{"title":"Pulsed-Field Ablation: What We Know and What We Don't","authors":"Sanghamitra Mohanty, Andrea Natale","doi":"10.1111/jce.70175","DOIUrl":"10.1111/jce.70175","url":null,"abstract":"","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"453-454"},"PeriodicalIF":2.6,"publicationDate":"2025-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145819307","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Faris Haddadin, Steven A. Kessler, Anthony Prisco, Emily Zhi, Madeeha Rizvi, Koray N. Potel, Farah Haddadin, Sharma Kattel, Venkatakrishna N. Tholakanahalli
Background
Activation mapping of scar-mediated ventricular tachycardias (VT) are often limited by hemodynamic instability. Substrate mapping and 12-lead ECG localization of VT exit site is often limited by variable scar complexity. Emphasis on other mapping strategies in sinus rhythm would improve catheter ablation success in such cases.
Objective
The aim was to investigate the level of agreement between artificial intelligence (AI) based 12-lead ECG localization of VT exit site and mapping utilizing pace-mapping and mapping of channels of slow conduction within the scar tissue of hemodynamically unstable VT.
Methods
This was a single-center proof-of-concept study that included patients who underwent catheter ablation procedure of hemodynamically unstable scar-mediated VT. The performance of AI-assisted ECG analysis of VT exit site (Vektor Medical, San Diego, CA) was compared with sites of successful ablation based on substrate mapping in sinus rhythm.
Results
A total of nine hemodynamically unstable VT rhythms were induced in four patients. In the seven VTs were AI-assisted ECG analysis was used; there was a 100% level of agreement with the site of successful ablation based on substrate mapping. Ablation targeting those sites resulted in non-induction of all induced and mapped VTs. None of the four patients had device therapy for recurrent VT or all-cause mortality at 6 months of follow-up.
Conclusion
A multi-strategic approach utilizing digitalized analysis of 12-lead ECG of VT exit site, pace-mapping and mapping of channels of slow conduction in scar tissue, has the potential to enhance successful catheter ablation of hemodynamically unstable VT.
{"title":"A Novel Workflow Combining Artificial Intelligence—Twelve Lead Electrocardiographic Analysis and Real-Time Mapping for Hemodynamically Unstable Ventricular Tachycardia","authors":"Faris Haddadin, Steven A. Kessler, Anthony Prisco, Emily Zhi, Madeeha Rizvi, Koray N. Potel, Farah Haddadin, Sharma Kattel, Venkatakrishna N. Tholakanahalli","doi":"10.1111/jce.70230","DOIUrl":"10.1111/jce.70230","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Activation mapping of scar-mediated ventricular tachycardias (VT) are often limited by hemodynamic instability. Substrate mapping and 12-lead ECG localization of VT exit site is often limited by variable scar complexity. Emphasis on other mapping strategies in sinus rhythm would improve catheter ablation success in such cases.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>The aim was to investigate the level of agreement between artificial intelligence (AI) based 12-lead ECG localization of VT exit site and mapping utilizing pace-mapping and mapping of channels of slow conduction within the scar tissue of hemodynamically unstable VT.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This was a single-center proof-of-concept study that included patients who underwent catheter ablation procedure of hemodynamically unstable scar-mediated VT. The performance of AI-assisted ECG analysis of VT exit site (Vektor Medical, San Diego, CA) was compared with sites of successful ablation based on substrate mapping in sinus rhythm.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of nine hemodynamically unstable VT rhythms were induced in four patients. In the seven VTs were AI-assisted ECG analysis was used; there was a 100% level of agreement with the site of successful ablation based on substrate mapping. Ablation targeting those sites resulted in non-induction of all induced and mapped VTs. None of the four patients had device therapy for recurrent VT or all-cause mortality at 6 months of follow-up.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>A multi-strategic approach utilizing digitalized analysis of 12-lead ECG of VT exit site, pace-mapping and mapping of channels of slow conduction in scar tissue, has the potential to enhance successful catheter ablation of hemodynamically unstable VT.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"381-389"},"PeriodicalIF":2.6,"publicationDate":"2025-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145819388","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Taro Koya, Ikram U. Haq, Jason A. Tri, Ying Yang, Naoto Otsuka, William H. Sauer, Samuel J. Asirvatham, Duy T. Nguyen
Background
Pulsed-field ablation (PFA) offers myocardial selectivity with minimal thermal injury, but depth for ventricular lesions may be insufficient or heterogeneous at clinically tolerable field strengths. Calcium electroporation—local calcium chloride (CaCl₂) infusion after PFA—may amplify electroporation-mediated cell death while maintaining low energy settings.
