Journal of Interventional Cardiac Electrophysiology最新文献

Background: A phrenic nerve injury (PNI) during cryoballoon (CB) pulmonary vein isolation (PVI) continues to represent a limitation of this technique. The objective of this study was to develop a novel technique with the aim of reducing the incidence of PNI.

Methods: We performed a retrospective analysis of data from two hospitals in patients with symptomatic, drug-resistant atrial fibrillation (AF) over 7 years to evaluate the incidence and clinical characteristics of PNI during cryoballoon PVI. Patients in the intervention group were treated with a new technique consisting of the following consecutive steps: (A) phrenic nerve stimulation near stimulation threshold instead of 10 V stimulation; (B) advanced ablation to the right superior pulmonary vein (PV) using a pre-freezing technique; (C) "pulling away" of the CB after vein isolation and/or after reaching - 40 °C for both right PVs. Two subtypes of PNI were studied: persistent (no recovery to discharge) and transient (recovery to discharge) PNI.

Results: Nine hundred patients with a mean age of 62.3 (± 10.9) years (38% female) were analyzed. Transient PNI occurred in 8/250 patients (3.2%) in the intervention group compared to 39/750 patients (6%) in the control group (p = 0.09). Persistent PNI occurred in one patient (0.4%) in the intervention group compared to 18 (2.8%) in the control group (p = 0.03). Any PNI occurred in 9 patients in the intervention group (3.6%) compared to 57 patients (8.8%) in the control group (p = 0.008).

Conclusion: In this retrospective analysis, a new cryo-PVI technique significantly reduces the incidence of PNI, particularly persistent PNI.

Background: Recent evidence suggests atrial fibrillation (AF) causes cardiomyopathy due to remodeling driven by both irregular rate and rhythm. Atrial fibrillation (AF) ablation in patients with reduced ejection fraction (EF) ≤ 35% has been shown to improve EF and mortality. It is unknown whether the benefits of AF ablation among patients with reduced EF are affected by the degree of pre-ablation rate control.

Objectives: To evaluate AF ablation echocardiographic outcomes for patients who have EF ≤ 35% with varying degrees of pre-ablation rate control.

Methods: Single-center, retrospective study of patients with EF ≤ 35% undergoing first-time ablation of persistent AF. Primary analyses evaluated the degree to which pre-ablation rate control impacted echocardiographic outcomes. Rates of EF recovery to > 35% were compared at three different cutoffs: 110 bpm, 90 bpm, and 70 bpm. A linear regression analysis was then performed to evaluate whether baseline heart rate (HR) predicted change in EF.

Results: Among 73 patients, the mean pre-ablation resting HR was 90 ± 25 bpm, and baseline EF was 27 ± 7%. Patients experienced significant improvements in EF by mean + 14% ± 11% (p < 0.001). Post-ablation EF recovery occurred in 60% of patients. No differences in EF improvement were detected at HR control targets of ≤ 110 bpm or ≤ 90 bpm, while patients achieving HR ≤ 70 bpm had less improvement in EF (+ 9% ± 9%) compared to those with HR above the cutoff (+ 16% ± 11%; p = 0.01). Linear regression analysis did not reveal baseline HR as a significant predictor of change in LVEF (slope = 0.09, r² = 0.05, p = 0.07).

Conclusions: Catheter ablation of persistent AF in patients with reduced EF frequently resulted in recovery in EF > 35%, irrespective of pre-ablation achieved rate control. While patients with HR > 70 bpm experienced a greater improvement in EF compared to those ≤ 70 bpm, patients with baseline HR below this target still experienced significant EF improvements. Further investigation into irregularity-mediated cardiomyopathy is warranted.

Background: Pulsed-field ablation (PFA), as a nonthermal ablative approach for atrial fibrillation, has attracted much attention in recent years. And there are few comparative studies on PFA versus conventional thermal ablation, including radiofrequency ablation (RFA) and cryoballoon ablation (CBA). The efficacy, safety, and somatic sensation of PFA and thermal ablation need to be further compared.

Methods: A total of 109 patients with paroxysmal atrial fibrillation were divided into three groups (27 in the PFA group, 41 in the CBA group, and 41 in the RFA group), and the operation characteristics, efficacy, safety, and somatic sensation were recorded and analyzed. All patients were followed for 2 years.

