Journal of Interventional Cardiac Electrophysiology最新文献

Background: The time from the initial diagnosis of atrial fibrillation (AF) to the index ablation procedure, known as diagnosis-to-ablation time (DAT), is a modifiable risk factor that is correlated to affect the recurrence of AF. The objective of this meta-analysis was to examine the correlation between diagnosis-to-ablation time and AF recurrence.

Methods: A systematic search was performed in PubMed, Google Scholar, and Cochrane Library from database inception till June 2024. Studies reporting diagnosis-to-ablation time and its relation with AF recurrence were included. The primary analysis evaluated outcomes segregated by DAT ≤ 1 year versus > 1 year. Random-effects model with the Mantel-Haenszel method was used to evaluate AF recurrence.

Results: Of the 9177 articles, only 6 observational studies got through the inclusion criteria with a total participant count of 14,862. DAT of greater than 1 year was associated with increased risk of AF recurrence in all the included studies while DAT of ≤ 1 year was correlated with lower risk of AF recurrence (RR, 0.76 (95% CI, 0.73-0.79); P < 0.01). Similarly, DAT of ≤ 3 years was correlated with lower AF recurrence risk (RR, 0.82 (95% CI, 0.79-0.85); P < 0.01).

Conclusion: Evidence from observational cohorts suggests that the optimum time for ablation in AF patients is less than 1 year and a DAT of ≤ 1 year is linked to 24% lower chances of recurrence in AF patients, compared to DAT of ≥ 1 year.

Background: The radiofrequency (RF) lesions obtained using very high-power short-duration (vHPSD) are shallower compared to high-power sort-duration (HPSD) or conventional ablation settings. Thus, there is a possibility that vHPSD RF applications may not achieve transmurality at thick parts of the anterior aspects of the pulmonary vein (PV)-left atrial (LA) wall junction. The aim of the study was to compare acute efficacy of pulmonary vein isolation (PVI) using vHPSD versus HPSD guided by AI ablation at the anterior aspects of PV in patients undergoing atrial fibrillation (AF) ablation.

Methods: The A-Q-RATE POWER Trial was a prospective, dual-center, randomized study. Patients were assigned to receive vHPSD versus HPSD ablation delivered at the anterior aspects of PV. In both arms, the posterior parts of PV were ablated with vHPSD. The primary outcome was the need for additional RF applications at the anterior aspect of PVs to achieve complete PVI.

Results: Seventy patients were randomly assigned to vHPSD (n = 35) or HPSD (n = 35). The vHPSD group required more touch-up RF applications at the anterior aspects of PV than the HPSD group (46% vs 19%, p < 0.001), especially at the right PVs (57% vs 20%, p = 0.001) compared to the left PVs (34% vs 17%, p = 0.1). The median duration of the procedure, LA dwell time, and fluoroscopy time were similar in both groups (112 [IQR 90-130] min vs 107 [90-125] min, p = 0.58; 95 [70-106] min vs 90 [71-100] min, p = 0.55; and 28 [IQR 14-69] s vs 46 [IQR 0-89] s, p = 0.97,respectively).

Conclusion: The proposed hybrid strategy is associated with a significantly lower need for additional touch-up RF applications than vHPSD only, without extending procedural and fluoroscopy duration.

Background: Fibrillatory wave amplitude (fWA) on 12-lead ECG predicts the outcome of ablation in atrial fibrillation (AF). We hypothesized that changes in fWA following wide circumferential isolation of pulmonary veins (WPVI) in persistent AF (peAF) is a better predictor of ablation outcome compared to baseline fWA.

Methods: Eighty-nine patients (sustained peAF 7 ± 7 months) underwent a first-time WPVI. Sixty-second ECG signals devoid of QRST waves were recorded at baseline and at the end of the WPVI (endWPVI). fWA for each ECG lead and mean fWA (meanfWA) across the 12-lead ECG were computed. Patients with recurrence after the index WPVI underwent a redo to ensure complete PVI. The primary endpoint was long-term AF freedom OFF antiarrhythmics drugs (AADs) after one or two WPVI (SUCCESS group). The FAILURE group was defined as AF recurrence post-redo.

Results: Over a mean follow-up of 35 ± 10 months, freedom from AF OFF AADs was achieved in 61% (SUCCESS group), while 29% had AF recurrence after redo WPVI (FAILURE group). The SUCCESS group showed significantly higher fWA values in ECG leads V₁, V₄, and V₅ at baseline (p < 0.05), as well as in leads III, aVL, aVF, and V₄, and in meanfWA at endWPVI (p < 0.05) compared to the FAILURE group. A baseline mean fWA ≥ 0.044 mV or a decrease in mean fWA ≤ 11% following WPVI predicted long-term sinus rhythm restoration with a sensitivity of 81% and a specificity of 69% (p < 0.05).