Objective
To determine whether immediate post-PFA CaCl₂ infusion enhances acute and chronic ventricular lesion formation in vivo.
Methods
Nine swine underwent focal ventricular PFA (750–1000 V, biphasic, 20 μs × 50 pulses, 200 ms interpulse) via an irrigated focal catheter and benchtop electroporator. Immediately post-PFA, lesions were randomized to saline, 0.2 g Ca, or 0.4 g Ca infused locally through the catheter tip. Acute hearts were explanted for TTC analysis; surviving animals were studied at 7 days for chronic lesion geometry.
Results
Among 41 acute lesions (17 control, 12 Ca 0.2 g, 12 Ca 0.4 g), Ca 0.4 g increased dark-zone depth (3.5 ± 1.4 vs. 2.3 ± 0.8 mm; p = 0.038) and pale-zone depth (2.6 ± 1.3 vs. 1.3 ± 0.8 mm; p = 0.011) versus control. At 7 days (n = 33 lesions), Ca 0.4 g produced larger scars than control (width 11.6 ± 2.1 vs. 10.0 ± 1.9 mm; p = 0.027; depth 4.2 ± 1 vs. 3.0 ± 0.8 mm; p < 0.001; volume 193.6.4 ± 82.3 vs. 109.4 ± 48.2 mm³; p = 0.001).
Conclusions
Local CaCl₂ infusion after ventricular PFA significantly augments acute electroporation effect and chronic lesion size at low output, supporting facilitated PFA as a strategy for deeper, more durable ventricular ablation.
背景：脉冲场消融（PFA）提供心肌选择性和最小的热损伤，但在临床可耐受的场强下，心室病变的深度可能不足或不均匀。电穿孔钙- pfa后局部氯化钙（cacl2）输注-可在维持低能量设置的情况下放大电穿孔介导的细胞死亡。目的：观察pfa术后即刻灌注cacl2是否能促进急性和慢性心室病变的形成。方法：9头猪经灌胃局灶导管和台式电穿孔仪行局灶性心室PFA （750 ~ 1000 V，双相，20 μs × 50脉冲，脉冲间隔200 ms）。pfa后立即将病变随机分为生理盐水、0.2 g Ca或0.4 g Ca，通过导管尖端局部输注。急性心脏外植作TTC分析；存活动物在第7天进行慢性病变几何研究。结果：41例急性病变（对照组17例，Ca 0.2 g 12例，Ca 0.4 g 12例）中，Ca 0.4 g较对照组增加暗区深度（3.5±1.4比2.3±0.8 mm, p = 0.038）和淡区深度（2.6±1.3比1.3±0.8 mm, p = 0.011）。在第7天（n = 33个病变），Ca 0.4 g产生的疤痕比对照组更大(宽度11.6±2.1 vs 10.0±1.9 mm; p = 0.027；深度4.2±1 vs 3.0±0.8 mm； p结论：心室PFA后局部灌注cacl2显著增加急性电穿孔效应和低输出时的慢性病变大小，支持促进PFA作为更深入、更持久的心室消融策略。
{"title":"Local Calcium Chloride Infusion Enhances Acute and Chronic Efficacy of Ventricular Pulsed-Field Ablation","authors":"Taro Koya, Ikram U. Haq, Jason A. Tri, Ying Yang, Naoto Otsuka, William H. Sauer, Samuel J. Asirvatham, Duy T. Nguyen","doi":"10.1111/jce.70228","DOIUrl":"10.1111/jce.70228","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Pulsed-field ablation (PFA) offers myocardial selectivity with minimal thermal injury, but depth for ventricular lesions may be insufficient or heterogeneous at clinically tolerable field strengths. Calcium electroporation—local calcium chloride (CaCl₂) infusion after PFA—may amplify electroporation-mediated cell death while maintaining low energy settings.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To determine whether immediate post-PFA CaCl₂ infusion enhances acute and chronic ventricular lesion formation in vivo.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Nine swine underwent focal ventricular PFA (750–1000 V, biphasic, 20 μs × 50 pulses, 200 ms interpulse) via an irrigated focal catheter and benchtop electroporator. Immediately post-PFA, lesions were randomized to saline, 0.2 g Ca, or 0.4 g Ca infused locally through the catheter tip. Acute hearts were explanted for TTC analysis; surviving animals were studied at 7 days for chronic lesion geometry.