Journal of Interventional Cardiac Electrophysiology最新文献

Introduction: In ablation procedures for patients with perimitral atrial tachycardia, it is often necessary to apply radiofrequency energy inside the coronary sinus. Although this location is anatomically close to the left circumflex artery, its occlusion is a rare complication. A 40-year-old man underwent ablation for perimitral atrial tachycardia with radiofrequency applications inside the coronary sinus to create a lateral mitral block line. Minutes after the tachycardia was interrupted, the patient suddenly developed ST-segment elevation in the inferior leads and underwent successful angioplasty of the circumflex artery, with good clinical evolution over a 30-month follow-up period.

Discussion: Coronary artery injury secondary to radiofrequency ablation procedures is a rare complication. However, the incidence of circumflex artery injury during applications inside the coronary sinus may be underestimated, as suggested by some studies. Several strategies, including meticulous procedural planning, can help mitigate this risk. However, further research is essential to develop strategies that eliminate the risk altogether.

Cardiac imaging (CI), including echocardiography, multidetector computed tomography (MDCT), and cardiac magnetic resonance (CMR), is gaining increasing interest to aid atrial fibrillation (AF) ablation procedures, from pre-procedural planning to intra-procedural guidance. Transthoracic echocardiography is widely used for imaging, especially for preprocedural assessment, while transesophageal and intracardiac echocardiography (ICE) are used for intraprocedural guidance during transseptal puncture. Cardiac MDCT, leveraging its high spatial resolution, offers a detailed anatomical visualization of cardiac chambers and adjacent structures; moreover, left atrial wall thickness assessed by MDCT may guide radiofrequency energy titration to enhance procedural safety and efficiency. At the same time, CMR allows for detailed myocardial tissue characterization and the detection of fibrosis. ICE, MDCT, and CMR also permit intra-procedural image integration with electroanatomical maps, allowing to be aware of a greater amount of intra-procedural real-time information regarding the anatomy and the local characteristics of the tissue in contact with the ablation catheter. One of the primary objectives of performing CI-aided AF ablations is to increase procedural safety and to permit more personalized procedures, according to the characteristics of each patient. This review offers a comprehensive overview of the current applications of CI during the different phases of AF ablation and explores the potential future applications of CI in this context.

Background: The pace-and-ablate strategy is second -line therapy to obtain rate control in patients with persistent symptomatic atrial fibrillation (AF) when other treatment options fail. This study aims to evaluate long-term effects on clinical outcomes following pace-and-ablate strategy in AF patients.

Methods: This retrospective study includes patients who underwent successful pacemaker implantation (right ventricular pacing (RVP) or cardiac re-synchronization therapy (CRT)) followed by atrioventricular node ablation (AVNA) between 2010 and 2020. Patients were treated according to the prevailing guidelines. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization (HFH). Secondary endpoints were individual outcomes of all-cause mortality, HFH, and left-ventricular ejection fraction (LVEF) change.

Results: Two hundred ninety-eight patients were included, 162 undergoing RVP, and 136 receiving CRT, with a median follow-up of 5.8 years [4.1-8.0]. The primary endpoint occured in 47% of the RVP group and 49% of the CRT group (p = 0.206). All-cause mortality occurred in 36% of the RVP group and in 45% of the CRT group (p = 0.005). HFH occurred in 22% of the RVP group and in 15% of the CRT group (p = 0.328), with 17(10%) upgrades to CRT in the RVP group. Median LVEF in the RVP group remained stable (56% [49-60] to 53% [43-57]; p = 0.081), while it improved in the CRT group (31% [22-38] to 43% [32-51]; p < 0.001).

Conclusion: Mortality and HFH in patients with AF managed through a pace-and-ablate strategy are high. Reassuringly, LVEF deterioration requiring upgrade to CRT is uncommon in patients undergoing RVP with normal baseline LVEF before AVNA. CRT improves LVEF in patients with reduced LVEF before AVNA.

Introduction: Catheter ablation is a cornerstone in managing patients with symptomatic, drug-refractory atrial fibrillation (AF), and while effective, traditional thermal ablation techniques are associated with rare but significant complications due to a non-selective thermal energy transfer to all biologic tissues. Pulsed field ablation (PFA) offers a non-thermal approach, targeting myocardial tissue selectively while sparing adjacent structures. The PulseSelect system is a novel PFA platform, and this analysis examines the procedural outcomes, acute complications, and the learning curve associated with introduction of the PulseSelect system in six European centers.

Methods: The One Shot to Pulmonary Vein Isolation (1STOP) project prospectively included 131 patients with paroxysmal or persistent AF treated with the PulseSelect system across six centers. Procedural data, patient characteristics, and acute outcomes were summarized. Additionally, sedation protocols, fluoroscopic times, and acute success rates were reported.

Results: Patients (mean age 61.7 ± 9.7 years; 31.3% female) had predominantly paroxysmal AF (80.9%). Median procedural and fluoroscopy times were 55.0 and 16.0 min, respectively. General anesthesia was used in 75.5% of cases, while in the remaining 24.5% moderate sedation protocols allowed procedures (even in 15.1% without an anesthesiologist). Acute PVI success was 100%, and no major complications were observed. A short learning curve was noted, with significant reductions in procedural times after the initial 2-3 cases at each center.

