Journal of Interventional Cardiac Electrophysiology最新文献

Background: Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, is used in the treatment of B-cell malignancies (e.g., chronic lymphocytic leukemia [CLL]). Initial risk stratification of ibrutinib-associated atrial fibrillation (IAAF) may inform atrial fibrillation (AF) surveillance strategies. The performance of existing AF risk scores to predict incident AF among patients newly treated with ibrutinib is unknown.

Methods: We conducted a single-center retrospective study of all patients without a history of AF who were treated with ibrutinib (2012-2016). Patient demographics were compared between cohorts by the presence of IAAF within 24 months of treatment initiation. First, the predictive ability of established AF risk models was assessed. Secondly, univariate and multivariate analyses were used to create a new IAAF risk model which was compared to established AF risk models by area under the curve (AUC) analysis.

Results: Of 167 patients (66 ± 11 years, 70% male), 24 (14.4%) developed incident IAAF (mean time to IAAF, 7.1 ± 6.3 months). Univariate analysis showed that hypertension (HTN), diabetes (DM), systolic heart failure (HFrEF), and obstructive sleep apnea (OSA) were associated with IAAF. Logistic regression analysis of variables of interest and those with p < 0.1 on univariate analysis demonstrated that left atrial diameter (LAD) > 43 mm and obstructive sleep apnea were independently associated with IAAF. Existing AF risk scores had reasonable performance (AUC, 0.68-0.72). A new simple clinical risk score was developed: OSA 5 points, HFrEF 3 points, DM 2 points, and hyperlipidemia 2 points. This simple IAAF risk score achieved a numerically greater AUC than that of established risk models (AUC = 0.77). There was no statistically significant difference in the AUC performance between risk scores.

Conclusion: Among 167 ibrutinib naïve patients, risk factors for incident AF development resemble those of the general population. However, common AF risk models have moderate predictive ability. Large validation studies are needed to confirm the superior IAAF predictive ability of this simple risk score and investigate the incremental predictive value of echocardiographic variables.

Background: Long-term safety and reaccessibility following the use of suture-mediated vascular closure systems (SMC) for femoral vein access are not well documented. This study aimed to assess the long-term outcomes and feasibility of repeated femoral vein punctures after SMC.

Methods: We analyzed 282 patients who underwent elective catheter ablation via femoral vein access using an 8-13 Fr sheath. Patients were randomized into the pre-close or post-close groups using the ProGlide/ProStyle single-suture technique (Abbott Vascular). Duplex ultrasound evaluations were performed on day 1, day 90, and at 1 year to evaluate vascular complications. The primary and secondary endpoints included major and minor complications within 1 year. Reaccessibility was assessed in patients who required repeated procedures.

Results: Successful re-access was achieved in 21 patients (14.9%) in the pre-close group and 16 patients (11.3%) in the post-close group who underwent repeat procedures. Long-term safety was analyzed in 91 (64.5%) and 98 (69.5%) patients in the pre-close and post-close groups, respectively. The major complication rate was 2/189 (1.1%), and the minor complication rate was 28/189 (14.8%). No difference in complication rates was observed between the pre-close group (0/91, 0.0% major, 12/91, 13.2% minor) and post-close group (2/98, 2% major, 16/98, 16.3% minor), with P-values of 0.50 and 0.68, respectively. No new vascular stenosis occurred during the chronic phase in either group.

Conclusion: In the long-term follow-up after femoral vein access using SMC, new-onset chronic stenosis was not observed, and reaccess was possible in repeat procedures.

Clinical trial registration: UMIN000049174.

Background: The subcutaneous implantable cardioverter defibrillator (S-ICD) and leadless pacemaker (LP) are alternative options for patients at high risk of infection requiring ICD and pacing therapy. In this analysis, we described the simultaneous implantation of S-ICD and LP in patients with high infectious risk.

Methods: The study cohort comprised patients referred to our institution for ICD implantation due to high-risk factors of infection.

Results: Between 2018 and 2022, 13 patients were referred, including 11 with infected ICD and 2 for first ICD implantation in the presence of high-risk factors. In cases of infected ICD, successful extraction was performed using a mechanical dilatation technique. Reimplantation was delayed until resolution of infection with antibiotic therapy. The devices were implanted during a single procedure, with S-ICD implantation following LP placement for verification of sensing adequacy through surface ECG screening. Suitable vectors for sensing during inhibited and ventricular pacing were identified in all patients. Defibrillation testing was effective, and no issues with double counting or undersensing were observed. The postoperative period was uneventful, and during a median follow-up of 35 months, no complications or infections were reported. The median ventricular pacing percentage was 5%, and a single inappropriate shock episode due to myopotential interference was reported and resolved by reprogramming the sensing vector.

Conclusion: Simultaneous implantation of S-ICD and LP is feasible and safe in patients at high risk of infection requiring both ICD and pacing therapy. This combined approach provides an effective solution for these patients.