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 41 acute lesions (17 control, 12 Ca 0.2 g, 12 Ca 0.4 g), Ca 0.4 g increased dark-zone depth (3.5 ± 1.4 vs. 2.3 ± 0.8 mm; <i>p</i> = 0.038) and pale-zone depth (2.6 ± 1.3 vs. 1.3 ± 0.8 mm; <i>p</i> = 0.011) versus control. At 7 days (<i>n</i> = 33 lesions), Ca 0.4 g produced larger scars than control (width 11.6 ± 2.1 vs. 10.0 ± 1.9 mm; <i>p</i> = 0.027; depth 4.2 ± 1 vs. 3.0 ± 0.8 mm; <i>p</i> < 0.001; volume 193.6.4 ± 82.3 vs. 109.4 ± 48.2 mm³; <i>p</i> = 0.001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Local CaCl₂ infusion after ventricular PFA significantly augments acute electroporation effect and chronic lesion size at low output, supporting facilitated PFA as a strategy for deeper, more durable ventricular ablation.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"374-380"},"PeriodicalIF":2.6,"publicationDate":"2025-12-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145804698","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Xin Chu, Xiaohan Jiang, Qing Qiao, Xiaojun Wang, Hong Ye
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. Its incidence increases significantly with age and has become a major global public health issue. Although research into the mechanisms of AF has spanned over a century-ranging from the reentry theory to the rotor hypothesis-none of these theories can fully explain its complex dynamic characteristics. The electrical activity of AF exhibits similarities to fluid turbulence, and this analogy provides a new theoretical framework for understanding AF. This review systematically outlines the evolution of AF theories and analyzes the multidimensional connections between the electrophysiological properties of atrial myocardium and the principles of turbulence dynamics. These include the nonlinear propagation characteristics of electrical wavefronts, the impact of atrial tissue heterogeneity on wave conduction, and the therapeutic rationale of catheter ablation targeting the sources of turbulence. Based on this, the study proposes the hypothesis that cardiac electrical activity in AF resembles a turbulence-like state, suggesting that AF fundamentally represents a nonlinear dynamic turbulence-like phenomenon of myocardial excitation waves under certain conditions. This hypothesis posits that critical arrhythmogenic substrates in AF—characterized by established structural and electrophysiological heterogeneities—create conditions analogous to sites where turbulence dynamics emerge in fluid systems, providing a phenomenological framework for characterizing the spatial-temporal organization underlying ablation therapy efficacy. By integrating traditional AF theories with fluid dynamics concepts of turbulence, this hypothesis holds promise for more comprehensively explaining the complex characteristics and individual variability of AF, thereby offering a new theoretical foundation for improving AF management outcomes.
