), especially in structural heart disease. A previous study reported that pirfenidone, an antifibrotic agent, reduced atrial and left ventricular fibrosis in an animal model.

Objective: The present research aims to evaluate the effects of pirfenidone on arrhythmic and clinical outcomes in patients with idiopathic pulmonary fibrosis (IPF).

Methods: Our database of patients diagnosed with IPF between 2008 and 2023 was used to obtain echocardiography, electrocardiography (ECG), and 24-h Holter monitoring data. The study included all patients with IPF treated with or without pirfenidone. We compared arrhythmic events, including AF, atrial premature complexes, atrial tachycardia, and ventricular arrhythmias, as well as clinical outcomes based on pirfenidone use.

Results: Among 248 patients with IPF (74.0 ± 8.9 years), 106 (41.2%) received pirfenidone. No differences in the baseline characteristics were observed. During a median 36-month follow-up period, a lower incidence of arrhythmic events (p = 0.001) and diastolic dysfunction (p = 0.025) were observed in the pirfenidone group. Univariate analysis showed associations between arrhythmic events and hypertension, coronary artery disease, higher body weight, longer PR interval, QRS duration, and absence of pirfenidone use. In a multivariable analysis, higher body weight and absence of pirfenidone use were independent risk factors for arrhythmic events.

Conclusions: Pirfenidone use to treat IPF was associated with fewer arrhythmic events and less diastolic dysfunction compared to patients who did not use pirfenidone during long-term follow-up. Additionally, obesity is associated with a higher incidence of arrhythmic events in patients with IPF.

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).