Background: Limited data exist on outcomes of atrial fibrillation (AF) catheter ablation based on hospital setting and, specifically, the availability of onsite cardiothoracic surgery (CTS). We aimed to describe the characteristics and outcomes of catheter ablation for AF performed at a facility with and without CTS.

Methods: This was a retrospective study of consecutive patients who underwent catheter ablation for AF at hospital with (CTS) and without cardiothoracic surgery (N-CTS) from January 2011 through December 2019. Clinical and procedural characteristics, complications, and 1-year outcomes, including clinical events and AF recurrence, were collected.

Results: There were 326 unique patients who underwent an index AF ablation procedure: 206 CTS patients and 120 N-CTS patients. There were no differences in overall cardiac complications (2.5% vs. 5.8%), including mapping catheter entrapment requiring open-heart surgery (0% vs. 0.5%), pericardial effusion requiring pericardiocentesis (0.8% vs. 0.5%), hemopericardium (1.7% vs. 0.5%), acute myocardial infarction (0% vs. 1.0%), and sinus node injury (0% versus 0.5%) (all P values > .05) between N-CTS and CTS patients. Likewise, overall noncardiac complications (20.7% vs. 19.8%, P = .85), including bleeding, cerebrovascular accident, and phrenic or vagus nerve injury, were similar between N-CTS and CTS hospitals. Also, 1-year cumulative Kaplan-Meier estimates of overall AF recurrence (11.6% vs. 16.4%; log-rank P = 0.21; HR 1.47; 95% CI, 0.79-2.74) were not statistically significant between N-CTS and CTS hospitals.

Conclusion: Catheter ablation procedure is safe and effective regardless of onsite CTS presence, and there were no significant differences between the two hospital settings.

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.

Background: Invasive management of atrial tachycardias(ATs) requires proper diagnosis of the mechanism followed by elimination of the responsible substrate. A novel lattice-tip catheter with both high-density mapping and dual ablation properties(radiofrequency-RF/pulsed field ablation-PFA) has been recently introduced for catheter ablation of atrial fibrillation. We present the first study to assess its performance in the management of ATs (diagnostic and therapeutic).

Methods: Patients with documented ATs were selected. Activation mapping was used for the establishment of the AT mechanism. Confirmation with entrainment was performed, whenever appropriate. Accuracy of the activation mapping in diagnosis, acute ablation efficacy, and procedural characteristics were the study endpoints.

Results: Twenty patients were included (12 cavotricuspid isthmus-dependent atrial flutters, 5 mitral flutters, 2 roof flutters, and 2 focal ATs). Proper diagnosis was established by activation mapping in all cases. The mean mapping time was 7.85 ± 3.06 min with 296.82 ± 150.9 mean mapping points/minute. The mean ablation time was 54.25 ± 42.97 s. Conversion to sinus rhythm during ablation was achieved in all cases with the exception of a roof flutter that converted to mitral flutter and a case of a parahisian AT in which ablation was not attempted. Patients that received ablation did not experience any arrhythmia recurrence in a mean follow up of 4.14 ± 0.91 months. No major or minor complications occurred.

Conclusion: The lattice-tip catheter and its dedicated electroanatomical mapping system provided sufficiently detailed activation mapping for the diagnosis of the AT mechanism. The delivered lesions were highly effective acutely, with no adverse events. However, limitations exist and should be acknowledged.

Background: The sodium-glucose co-transporter 2 inhibitors (SGLT2i) have improved the outcomes of patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, their effects in cardiac resynchronization therapy (CRT) recipients are relatively scarce. This study has investigated the impact of SGLT2i treatment on clinical and echocardiographic outcomes in CRT patients at long-term follow-up.

Methods: Patients with HF, New York Heart Association (NYHA) II-III class, and LVEF ≤ 35% referred for CRT implant were enrolled. Patients were grouped in non-SGLT2i (1st group) and SGLT2i treatment (2nd group) cohorts. Clinical and echocardiographic outcomes were evaluated at 24 months. Patients were classified as CRT responders if they remained alive without HF hospitalization, experienced an improvement of at least one NYHA class, and had left ventricular end-systolic volume reduction ≥ 15%.

Results: A total of 82 patients were enrolled. At 24-month follow-up, 22 of 41 (53.6%) patients in the 1st group and 32 of 41 (78.0%) in the 2nd group were classified as CRT responders (p = 0.019). In multivariable analysis, the left bundle branch block eligible to Strauss criteria (LBBB_S) (odds ratio (OR) 9.58; confidence interval (CI) 95% 1.71-53.53; p = 0.01) and SGLT2i treatment (OR 3.32; CI 95% 1.18-9.30; p = 0.022) were independent predictors of CRT response.