{"title":"Understanding Atrial Fibrillation Complexity Through the Lens of Turbulence Dynamics: Implications for Treatment Strategies","authors":"Xin Chu, Xiaohan Jiang, Qing Qiao, Xiaojun Wang, Hong Ye","doi":"10.1111/jce.70229","DOIUrl":"10.1111/jce.70229","url":null,"abstract":"<p>Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. Its incidence increases significantly with age and has become a major global public health issue. Although research into the mechanisms of AF has spanned over a century-ranging from the reentry theory to the rotor hypothesis-none of these theories can fully explain its complex dynamic characteristics. The electrical activity of AF exhibits similarities to fluid turbulence, and this analogy provides a new theoretical framework for understanding AF. This review systematically outlines the evolution of AF theories and analyzes the multidimensional connections between the electrophysiological properties of atrial myocardium and the principles of turbulence dynamics. These include the nonlinear propagation characteristics of electrical wavefronts, the impact of atrial tissue heterogeneity on wave conduction, and the therapeutic rationale of catheter ablation targeting the sources of turbulence. Based on this, the study proposes the hypothesis that cardiac electrical activity in AF resembles a turbulence-like state, suggesting that AF fundamentally represents a nonlinear dynamic turbulence-like phenomenon of myocardial excitation waves under certain conditions. This hypothesis posits that critical arrhythmogenic substrates in AF—characterized by established structural and electrophysiological heterogeneities—create conditions analogous to sites where turbulence dynamics emerge in fluid systems, providing a phenomenological framework for characterizing the spatial-temporal organization underlying ablation therapy efficacy. By integrating traditional AF theories with fluid dynamics concepts of turbulence, this hypothesis holds promise for more comprehensively explaining the complex characteristics and individual variability of AF, thereby offering a new theoretical foundation for improving AF management outcomes.</p>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"400-412"},"PeriodicalIF":2.6,"publicationDate":"2025-12-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jce.70229","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145804708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sandeep A. Saha, Sarah Rosemas, Shantanu Sarkar, Veronica Ramos, Andrew P. Radtke, Shubha Majumder, Mirko De Melis, Jiani Zhou, J. Jason Sims
<div> <section> <h3> Background</h3> <p>Insertable cardiac monitors (ICMs) provide long-term continuous monitoring for arrhythmia diagnosis and management for various clinical indications. However, little data exists on comprehensive real-world arrhythmia diagnostic yield and therapy rates in patients indicated for ICMs with validated artificial intelligence (AI) algorithms enabling large-scale, automated adjudication of ICM-detected episodes. We report the largest real-world analysis of arrhythmia detection as well as medical and procedural therapies in patients with ICMs implanted for guideline-approved indications with long-term monitoring.</p> </section> <section> <h3> Methods</h3> <p>Patients who received a Reveal LINQ ICM between October 1, 2016, and June 30, 2020, with ≥ 1 year of follow-up were identified in two databases (Medtronic CareLink data warehouse, <i>N</i> = 12 020, and Optum Clinformatics Data Mart claims database, <i>N</i> = 17 037) to analyze arrhythmia detections and therapeutic interventions, respectively. Patients were categorized by clinical indication for ICM placement. All device-detected ECGs were identified and processed through arrhythmia-specific AI algorithms. Therapeutic interventions included procedural interventions (cardiovascular implantable electronic device implantation, cardioversions, and ablations) and medication initiation or titration (antiarrhythmics, rate-control medications, and oral anticoagulants) after ICM implant.</p> </section> <section> <h3> Results</h3> <p>Mean (SD) follow-up in the CareLink and Clinformatics claims databases was 24.6 (12.7) and 40.8 (15.6) months, respectively. Of the 12 020 patients in the arrhythmia detection analysis, 7284 (60.6%) had ≥ 1 arrhythmia detected (56.3% in the suspected AF population; 80.1% in the AF management population), and 376 (28.9%) had ≥ 2 arrhythmias detected during long-term follow-up. Among syncope patients with arrhythmia(s) detected, 71.2% had a finding other than pause/bradycardia; 50.4% of cryptogenic stroke patients and 62.6% of AF management patients with arrhythmias had ≥ 1 finding other than AF. Of the 17 037 patients in the therapeutic interventions analysis, 9820 (57.6%) had a therapeutic action post-ICM insertion, with 25% of all patients receiving a procedural intervention, and > 50% undergoing a medication adjustment. Mean (SD) follow-up to first arrhythmia detection was 7 (9) months. Mean (SD) duration from ICM insertion to therapeutic action was 13 (13) months for procedures and 7 (11) months for medication initiation.</p> </section> <section> <h3> Conclusions</h3>
