Journal of Cardiovascular Electrophysiology最新文献

Background: Discrete prepotentials (DPPs) mapped inside aortic sinuses of Valsalva (ASVs) are deemed as reliable targets for ablation of premature ventricular contractions (PVCs). Nevertheless, ablation may still fail, necessitating further investigation. This study aimed to investigate the electrophysiological features and ablation approaches for PVCs with failed ablation inside ASVs, despite identified DPPs.

Methods and results: Patients undergoing PVCs ablation requiring left ventricular outflow tract mapping were consecutively enrolled at six centers. Inclusion criteria comprised the presence of reproducible DPPs in ASVs and the earliest activation inside ASVs preceding the left ventricle. Patients were divided into ASV and non-ASV groups based on ablation outcomes within ASVs. Of 780 assessed patients, 40 (age 47.5 ± 19.4; 17 males) were included in the final analysis, with 10 in the non-ASV group. The interval from DPPs to QRS onset (DPP-QRS) in the ASV group significantly exceeded that in the non-ASV group (44.3 ± 6.7 ms vs. 15.0 ± 5.0 ms, p < 0.001). A DPP-QRS interval < 25 ms perfectly differentiated non-ASV from ASV cases. Successful ablation beneath ASVs was achieved in all non-ASV patients, despite the local potential preceding the QRS onset by only 2.3 ± 8.0 ms. In the non-ASV group, the distance between locations of targets and DPPs was 13.3 ± 4.2 mm, negatively correlated with the DPP-QRS interval (R² = 0.618, p = 0.007). Over a 22-month follow-up, one patient in the non-ASV group had recurrence.

Conclusion: DPPs mapped inside ASVs, despite being the earliest sites, do not necessarily represent PVCs targets. An infra-valvular approach is suggested with a DPP-QRS interval < 25 ms.

Background: Achieving a durable mitral line block using radiofrequency as a part of an anatomical approach for ablation in patients with persistent atrial fibrillation or for treating peri-mitral flutter has always been challenging due to the complex anatomy of the mitral isthmus. Epicardial ablation via the coronary sinus and the vein of Marshall has been proposed to help create durable lesions. Recently, a novel lattice-tip catheter using pulsed field ablation has shown promising results for creating mitral lines, despite limited data.

Methods and results: We present a case demonstrating the recovery of connection through the mitral isthmus after a waiting period, despite initial clear isolation achieved by creating an endocardial linear lesion. This necessitated further epicardial lesions, performed via ethanol infusion into the vein of Marshall, due to the presence of a coronary sinus CRT lead in this patient.

Conclusion: Despite the high rates of acute mitral line block with PFA the rate of recurrence might be significant. Considering its novelty, our experience with point-by-point PFA is more limited. The present case report highlights the risk of delayed reconnection treated with EI-VOM. Further studies are warranted to explore additional outcomes and recurrence patterns among these patients.

Introduction: Freedom from recurrences of atrial tachyarrhythmia (ATA) is suboptimal after pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PsAF). This sub-analysis from the Cryo Global Registry sought to investigate predictors of ablation success after PVI using cryoballoon ablation (CBA) for PsAF.

Methods and results: ATA recurrence was defined as ≥ 30 s recurrence of atrial fibrillation, atrial flutter or atrial tachycardia after a 90-day blanking period and through 12-months. Univariate and multivariable Cox regression analysis (with ATA recurrence as an endpoint) was performed to identify CBA responders. PsAF patients (N = 882) were on average 63.9 ± 11.3 years old (69.2% male), and freedom from ATA recurrence was 79.7% (76.8%-82.2%). Longer elapsed time from PsAF diagnosis to ablation (hazard ratio [HR] 1.07 (95% confidence interval [CI]: 1.03-1.11); p = 0.002) and a larger number of previously failed antiarrhythmic drugs (HR 1.39 (95% CI: 1.13-1.70); p < 0.002) were shown to be independent predictors of ATA recurrence in a multivariate model which included 703 evaluated patients.

Conclusion: These real-world results provide important insights to guide referral of PsAF patients, including the benefits of earlier treatment via CBA.

Background: Pulsed-field ablation (PFA) is an innovative non-thermal method for arrhythmia treatment. The efficacy of various PFA configurations in relation to contact force (CF) has not been well-studied in vivo.

Objectives: This study evaluated the effect of CF on acute bipolar PFA lesions in both a vegetal and an in vivo porcine heart model.

Methods: Bipolar PFA (500 V, 20 μs for 50 pulses) was applied to eight porcine ventricles, with CF categorized as standard (5-15 g), high (16-30 g), or very high (> 30 g) using the CARTO 3 system. PFA lesions were assessed by gross pathology, histology, and post-ablation voltage amplitude. Additionally, a vegetal model using oscillating russet potatoes replicated the motion of a beating heart to compare lesion parameters under dynamic conditions and various PFA configurations (monopolar vs. bipolar).

Results: A total of 61 in vivo bipolar PFA lesions across all groups were analyzed. No significant differences in lesion surface diameter, depth, or volume were found among CF groups. In the vegetal model, monopolar setting had a better correlation between CF and lesion depth compared to bipolar setting. In addition, oscillations and catheter position (perpendicular or parallel) significantly affected lesion dimensions.

Conclusion: Increasing CF has a minimal effect on the size of acute bipolar PFA lesions in the porcine ventricle, suggesting that, for bipolar PFA, adequate CF is more critical than its intensity in a beating heart. For monopolar PFA, greater CF can impact lesion depth.

