Journal of Interventional Cardiac Electrophysiology最新文献

Background: Single chamber atrial pacing (AAI) provides a disease-specific treatment for sick sinus syndrome (SSS) but has largely been replaced by DDD pacing. With the advent of leadless atrial pacemakers (PM), there is growing interest in long-term follow-up data in patients with SSS and an AAI pacemaker.

Purpose: To assess the incidence of system upgrade in patients treated with AAI-PM for SSS during long-term follow-up.

Methods: This is an analysis of prospectively enrolled patients undergoing implantation of an AAI-PM. Wenckebach block point (WBP) was measured at implantation and serially during follow up.

Results: We included 178 patients (58% female, median age at implantation 77 [71-83] years). The median follow-up duration was 6.5 [2.0-9.7] years. Twenty-three patients (13%) received a system upgrade to a DDD system, corresponding to a yearly upgrade rate of 2.0%. Median time to system upgrade was 5.2 [1.6-8.7] years. Reasons for system upgrade were higher-degree AVB (39%), atrial arrhythmias (35%), low WBP (17%), and syncope (9%). Median WBP at implantation was 130 [120-140] bpm, showing a significant decline over time in the upgrade-group compared to the rest of the cohort with 103 [91-130] bpm vs. 130 [120-130] bpm (p = 0.011).

Conclusion: In this cohort of patients undergoing AAI-PM implantation for SSS, upgrade to a DDD system was low during long-term follow-up. Therefore, AAI pacing for the treatment of SSS may be considered a patient-tailored treatment option, especially in light of novel leadless pacing therapies.

Background: Skin antisepsis plays a key role in the prevention of cardiac implantable electronic device (CIED) infections. Moreover, skin antisepsis by chlorhexidine-alcohol has not yet been fully evaluated.

Objectives: This single-center controlled study sought (1) to conduct a prospective observational analysis comparing two antiseptic skin preparations over two similar consecutive time periods, one conducted over a 1-year period using a povidone-iodine-alcohol solution (group I) and the other over the following year with a chlorhexidine-alcohol solution (group II) and (2) to determine real-life CIED infection predictive factors using the Prevention of Arrhythmia Device Infection Trial (PADIT) score.

Methods and results: CIED implantations were performed in 1689 patients. A total of 17 patients (1.01%) developed a CIED infection. Long-term follow-up (16 ± 13 months) revealed no significant differences between groups: infections were observed in 9/844 patients (1.07%) in group I versus 8/845 patients (0.95%) in group II (p = 0.99). Univariate and multivariate logistic regression analyses were performed to identify infectious risk factors. Adjusted odds ratios (ORs) and hazard ratios (HRs) were calculated. Univariate analyses revealed that infection occurrence was positively correlated with acute heart failure (OR: 3.55; 95%CI [1.24-9.37]; p = 0.01 and HR: 3.37; 95% CI [1.28-8.87]; p = 0.014), renal failure (OR: 2.71; 95% CI [0.88-8.42]; p = 0.08 and HR: 2.99; 95% CI [0.97-9.17]; p = 0.05), use of temporary pacing before the implantation procedure (OR: 4.45; 95% CI [1.003-20.3]; p = 0.04 and HR: 4.35; 95% CI [0.99-19.05]; p = 0.05), PADIT score (OR: 1.3; 95% CI [1.064-1.54]; p = 0.009 and HR: 1.27; 95% CI [1.052-1.53]; p = 0.013), and PADIT score ≥ 5 (OR: 4.185; 95% CI [1.6-10.9]; p = 0.003 and HR: 3.91; 95% CI [1.51-10.149]; p = 0.005). No clear significant difference was found regarding the antiseptic skin preparation choice (OR: 0.88; 95% CI [0.34-2.3]; p = 0.8 and HR: 1.11; 95% CI [0.416-2.98]; p = 0.82). In multivariate analysis, the PADIT score ≥ 5 (OR: 3.18; 95% CI [1.125-8.99]; p = 0.003 and HR: 3.052; 95% CI [1.089-8.55]; p = 0.034) and use of temporary pacing before the implantation procedure (OR: 8.44; 95% CI [1.68-42.34]; p = 0.01 and HR: 8.49; 95% CI [1.732-41.69]; p = 0.008) were negatively correlated with the device infection risk.