{"title":"A Large, Real-World Cohort Analysis of Arrhythmia Detection and Therapeutic Interventions in Patients With Insertable Cardiac Monitors and Long-Term Monitoring","authors":"Sandeep A. Saha, Sarah Rosemas, Shantanu Sarkar, Veronica Ramos, Andrew P. Radtke, Shubha Majumder, Mirko De Melis, Jiani Zhou, J. Jason Sims","doi":"10.1111/jce.70214","DOIUrl":"10.1111/jce.70214","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Insertable cardiac monitors (ICMs) provide long-term continuous monitoring for arrhythmia diagnosis and management for various clinical indications. However, little data exists on comprehensive real-world arrhythmia diagnostic yield and therapy rates in patients indicated for ICMs with validated artificial intelligence (AI) algorithms enabling large-scale, automated adjudication of ICM-detected episodes. We report the largest real-world analysis of arrhythmia detection as well as medical and procedural therapies in patients with ICMs implanted for guideline-approved indications with long-term monitoring.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Patients who received a Reveal LINQ ICM between October 1, 2016, and June 30, 2020, with ≥ 1 year of follow-up were identified in two databases (Medtronic CareLink data warehouse, <i>N</i> = 12 020, and Optum Clinformatics Data Mart claims database, <i>N</i> = 17 037) to analyze arrhythmia detections and therapeutic interventions, respectively. Patients were categorized by clinical indication for ICM placement. All device-detected ECGs were identified and processed through arrhythmia-specific AI algorithms. Therapeutic interventions included procedural interventions (cardiovascular implantable electronic device implantation, cardioversions, and ablations) and medication initiation or titration (antiarrhythmics, rate-control medications, and oral anticoagulants) after ICM implant.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Mean (SD) follow-up in the CareLink and Clinformatics claims databases was 24.6 (12.7) and 40.8 (15.6) months, respectively. Of the 12 020 patients in the arrhythmia detection analysis, 7284 (60.6%) had ≥ 1 arrhythmia detected (56.3% in the suspected AF population; 80.1% in the AF management population), and 376 (28.9%) had ≥ 2 arrhythmias detected during long-term follow-up. Among syncope patients with arrhythmia(s) detected, 71.2% had a finding other than pause/bradycardia; 50.4% of cryptogenic stroke patients and 62.6% of AF management patients with arrhythmias had ≥ 1 finding other than AF. Of the 17 037 patients in the therapeutic interventions analysis, 9820 (57.6%) had a therapeutic action post-ICM insertion, with 25% of all patients receiving a procedural intervention, and > 50% undergoing a medication adjustment. Mean (SD) follow-up to first arrhythmia detection was 7 (9) months. Mean (SD) duration from ICM insertion to therapeutic action was 13 (13) months for procedures and 7 (11) months for medication initiation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"359-373"},"PeriodicalIF":2.6,"publicationDate":"2025-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jce.70214","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145774723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Elena Rimskaya, Mikhail Chmelevsky, Olga Aparina, Anastasia Bazhutina, Margarita Budanova, Svyatoslav Khamzin, Svetlana Kashtanova, Madina Utsumueva, Svetlana Gaman, Olga Stukalova, Sergey Ternovoy, Sergey Golitsyn
Background
Left bundle branch block (LBBB) is associated with heterogeneous electrical and structural remodeling; however, the interplay between myocardial fibrosis and conduction abnormalities remains incompletely characterized.
Aims
To investigate fibrosis distribution and electrical activation patterns in LBBB patients with preserved (LBBB idiopathic [LBBBi]) and reduced (15 cardiac resynchronization therapy [CRT] recipients) systolic function using noninvasive electrocardiographic activation mapping (NEAM) and late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR).
Materials and Methods
Twenty LBBB patients (15 CRT, 5 LBBBi) and five healthy volunteers (HV) underwent NEAM and LGE-CMR. Global and segmental activation times (epicardial/endocardial ATs), fibrosis volume, and latest activation zone (LAZ) localization were analyzed. Segmental correlations between fibrosis and activation parameters were evaluated in the CRT group.
Results
CRT patients demonstrated longer total ATs than LBBBi (176 ± 18 vs. 148 ± 10 ms, p < 0.001). LAZ localized to segments 5–6 in 80% of cases, with displacement in three CRT patients with midwall fibrosis. Fibrosis (17.4 [7.3–53.7] cm³) was present in 86.7% of CRT patients but absent in LBBBi and HV. Global ATs showed no correlation with fibrosis volume (r = −0.159, p = 0.571), but segmental fibrosis volume moderately correlated with epicardial (r = 0.37, p < 0.001) and endocardial (r = 0.307, p < 0.001) ATs. Most segments in both groups demonstrated prolonged epicardial conduction, while endocardial conduction remained near-normal.