Introduction: Permanent implantation of a DF-4 implantable cardiac defibrillator (ICD) lead in the left bundle branch area (LBBA-ICD) is the next paradigm in amalgamating cardiac resynchronization therapy (CRT) and defibrillation. We systematically investigated feasibility/success rate, procedural caveats, and complications associated with a permanent DF-4 LBBA ICD implant and pertinent data at short-term follow-up.

Methods: We prospectively attempted implantation of 7 Fr Durata (Abbott, Chicago, IL, USA) single coil DF-4 ICD lead at the LBBA using a fixed-curve non-deflectable CPS locator delivery sheath. Standard criteria defined LBBA capture. Relevant sensing/pacing, defibrillation, radiographic, and echocardiographic parameters testing were recorded at implant, discharge and 5-month follow-up.

Results: We enrolled 12 consecutive cardiac device-naïve patients (median age 67.5 years, male 91.7%, median LVEF 30%, median septal thickness 9 mm, median QRS duration 140 ms, class I CRT indication 58.3%, primary prevention ICD indication 75%). Minor complications (two transeptal perforations and one micro-dislodgment) were noted in 3/12 (25%) patients. Successful permanent LBBA ICD implant with adequate sensing/pacing was achieved in 9/12 (75%) subjects. Sustained ventricular fibrillation (VF) was inducible in 7/9 patients with successful implants with effective sensing and defibrillation in all. Follow-up device-related and echocardiographic parameters were similar at discharge and 5-month follow-up.

Conclusion: Permanent DF-4 LBBA ICD implant is feasible and successful in 75% of patients with an indication for ICD. With dedicated toolkits, higher volumes, and an obligate learning curve, the higher-than-expected frequency (25%) of minor complications may be ameliorated. Short-term data regarding lead and selected RV parameters remained favorable.

Introduction: Data regarding safety and long-term outcome of very high-power-short duration (vHPSD) ablation in adult congenital heart disease (ACHD) patients with paroxysmal or persistent atrial fibrillation (AF) are lacking.

Methods: Retrospective observational single-center study. The data of 66 consecutive ACHD patients (mean age 60 ± 12.8 years, 46% male) with mild (69.7%), moderate (22.7%), or complex (7.6%) congenital heart disease (CHD) who underwent ablation for paroxysmal (40.9%) or persistent AF (59.1%) were analyzed. Circumferential PVI was performed in all patients and additional substrate ablation in 79,4% of persistent AF patients using irrigated RF energy with vHPSD settings of 70 W/5-7 s or 60 W/7-10 s.

Results: Mean procedure time was 123.6 ± 42 min with a mean RF time of 18.19 ± 10 min. No technique related adverse events occurred. Vascular access complications were detected in seven patients (10.6%) requiring intervention in four patients (6%). A median follow-up time of 491 days (IQR: 194-1054 days). Freedom from any atrial arrhythmia off antiarrhythmic drugs (AAD) at 1 year was present in 58% of patients (77.8% with paroxysmal AF, 43.6% with persistent AF).

Conclusion: vHPSD for ablation of paroxysmal or persistent AF in ACHD patients is safe and effective. Regardless of CHD complexity, no vHPSD ablation modality related complications occurred. Long-term outcome for paroxysmal AF after one ablation was excellent whereas results for persistent AF were limited.

Background: Pulsed field ablation (PFA) is gaining recognition as a nonthermal, tissue-specific technique for the treatment of atrial fibrillation (AF). The preclinical evaluation of the investigated novel PFA system from Insight Medtech Co. Ltd has demonstrated feasibility, safety, and 30-day efficacy for pulmonary vein isolation (PVI) in the swine model. We are currently conducting a randomized controlled trial to compare the PFA directly with ablation-index (AI)-guided radiofrequency ablation (RFA) for PVI.

Methods and results: The InsightPFA trial is a prospective, multicenter, randomized controlled trial to compare the effectiveness and safety of PFA versus RFA for PVI in Chinese patients with symptomatic paroxysmal AF. Two hundred and ninety-two patients diagnosed with symptomatic paroxysmal AF will be randomly assigned to either the PFA group or the RFA group in a 1:1 ratio. All subjects will undergo PVI using PFA or AI-guided RFA and be followed up to 12 months. The primary endpoint is defined as freedom from any episodes of AF/AFL/AT without Class I or III antiarrhythmic drugs during the 9-month follow-up period after a 90-day blank period. The secondary endpoints of effectiveness include acute treatment success and procedural data. The safety evaluation includes a composite of death, stroke and transient ischemic attack, procedure-related complications, device-related adverse events, and serious adverse events. A noninferiority comparison will be conducted between the novel PFA system and the existing RFA system in terms of both effectiveness and safety.

Conclusions: This trial aims to determine whether the InsightPFA for PVI is as effective and safe as standard RFA in the treatment of symptomatic paroxysmal AF.

Trial registration: https://www.

Clinicaltrials: gov/study/NCT06014996; NCT06014996.

Introduction: A leadless pacemaker (LLPM) was recommended for a patient with intermittent complete heart block and near-syncope.

Methods and results: Delivery of LLPM is through a large sheath that has limited deflection and steerability. This report describes the successful deployment of a ventricular LLPM in a patient with prior surgical correction of AV septal defect with subsequent significant right atrial enlargement. The LLPM could not traverse the tricuspid valve. A snare was advanced to the right atrium and used to create greater tip deflection of the delivery sheath. Importantly, once the delivery sheath crosses the tricuspid valve, the snare is loosened to allow directing the sheath to the right ventricular septum rather than the initial direction that was toward the right ventricular apex. The ventricular LLPM was successfully fixated.

Conclusion: In the presence of complex anatomy, deployment of a LLPM delivery sheath can be facilitated with use of a snare to assist with increased deflection then subsequent guidance to the preferred right ventricular location of the septum.