Conclusion: Low fWA values and a significant reduction in fWA following WPVI are associated with a high risk of AF recurrence in patients with peAF.

Background: Transcatheter aortic valve replacement (TAVR) is occasionally complicated by high degree atrioventricular block (AVB) requiring permanent pacemaker (PPM) placement. Newer valve design, delivery platform evolution, and deployment technique refinement have lowered this risk. Ventricular pacing ≥ 30% has been previously identified as a predictor for worse clinical outcomes in this population. This study aims to assess the prevalence of high long-term pacing burden in this cohort.

Methods: This is a retrospective study to evaluate patients from 2019 to 2023 who required PPM for high degree AVB following TAVR. Baseline demographics, clinical characteristics, procedural details were obtained. Ventricular pacing (VP) percentages were collected from PPM interrogations at 1, 6 and 12 months.

Results: 138 patients had PPM placement post-TAVR. Approximately one third of patients demonstrated ventricular pacing less than 25% at 1 month, 6 months, and 12 months (Fig. 1). Roughly 50% of patients had > 75% ventricular pacing at 1 month, 6months and 12 months. There was no difference in baseline demographics or EKG characteristics at 1 month. In a univariable logistic regression analysis, there were no statistically significant predictors of VP ≥ 30%. Although, balloon expandable valves and lower STS scores demonstrated an association with lower risk of VP ≥ 30%.

Conclusions: Our study suggests that a significant portion of patients with PPM for high degree AVB after TAVR have low pacing burden at 6-12 months. Further investigation is needed to assess valve-specific predictors and alternative pacing approaches of AVB management.

Background: The identification of potential gap sites after pulmonary vein isolation (PVI) and prevention of these warning points during ablation are crucial. We evaluated the changes in peak frequency (PF) on electrograms and examined the relationship between its value and the residual pulmonary vein (PV) gap after PVI.

Methods: We included patients with a PV gap after PVI with a power setting of 50 W using a novel irrigated-tip catheter (TactiFlex, Abbott). The PF on bipolar electrograms in the ablation catheter was recorded immediately before and after ablation at all available ablation points, using Omnipolar technology near field. We compared the pre- and post-PF values, changes in PF, contact force, and impedance drop between points with and without a PV gap following PVI.

Results: A total of 695 ablation points in 13 patients were analyzed. There were 19 and 676 points with and without the PV gap, respectively. The PV gap group demonstrated significantly lower PF drop and contact force (-14 ± 43 Hz vs. 61 ± 57 Hz, p < 0.001; and 8 [7-10] g vs. 10 [4-14] g, p = 0.039), and higher post-PF (226 ± 49 Hz vs. 176 ± 47 Hz, p < 0.001) than in the non-PV gap group. The PF drop had the highest area under the curve of 0.878 (95% confidence interval: 0.791-0.964) on receiver operating characteristic curve analysis for predicting the PV gap, with a cutoff value of 10.5 Hz (sensitivity, 81.8%; specificity, 89.5%).

Conclusion: PF drop during PVI is a useful parameter for predicting the non-PV gap with a high probability.

Background: Treatment of PAF with PVI is the gold standard approach. Recently, esophageal cooling has been shown to significantly reduce the risk of esophageal injury during thermal ablation. This study investigated outcomes of HPSD before and after instituting esophageal cooling.

Methods: In this natural experiment, we enrolled 346 consecutive patients with PAF undergoing initial ablation using HPSD, 143 patients immediately prior to and 203 patients immediately after switching from luminal esophageal monitoring (LET arm) to esophageal cooling with ensoETM (ensoETM arm). The primary endpoint was time-to-atrial arrhythmia recurrence.

Results: The procedure times were significantly faster with ensoETM (82.9 ± 27 vs 112 ± 49 min, p < 0.0001). At a median follow-up of 10.3 ± 3.4 months, the atrial arrhythmia recurrence rate did not significantly differ between LET and ensoETM arms (25.2% vs 30.0%, p = 0.3202). Kaplan-Meier analysis showed no significant difference in the overall atrial arrhythmia recurrence (log-rank, p = 0.3780). Statistical analysis of all notable comorbidities revealed no significant association with procedural outcomes.

Conclusion: In patients with PAF undergoing an initial ablation procedure with HPSD, esophageal cooling led to significantly faster procedures, with no decrease in efficacy.