Conclusion
Integrated NEAM-LGE-CMR analysis demonstrated that myocardial fibrosis modulates local conduction abnormalities without influencing global activation times. All LBBB patients exhibit prolonged epicardial activation time regardless of fibrosis burden, while endocardial activation time remains preserved in most left ventricular segments.
背景：左束分支阻滞（LBBB）与不均匀的电和结构重构有关；然而，心肌纤维化与传导异常之间的相互作用尚未完全确定。目的：利用无创心电图激活测绘（NEAM）和晚期钆增强心血管磁共振（LGE-CMR）研究LBBB特发性[LBBBi]和收缩功能减弱（15例心脏再同步化治疗[CRT]接受者）患者的纤维化分布和电激活模式。材料与方法：20例LBBB患者（CRT 15例，LBBBi 5例）和5例健康志愿者（HV）行NEAM和LGE-CMR。分析全局和节段性激活时间（心外膜/心内膜at）、纤维化体积和最新激活区（LAZ）定位。在CRT组中评估纤维化和激活参数之间的节段相关性。结果：CRT患者的总ATs比LBBBi患者长（176±18 vs 148±10 ms）。结论：综合NEAM-LGE-CMR分析表明，心肌纤维化调节局部传导异常，但不影响整体激活时间。无论纤维化负荷如何，所有LBBB患者均表现出心外膜激活时间延长，而心内膜激活时间在大多数左心室节段保持不变。
{"title":"Myocardial Fibrosis Distribution and Electrical Activation Patterns in Left Bundle Branch Block: Integration of Non-Invasive Electrocardiographic Activation Mapping and Cardiovascular Magnetic Resonance Imaging Late Gadolinium Enhancement","authors":"Elena Rimskaya, Mikhail Chmelevsky, Olga Aparina, Anastasia Bazhutina, Margarita Budanova, Svyatoslav Khamzin, Svetlana Kashtanova, Madina Utsumueva, Svetlana Gaman, Olga Stukalova, Sergey Ternovoy, Sergey Golitsyn","doi":"10.1111/jce.70226","DOIUrl":"10.1111/jce.70226","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Left bundle branch block (LBBB) is associated with heterogeneous electrical and structural remodeling; however, the interplay between myocardial fibrosis and conduction abnormalities remains incompletely characterized.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Aims</h3>\u0000 \u0000 <p>To investigate fibrosis distribution and electrical activation patterns in LBBB patients with preserved (LBBB idiopathic [LBBBi]) and reduced (15 cardiac resynchronization therapy [CRT] recipients) systolic function using noninvasive electrocardiographic activation mapping (NEAM) and late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Materials and Methods</h3>\u0000 \u0000 <p>Twenty LBBB patients (15 CRT, 5 LBBBi) and five healthy volunteers (HV) underwent NEAM and LGE-CMR. Global and segmental activation times (epicardial/endocardial ATs), fibrosis volume, and latest activation zone (LAZ) localization were analyzed. Segmental correlations between fibrosis and activation parameters were evaluated in the CRT group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>CRT patients demonstrated longer total ATs than LBBBi (176 ± 18 vs. 148 ± 10 ms, <i>p</i> < 0.001). LAZ localized to segments 5–6 in 80% of cases, with displacement in three CRT patients with midwall fibrosis. Fibrosis (17.4 [7.3–53.7] cm³) was present in 86.7% of CRT patients but absent in LBBBi and HV. Global ATs showed no correlation with fibrosis volume (<i>r</i> = −0.159, <i>p</i> = 0.571), but segmental fibrosis volume moderately correlated with epicardial (<i>r</i> = 0.37, <i>p</i> < 0.001) and endocardial (<i>r</i> = 0.307, <i>p</i> < 0.001) ATs. Most segments in both groups demonstrated prolonged epicardial conduction, while endocardial conduction remained near-normal.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Integrated NEAM-LGE-CMR analysis demonstrated that myocardial fibrosis modulates local conduction abnormalities without influencing global activation times. All LBBB patients exhibit prolonged epicardial activation time regardless of fibrosis burden, while endocardial activation time remains preserved in most left ventricular segments.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"347-358"},"PeriodicalIF":2.6,"publicationDate":"2025-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145768141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Birju R. Rao, Vardhmaan Jain, Miguel A. Leal, Neal K. Bhatia, Mikhael F. El Chami, Faisal M. Merchant
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.