Conclusion: This study found that chlorhexidine-alcohol and povidone-iodine-alcohol solutions displayed similar antiseptic effects regarding CIED infection prevention. Both use of temporary pacing before the implantation procedure and PADIT score ≥ 5 correlated with the device infection risk.

Background: Dilated cardiomyopathy (DCM) and cardiac sarcoidosis (CS) manifest unique late gadolinium enhancement (LGE) patterns on cardiac magnetic resonance (CMR), indicative of different myocardial scar distributions. However, the overlap in these patterns due to their lack of specificity complicates differentiation. This study introduces a novel quantitative method employing z-score analysis of LGE-CMR intensity to objectively compare the spatial distribution of LGE intensity between DCM and CS.

Methods: This retrospective study included 22 NICM patients (13 DCM, 9 CS) who underwent CMR before electrophysiology study from November 2018 to May 2023. LGE images were delineated into sub-endocardial, mid-myocardial, and sub-epicardial layers across anterior, lateral, inferior, and septal walls using the AHA 17-segment model. CMR signal intensities were standardized to z-scores (z = (x - μ)/σ), with x as the signal intensity for a specific myocardial segment, and μ and σ as the mean and SD for all LV myocardial segments, to map regional intensity variations.

Results: Compared to DCM, CS patients exhibited significantly higher CMR signal intensity z-scores in the septum (β = 0.32, p = 0.009), particularly in the endocardial third of the right ventricular (RV) side (β = 0.56, p = 0.001). A z-score greater than 0.40 in this area was associated with a CS diagnosis, with an area under the ROC curve of 0.692 in fivefold cross-validation.

Conclusion: Patients with CS exhibit higher affinity for contrast in the septum, particularly on the RV endocardium. Standardized analysis of CMR signal intensities provides a novel, quantitative method for distinguishing CS from DCM, with the former exhibiting higher CMR signal intensity z-scores in the septum.

Background: Patients with chronic right ventricular (RV) pacing are at risk for developing pacing-induced cardiomyopathy (PICM). Data regarding the incidence of PICM when pacing the RV septum using a leadless pacemaker (LP) are limited. Left bundle branch area pacing (LBBAP) has emerged as a viable alternative to RV pacing with a low incidence of PICM.

Methods: All patients who received either a LP capable of providing atrioventricular (AV) synchronous pacing or a permanent pacemaker (PPM) with a LBBAP lead (lumenless or stylet-driven leads) for AV block between January 2021 and January 2023 at a single center were screened. Patients were included in the final analysis if they had both a pre- and post-operative transthoracic echocardiogram, pre- and post-operative electrocardiograms, and a pacing burden of ≥ 20%. The incidence of PICM, defined as a decrease in the left ventricular ejection fraction (LVEF) by ≥ 20% and to a value < 50% after a follow-up of at least six months, was compared between LBBAP and LP groups.

Results: Over the study period, 533 PPMs were implanted for AV block. Of these, 95 patients met the inclusion criteria; 70 underwent LBBAP and 25 received LPs. The average age of the population was 75 ± 13 years; 64 (63%) were men. There was no difference in the mean pre-operative LVEF (57% ± 16% vs. 61% ± 10%; p = 0.25) or QRS duration (123 ± 33ms vs. 130 ± 29ms) between the LBBAP and LP groups. There was a high burden of ventricular pacing in both groups (90% ± 19% vs. 92% ± 13%; p = 0.52). After a follow-up of 14 ± 8 months, the incidence of PICM was significantly lower in the LBBAP group compared to the LP group (4.3% vs. 24%; p = 0.0039).

Conclusion: In patients who are not candidates for cardiac resynchronization, who require a high burden of ventricular pacing, LBBAP may lead to a lower incidence of PICM than right ventricular septal pacing with a LP.

Background: Peak frequency (PF) analysis has emerged as a novel tool for identifying arrhythmogenic substrates in ventricular tachycardia (VT) ablation, particularly when combined with traditional substrate mapping techniques such as voltage mapping and Isochronal Late Activation Mapping (ILAM). This study evaluates the utility of PF analysis in scarred myocardial regions, with a focus on areas containing manually annotated late potentials (LPs).