Conclusion: The SGLT2i treatment in CRT patients improves the combined CRT response at long-term follow-up. In our patient cohort, the CRT response is associated with LBBB_S morphology and SGLT2i treatment.

Background: Patients undergoing cardiovascular implantable electronic device (CIED) implantation are often on direct oral anticoagulation (DOAC). However, the evidence on whether to continue or temporarily discontinue DOAC therapy during the perioperative period in these patients is unclear.

Methods: We conducted a comprehensive literature review using PubMed, Embase, and Cochrane databases through July 2024. We included studies comparing uninterrupted versus interrupted perioperative DOAC therapy in patients undergoing CIED procedure- primary implants, pulse generator replacement, and device upgrades. Primary outcomes were clinically significant device-pocket hematoma and thromboembolic events. Secondary outcomes included any device-pocket hematoma, all-cause mortality, major bleeding, and any bleeding.

Results: A total of 1,607 patients from 8 studies were included. The mean age was 73.2 years, with atrial fibrillation as the indication for DOAC therapy in most patients. The mean CHA2DS2-VASc was 3.4. Among the included studies, 2 were randomized control trials (RCTs), while the others were observational cohort studies, including one that was propensity score matched. Our meta-analysis found both strategies to be similar in terms of clinically significant pocket hematoma (RR 1.70; 95%CI 0.84-3.45; p = 0.14; I² = 0%), thromboembolic complications (RR 0.35; 95%CI 0.04-3.32; p = 0.36; I² = 19%), any pocket hematoma, all-cause mortality and any bleeding with a higher risk of major bleeding with uninterrupted anticoagulation.

Conclusion: This meta-analysis shows that uninterrupted DOAC therapy is comparable to interrupted therapy for CIED procedures, with a potential increase in major bleeding risk but low overall complication rates. Further research is needed to confirm the best approach of periprocedural anticoagulation in these patients.

Introduction: Atrial cardiomyopathy (AC) establishes links between atrial fibrillation (AF), left atrial (LA) mechanical dysfunction, structural remodeling, and thromboembolic events. Early diagnosis of AC may impact AF treatment and stroke risk prevention. Modern endocardial contact-mapping provides high-resolution electro-anatomical (EA) maps of the LA, thus allowing to display the myocardial substrate based on impaired signal amplitude and to characterize AC. Correlation of invasively assessed AC using a novel, multipolar mapping catheter (OCTARAY™, Biosense Webster, limited market release) and LA echocardiographic parameters could form the basis for a set of echo parameters for non-invasive prediction of AC.

Methods: We retrospectively identified 50 adult patients who underwent primary pulmonary vein isolation (PVI) for paroxysmal or persistent AF between 08/22 and 05/23 fulfilling the selection criteria: (i) EA mapping with a novel multipolar mapping catheter (Octaray®); (ii) acquisition of voltage maps in sinus rhythm (SR) with ≥ 5000 points/map; and (iii) transthoracic echocardiography acquired in SR ≤ 48 h before PVI. Exclusion criterion was previous LA ablation. We generated EA maps with two sets of upper voltage thresholds (0.2-0.5 mV and 0.2-1.0 mV) and assessed total LA low voltage area (LVA). As LVA thresholds for the classification of AC are not yet established, an unsupervised machine learning cluster analysis was performed using a Gaussian mixture model (GMM), and two groups of patients with mild and severe AC were identified. Based on these two groups, we selected echo parameters for further analysis by applying the Boruta algorithm. The predictive capacity of the selected parameters was evaluated using a support vector machine.

Results: The mean age of the studied sample (n = 50) was 63 ± 11 years, 62% were men, 64% showed persistent AF, median CHA₂DS₂-VASc score was 2 (quartiles 1, 3), and NT-proBNP was 190 (71, 391) pg/ml. A median of 5771 (5217, 6988) points/map were acquired. GMM yielded clusters of mild AC (n = 28) and severe AC (n = 22). Median LVA was 0.6 cm² (< 0.5 mV) resp. 4.1 cm² (< 1.0 mV) in group mild AC and 6.9 cm² (< 0.5 mV) resp. 27.2 cm² (< 1.0 mV) in group severe AC. Several echocardiographic parameters differed between the groups of mild and severe AC: dynamic LA parameters (end diastolic LA reservoir strain: 24.5% (22, 29) vs 15% (12, 19), p < 0.001; LA reservoir strain at atrial contraction: 22% (19, 25) vs 15% (11, 18), p < 0.001, end diastolic LA contraction strain: 13% (8, 15) vs 7.5% (3, 13), p < 0.01) as well as LA end-systolic volume index to a´ ratio (LAVI/a': 297 (231,365) vs 510 (326,781), p < 0.01). Consistent distribution of NT-proBNP (mild AC: 125 (48,189) pg/ml, severe AC: 408 (254,557) pg/ml, p < 0.0001) and CHA₂DS₂-VASc score (mild AC: 1 (1-