{"title":"Outcomes of Transvenous Lead Extraction in Patients With End-Stage Renal Disease","authors":"Birju R. Rao, Vardhmaan Jain, Miguel A. Leal, Neal K. Bhatia, Mikhael F. El Chami, Faisal M. Merchant","doi":"10.1111/jce.70232","DOIUrl":"10.1111/jce.70232","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>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.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>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.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>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%, <i>p</i> < 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).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>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.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"420-423"},"PeriodicalIF":2.6,"publicationDate":"2025-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145768199","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Therapeutic Strategy for Patients With Heart Failure and Atrial Fibrillation.","authors":"Naoya Kataoka, Teruhiko Imamura","doi":"10.1111/jce.70227","DOIUrl":"https://doi.org/10.1111/jce.70227","url":null,"abstract":"","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145762756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Youmei Shen, Weizhu Ju, Hongwu Chen, Hailei Liu, Linlin Wang, Xiaohong Jiang, Gang Yang, Mingfang Li, Kai Gu, Minglong Chen
Background
Pre-implantation screening is a crucial step in preventing inappropriate sensing in patients with subcutaneous implantable cardioverter defibrillators (S-ICDs). Paced QRS-T morphology may influence screening outcomes. We aimed to explore the impact of pacing rhythm and different pacing sites on pre-implantation screening of S-ICD.
Methods and Results
This prospective, single-center study enrolled patients referred for radiofrequency ablation, with both left and right-heart access. A contact-force ablation catheter was used to mimic ventricular pacing at different sites. Automatic screening tests for S-ICD eligibility were performed during pacing and sinus rhythm. The impact of pacing sites on S-ICD eligibility was assessed. Thirty patients (age 54.0 ± 15.0 years, 73.3% male) were enrolled. The overall passing rate during intrinsic sinus rhythm was 86.7%. Compared with sinus rhythm, conduction system pacing from His bundle or left bundle branch demonstrated comparable pass rates and the number of passed vectors, whereas right ventricular septum (RVS) pacing exhibited significantly lower pass rates and less pass vectors. Among all RVS pacing sites, the lowest pass rate was observed at the apical portion, followed by middle and basal portion (p < 0.001 for all comparisons).
Conclusion
Conduction system pacing preserves patient eligibility for S-ICD comparable to sinus rhythm, while RVS pacing significantly impairs sensing performance, with the greatest deterioration observed in apical pacing. These findings underscore the advantages of conduction system pacing in optimizing sensing function for patients eligible for both S-ICDs and pacemakers.
{"title":"Impact of Different Pacing Sites on Pre-Implantation Screening Test of Subcutaneous Implantable Cardioverter Defibrillators","authors":"Youmei Shen, Weizhu Ju, Hongwu Chen, Hailei Liu, Linlin Wang, Xiaohong Jiang, Gang Yang, Mingfang Li, Kai Gu, Minglong Chen","doi":"10.1111/jce.70216","DOIUrl":"10.1111/jce.70216","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Pre-implantation screening is a crucial step in preventing inappropriate sensing in patients with subcutaneous implantable cardioverter defibrillators (S-ICDs). Paced QRS-T morphology may influence screening outcomes. We aimed to explore the impact of pacing rhythm and different pacing sites on pre-implantation screening of S-ICD.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods and Results</h3>\u0000 \u0000 <p>This prospective, single-center study enrolled patients referred for radiofrequency ablation, with both left and right-heart access. A contact-force ablation catheter was used to mimic ventricular pacing at different sites. Automatic screening tests for S-ICD eligibility were performed during pacing and sinus rhythm. The impact of pacing sites on S-ICD eligibility was assessed. Thirty patients (age 54.0 ± 15.0 years, 73.3% male) were enrolled. The overall passing rate during intrinsic sinus rhythm was 86.7%. Compared with sinus rhythm, conduction system pacing from His bundle or left bundle branch demonstrated comparable pass rates and the number of passed vectors, whereas right ventricular septum (RVS) pacing exhibited significantly lower pass rates and less pass vectors. Among all RVS pacing sites, the lowest pass rate was observed at the apical portion, followed by middle and basal portion (<i>p</i> < 0.001 for all comparisons).