Methods: Electroanatomical mapping using the EnSite X™ system was performed in 20 patients undergoing VT ablation. PF analysis was applied to scarred regions with voltages < 1.5 mV, with and without LPs, to identify zones of high-frequency activity. PF zones (PFZs) were compared to voltage maps and ILAM to assess spatial correlation with deceleration zones (DZs) and their role in defining ablation targets.

Results: Peak frequency distributions differed significantly across myocardium conditions (H = 254.92, p < 0.0001). The median peak frequency was 120.0 Hz (77.3-179.0 Hz) in normal voltage myocardium, 145.0 Hz (100.0-194.3 Hz) in low-voltage myocardium without LPs, and 291.0 Hz (190.3-380.3 Hz) in low-voltage myocardium with LPs. Pairwise comparisons showed significant differences: normal voltage vs. low voltage without LPs (U = 46,455.0; p = 0.0019), normal voltage vs. low voltage with LPs (U = 20,935.5; p < 0.0001), and low voltage without LPs vs. low voltage with LPs (U = 19,548.0; p < 0.0001). PFZs exhibited strong colocalization with DZs identified via ILAM, with > 50% spatial overlap in most cases. The automated peak frequency annotation algorithm demonstrated high reproducibility, significantly reducing operator dependency compared to manual annotation.

Conclusion: PF analysis provides a robust and reproducible method for identifying arrhythmogenic substrates in VT ablation. When integrated with voltage mapping and ILAM, it facilitates precise localization of critical ablation targets, particularly in regions with LPs. These findings highlight the potential of PF analysis to enhance the efficacy of substrate-based ablation strategies.

Background: Cardiomyopathy (CM) is associated with atrial remodeling and atrial fibrillation (AF), often complicating rhythm management. Ventricular dysfunction contributes to AF through pressure and volume overload, while AF worsens ventricular function via tachycardia and irregular activation. Evidence suggests catheter ablation improves outcomes in CM patients, though success is influenced by the extent of atrial and ventricular remodeling.

Methods: Patients undergoing their first catheter ablation for AF were divided into hypertrophic (HCM), ischemic (ICM), non-ischemic (NICM), and no-CM groups. Pre-ablation late-gadolinium enhancement cardiac magnetic imaging (LGE-MRI) was used to assess left atrial (LA) fibrosis burden and anatomical distribution. Patients were followed prospectively for arrhythmia recurrence.

Results: A total of 552 patients, 39 HCM (69% obstructive), 39 ICM, 115 with NICM, and 359 without CM were included between January 2015 and December 2022. LA fibrosis was significantly higher in patients with CM (19.1 ± 7.5% vs. 16.5 ± 6.9%; P = 0.01). HCM and ICM had the greatest LA fibrosis among the different CM subtypes (21.3 ± 8.7% and 21.9 ± 9.1%, respectively). There was no significant difference in the regional distribution of fibrosis among the various groups. AF recurrence was observed in 321 (58.2%) after 456 (175-1204) days. Multivariate analysis revealed that compared to no CM, HCM was associated with a three-fold increase in AF recurrence (HR = 3.07, 95% CI 2.06-4.58, P < 0.001), followed by ICM (HR 1.61, 95%, CI 0.95-2.72; P = 0.07) and NICM (HR of 1.53, 95% CI 1.14-2.06; P = 0.05). LA fibrosis and volume index were independently associated with recurrence (HR = 1.03, 95% CI 1.01-1.06, P = 0.01 and HR = 1.02, 95% CI 1.01-1.03, P = 0.01). Genetic testing revealed key distinctions between HCM and NICM, with MYBPC3 and MYH7 as prominent genes in HCM and a heterogeneous genetic basis in NICM.

Conclusion: Hypertrophic cardiomyopathy is associated with the highest risk of AF recurrence followed by ischemic and non-ischemic cardiomyopathy after catheter ablation. LA fibrosis regional patterns did not differ between cardiomyopathy types, while overall fibrosis and volume predicted recurrence.

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.