Results: All pulmonary veins were successfully isolated except for 1 pulmonary vein that was not successfully isolated during the CBA process (PFA vs. CBA vs. RFA = 100% vs. 99% vs. 100%). The total operation time for PFA is considerably shorter than that for thermal ablation (PFA vs. CBA vs. RFA = 65.28 ± 22.78 min vs. 75.38 ± 18.53 min vs. 96.26 ± 23.23 min, P < 0.001), and the same applies to all the sub-phases. PFA was similarly more dominant in terms of somatosensory perception, mainly in headache (PFA vs. CBA = 1.17 ± 0.48 vs. 2.31 ± 1.06, P < 0.001) and chest pain (PFA vs. RFA = 1.45 ± 0.88 vs. 2.52 ± 1.06, P < 0.001). All these three groups demonstrated good maintenance rates (PFA vs. CBA vs. RFA = 85.00% vs. 80.49% vs. 78.05%, 2 years after operation).

Conclusion: PFA demonstrates its excellent somatic sensation and favorable safety. And it also showed a great immediate success and maintenance rate, which is not inferior to thermal ablation.

Background: Despite advances in ablation and other therapies for AF, progression of atrial fibrillation (AF) remains a significant clinical problem, associated with worse prognosis and worse treatment outcomes. Upstream therapies targeting inflammatory or antifibrotic mechanisms have been disappointing in preventing AF progression, but more recently genetic and genomic studies in AF suggest novel cellular and metabolic stress targets, supporting prior studies of lifestyle and risk factor modification (LRFM) for AF. However, while obesity is a significant risk factor, weight loss and risk factor modification have not been successfully applied in a US population with AF. Metformin, a common drug that targets metabolic stress pathways, has demonstrated potential in reducing the burden of AF.

Methods: The Targeting Risk Interventions and Metformin for Atrial Fibrillation (TRIM-AF, NCT03603912) is a randomized clinical trial designed to examine reduction of AF burden and progression, targeting metabolic upstream therapies. This single center trial, at the Cleveland Clinic, is designed as a prospective randomized open-label blinded endpoint (PROBE) 2 × 2 factorial study of metformin extended release up to 750 mg twice daily and lifestyle and risk factor modification (LRFM) in patients with a cardiovascular implantable electronic device (CIED) that have had at least one ≥ 5-min episode of atrial fibrillation (AF) over the prior 3 months. Randomization is stratified by pacemaker vs. ICD and rhythm at enrollment (sinus rhythm/atrial paced vs. AF).

Conclusion: TRIM-AF trial aims to determine if metformin, lifestyle, and risk factor modification (LRFM) reduce AF burden and its progression and assess whether combined therapy outperforms individual treatments.

Trial registration: URL: https://clinicaltrials.gov/ ; Unique Identifier: NCT03603912.

Background: Cardioneuroablation (CNA) treats reflex syncope by ablating ganglionated plexi (GPs) either confined to the right (RA) or left atrium (LA), or accessible from both. We assessed whether GP ablation in one atrium affects parasympathetic modulation in the other and how ablation sequence (RA then LA, or vice-versa) impacts efficacy.

Methods: Two propensity-matched groups of patients with reflex syncope or functional bradycardia were analyzed. Group 1 received CNA in the RA first, followed by LA. Group 2 in the reverse order.

Results: Thirty-four patients were enrolled. In group 1, RA ablation prompted a heart rate (HR) increase (49.8 ± 10.6 vs. 61.2 ± 13.8 bpm; p < 0.01) that was enhanced after LA ablation (60.3 ± 14.5 vs. 64.5 ± 14.4 bpm; p = 0.02). RA ablation did not reduce PR interval in any patient or modify the Wenckebach point (WP) (596 ± 269 vs. 609 ± 319 ms; p = 0.68), while additional LA ablation reduced PR interval in 3 patients and mean WP (611 ± 317 vs. 482 ± 191 ms; p = 0.03). In group 2, LA ablation increased HR (56.7 ± 6.6 vs. 76.4 ± 13.8 bpm; p < 0.01), with an additional effect of RA ablation (76.0 ± 16.5 vs. 85.4 ± 15.9 bpm; p < 0.01). LA ablation decreased PR interval in 3 patients and mean WP (512 ± 182 vs .399 ± 85 ms; p = 0.01). Further RA ablation did not decrease PR or WP. CNA success was 82% in group 1 and 100% in group 2 (p = 0.552). After 24.5 ± 6.1 months, 2 patients in group 1 vs. no patients in group 2 experienced symptom recurrence.