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Conduction system pacing preserves patient eligibility for S-ICD comparable to sinus rhythm, while RVS pacing significantly impairs sensing performance, with the greatest deterioration observed in apical pacing. These findings underscore the advantages of conduction system pacing in optimizing sensing function for patients eligible for both S-ICDs and pacemakers.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 2","pages":"331-337"},"PeriodicalIF":2.6,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145762759","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Chengye Di, Longyu Li, Qun Wang, Yanxi Wu, Yan Zhang, Wenhua Lin
Accessory pathways (APs) are classified as typical or variant according to their atrial and ventricular insertions. Typical APs connect atrial and ventricular working myocardium directly across the annulus, whereas variant APs—including the atrio-Hisian pathway (AHP), fasciculoventricular pathway (FVP), nodofascicular pathway (NFP), and nodoventricular pathway (NVP) pathways—partially or fully engage the atrioventricular node–His (AVN–His) axis. Focusing on trans-annular APs in the right para-septal region, this review emphasizes how their anatomic course and spatial relationship to the AVN–His axis determine their electrocardiographic (ECG) and electrophysiologic (EP) manifestations. Accurate interpretation of these features requires detailed understanding of para-septal anatomy. By integrating anatomic, ECG, and EP correlations, a unified schematic model is proposed to describe the relative positions, insertion sites, and conduction relationships of typical and variant APs within the right para-septal region. This framework clarifies how subtle anatomic variations along the AVN–His axis account for the distinct yet overlapping ECG and EP features of these pathways.
辅助通路（ap）根据其心房和心室插入分为典型或变异。典型的APs直接穿过心房环连接心房和心室工作心肌，而变异的APs——包括心房- hisian通路（AHP）、束状室通路（FVP）、结节束状通路（NFP）和结节室通路（NVP）——部分或完全连接房室结- his （AVN-His）轴。本文以右侧隔旁区跨环形ap为重点，强调其解剖过程和与AVN-His轴的空间关系如何决定其心电图和电生理表现。准确地解释这些特征需要对隔旁解剖有详细的了解。通过整合解剖、ECG和EP相关性，提出了一个统一的示意图模型来描述右侧隔旁区域内典型和变异ap的相对位置、插入位置和传导关系。该框架阐明了沿着AVN-His轴的细微解剖变化如何解释这些通路的不同但重叠的ECG和EP特征。
{"title":"Revisiting Para-Septal Accessory Pathways: A Unified Anatomic, Electrocardiographic, and Electrophysiologic Framework for Typical and Variant Subtypes","authors":"Chengye Di, Longyu Li, Qun Wang, Yanxi Wu, Yan Zhang, Wenhua Lin","doi":"10.1111/jce.70223","DOIUrl":"10.1111/jce.70223","url":null,"abstract":"<div>\u0000 \u0000 <p>Accessory pathways (APs) are classified as typical or variant according to their atrial and ventricular insertions. Typical APs connect atrial and ventricular working myocardium directly across the annulus, whereas variant APs—including the atrio-Hisian pathway (AHP), fasciculoventricular pathway (FVP), nodofascicular pathway (NFP), and nodoventricular pathway (NVP) pathways—partially or fully engage the atrioventricular node–His (AVN–His) axis. Focusing on trans-annular APs in the right para-septal region, this review emphasizes how their anatomic course and spatial relationship to the AVN–His axis determine their electrocardiographic (ECG) and electrophysiologic (EP) manifestations. Accurate interpretation of these features requires detailed understanding of para-septal anatomy. By integrating anatomic, ECG, and EP correlations, a unified schematic model is proposed to describe the relative positions, insertion sites, and conduction relationships of typical and variant APs within the right para-septal region. This framework clarifies how subtle anatomic variations along the AVN–His axis account for the distinct yet overlapping ECG and EP features of these pathways.</p>\u0000 </div>","PeriodicalId":15178,"journal":{"name":"Journal of Cardiovascular Electrophysiology","volume":"37 1","pages":"165-176"},"PeriodicalIF":2.6,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145762728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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