Conclusion: The PulseSelect system showed short procedural times, with a rapid learning curve, thus leading with high procedural efficiency. In 1 out of 4 cases general anesthesia was not applied, and no major complications were observed.

Background: Atrioventricular node ablation (AVNA) and pacemaker implantation enhance prognosis in heart failure patients experiencing rapid ventricular response due to atrial fibrillation. This meta-analysis assessed the clinical benefits of various pacing modalities following AVNA.

Methods: The electrophysiological endpoint was defined as QRS duration, while the echocardiographic endpoint was the change in left ventricular ejection fraction. Secondary endpoints included pacing threshold, mortality rates, and improvements in the 6-min walk test.

Results: This meta-analysis of 13 studies involving 1257 patients suggested that His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) conferred an advantage in narrowing QRS duration compared to biventricular pacing (BVP) (HBP vs BVP OR = - 59.05, 95%CI = - 73.12 to - 44.97; LBBAP vs BVP OR = - 48.64, 95%CI = - 64.05 to - 33.24). The findings of echocardiographic endpoints suggested that LBBAP and HBP emerged as the optimal strategies over RVP (vs HBP OR = - 7.59, 95%CI = - 11.85 to - 3.32; vs LBBAP OR = - 6.58, 95%CI = - 12.08 to - 1.07). LBBAP reduced all-cause mortality compared to BVP (OR = 0.10, 95%CI = 0.01-0.78); however, no significant differences in all-cause mortality were observed between LBBAP and HBP. The pacing threshold of LBBAP was significantly lower than HBP (OR = - 0.40, 95%CI = - 0.57 to - 0.23).

Conclusion: LBBAP not only demonstrated superior clinical outcomes regarding mortality compared to ventricular pacing strategies, but also was associated with a lower pacing threshold than HBP, thereby indicating its potential advantage over HBP in patients undergoing AVNA and subsequent pacemaker implantation.

Background: Short-duration radiofrequency ablation is designed to enhance efficiency of pulmonary vein isolation (PVI). We investigated the performance of a novel stability algorithm (STABILITY +).

Methods: In a prospective, single-center study, consecutive patients undergoing first-time PVI were included. Patients were categorized into four groups: Group 1, Hybrid (anterior, 50 W, 550 AI; posterior, 90 W 4 s) using Viistag; Group 2, Hybrid using STABILITY + ; Group 3, 90 W (anterior and posterior, 90 W 4 s) using Visitag; Group 4, 90 W using STABILITY + . Clinical, procedural and follow-up data were systematically collected.

Results: A total of 268 patients were included. In total, 130 patients had Hybrid ablation while 138 underwent 90-W ablation. Procedure time was comparable in Groups 1, 2, and 3 however was lower in Group 4 (65 min, 65 min, 70 min, 54 min, p < 0.001). RF-time was longer in Group 1 and 2 vs 3 and 4 (11.6 min, 9.7 min, 4.5 min, 5.2 min, p < 0.001). First-pass isolation rates were comparable between all 4 groups (88%, 91%, 83.9%, 90%, p = 0.480). Freedom from arrhythmia at 6 months was also comparable (9%, 9%, 16.6%, 10.4%, p = 0.341). Complications were comparable and low and restricted to vascular access-related complications (2%, 1%, 0%, 2%, p = 0.388).

Conclusions: Irrespective of the mode of ablation, the novel STABILITY + algorithm can be used in PVI ablations without compromising safety and efficiency and has the potential to improve first-pass isolation using 90-W HPSD ablation.

Background: Current treatment strategies for vasovagal syncope (VVS) patients recommended by the guidelines are diverse, but effects of these therapies are still unsatisfactory with respective limitations on the indications. Cardioneuroablation (CNA), an innovative and promising therapy, has shown potently effective against syncopal recurrences in numerous observational studies. Recently, a single-center randomized clinical trial has reported CNA was superior to non-pharmacologic therapy for VVS patients. Therefore, this study is designed to compare the efficacy of CNA with pharmacologic treatment in a multicenter and randomized fashion.

Methods and results: The Cardioneuroablation versus Midodrine in Patients with Vasovagal Syncope (CAMPAIGN) study is an international multicenter, prospective, open-label, randomized controlled trial. The recurrent VVS patients with a positive response to tilt testing despite sufficient conventional treatment will be predominantly enrolled at different medical centers in China, Russia, and Turkey. All eligible participants will be randomized in a ratio of 1:1 to treatment with CNA versus midodrine, and followed up for 12 months after randomization. Approximately 184 subjects are projected to enroll from April 2023 to December 2024 with follow-up until 2025. The primary endpoint is the recurrence rate of syncope at 12 months of follow-up. The secondary endpoints are comprised of quality of life assessed with the Impact of Syncope on Quality of Life, tilt-induced syncope, blood pressure, cardiac deceleration capacity, and heart rate variability.

Conclusion: A prospective and multicenter clinical trial to compare outcomes of CNA with drug therapy is still lacking. The CAMPAIGN study will provide outcome-based evidence for VVS treatment strategy.

Trial registration: Clinicaltrials.gov: NCT05803148 (Date: March 9, 2023).