Conclusions: Bi-atrial CNA provides incremental benefits after both RA and LA ablation. Starting ablation in the LA provides the most significant effect on vagal modulation.

Background: New-onset atrial fibrillation (NOAF) complicating ST-segment elevation myocardial infarction (STEMI) remains clinically challenging. The aim of this study was to assess the incidence of NOAF, identify risk factors for the development of atrial fibrillation (AF), and analyze the impact on patient care, therapy, and outcomes during long-term follow-up.

Methods: This retrospective single-center study reviewed consecutive patients undergoing coronary angiography (CAG) for acute STEMI between May 2015 and September 2023. Patients were stratified in NOAF, defined as AF diagnosed during the index hospitalization or within 12 months of follow-up, AF prior to the hospitalization for STEMI, and patients with no AF.

Results: We analyzed 1301 consecutive patients undergoing CAG for STEMI. NOAF was detected in 112 patients (9.8%), and 68 patients (5.2%) had prior AF. NOAF patients were 74% males, with a mean age of 69 ± 11 years. During a median follow-up of 683 days, the rates of stroke were 10% in patients with NOAF compared to 3.8% (p = 0.001) in patients without AF. Major bleeding occurred in 7% vs. 1.7%, p = 0.001, and death in 16% vs. 6.8%, p < 0.001 of patients with NOAF vs. no AF.

Conclusion: NOAF was detected in almost 1 out of 10 STEMI patients and was associated with a higher rate of stroke, major bleeding, and death as in patients with no AF and with similar rates compared with prior AF. Future studies assessing optimal anticoagulation therapy in this challenging patient population are warranted.

This retrospective study evaluated two groups: patients receiving RFA for PVI, posterior wall isolation, mitral isthmus, and coronary sinus (CS) ablation with adjunctive VOM ethanol injection (VOM/RFA ALL (N = 53)), and patients receiving PVI with PFA using pentaspline catheter followed by mitral isthmus and CS ablation with RFA (PFA PV + PW/RFA MITRAL (N = 12)). We hypothesized that PFA for pulmonary vein isolation (PVI) facilitates mitral block without adjunctive vein of Marshall (VOM) ethanol injection. Mitral block was achieved in 92.5% of VOM/RFA ALL patients and 83.3% of the PFA PV + PW/RFA MITRAL group (p = 0.31). Endocardial ablation time of the mitral isthmus and RF applications required to achieve a complete block were significantly shorter in the VOM/RFA ALL group (208 s vs 356 s, p < 0.01 and 14.5 vs 24.0, p < 0.01, respectively). Adjunctive VOM ethanol injection appears to still have a role for facilitation of mitral isthmus block in the new era of PFA.

Introduction: The optimal reimplantation strategies following the removal of infected cardiovascular implantable electronic devices (CIEDs) remain inadequately understood. Given the limitations and risks associated with traditional approaches, the investigation of alternative devices, such as leadless pacemakers (LPs), has gained attention due to their potentially lower infection risk.

Methods: We reviewed literature sources including PubMed, Scopus, and Embase, utilizing a combination of search terms. The inclusion criterion was leadless pacemaker (LP) implantation following lead removal (LR) of infected CIEDs, while the exclusion criterion was LR for noninfectious indications. Study endpoints encompassed patient outcomes during follow-up.

Results: Our literature review yielded 827 articles, of which 22 met the inclusion criteria, encompassing a cohort of 657 patients who underwent LR followed by LP implantation. A total of 295 (44.9%) patients underwent concurrent LP implantation during the LR procedure. The rest underwent delayed procedures, and the overall duration between LR of infected CIED and LP implantation was 4.32 ± 3.9 days. A total of 194 (29.5%) patients had systemic CIED infections, whereas 153 (23.3%) had isolated pocket infections. In our patient cohort, procedural complications were scarce. Over a mean follow-up period of 13.3 ± 9.4 months, pacemaker syndrome was observed in 4 patients (0.61%), and 3 patients (0.46%) experienced persistent or recurrent infections.

Conclusion: Our review finds both concurrent and delayed LP implantation after infected CIED extraction to be safe, with low reinfection rates and minimal complications. LPs could also serve as a bridge to CRT re-implantation minimizing the use of temporary pacing systems.