Journal of Interventional Cardiac Electrophysiology最新文献

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.

Introduction: Currently, there is no reliable endpoint for the conclusion of atrial fibrillation (AF) ablation. Atrial burst pacing and/or isoproterenol challenge are poor diagnostic tools. A newly proposed vagal AF induction test (VAFIT) uses effective atrial refractory period measurement, simultaneously with extra-cardiac vagal stimulation (ECVS) to study AF inducibility pre- and post-ablation. This is a prospective study in patients submitted to radiofrequency catheter pulmonary vein isolation (PVI) plus cardioneuroablation (CNA) evaluating the VAFIT result before and at the end of the procedure with AF recurrence.

Methods: Prospective study of 142 patients, 57.5 (48.9-70.2) years old, 71% males, with symptomatic AF (79.6% paroxysmal/20.4% persistent), left atrium diameter of 38.0 (35.0-41.2) mm, and left ventricular ejection fraction of 63.0 (62.0-68.2). VAFIT was considered positive or negative depending on whether AF induction occurred. It was performed at baseline and after PVI + CNA, with a single atrial extra stimulus during ECVS (5 s/50 Hz/1 V/kg up to 70 V/pulse width = 50 µs). Patients were followed for a median of 15.0 (7.0-20.0) months. The association of VAFIT-positive status at the end of the procedure with AF recurrence was investigated by univariate and multivariate Cox regression analysis.

Results: Pre-ablation VAFIT was positive in all cases and became negative in 62.9% of patients. AF recurrence: 18.7% in VAFIT-positive and 5.6% in VAFIT-negative patients (p = 0.012). VAFIT-positivity was associated with AF recurrence (HR 4.56 (1.37-15.23, p = 0.014).

Conclusion: A VAFIT-positive status following PVI + CNA was strongly and independently associated with AF recurrence. VAFIT negative status reduced 4.5 times the post-ablation AF recurrence. It remains to be investigated in randomized studies whether achieving VAFIT-negativity at the end of the procedure, as demonstrated in this study, would lead to better clinical outcomes.

Background: Pulmonary vein isolation (PVI) is a cornerstone of AF ablation. Posterior wall isolation (PWI) has become a frequently used adjunct to PVI. While there is data to suggest that PVI alone does not negatively impact left atrial function, the effect of PWI on left atrial mechanical function has not been definitively determined. Our aim was to determine if PVI plus PWI using a cryoballoon impacted left atrial mechanical function as measured by cardiac MRI.

Methods: We studied 28 patients who underwent ablation for AF. Fourteen patients had PVI alone and 14 patients had PVI plus PWI. All patients had cardiac magnetic resonance (CMR) before and after ablation. The primary outcome was change in LA ejection fraction (LAEF) as measured by CMR.

Results: There were no statistically significant differences in the average patient age, height, weight, type of AF, or frequency of concomitant diseases between groups. No statistically significant differences in LAEF, LA max volume, LA min volume, or LA stroke volume were identified between baseline and follow up CMRs for the PVI only group nor the PVI plus PWI group. When utilizing linear regression analysis to compare change in LAEF, LA max volume, LA min volume, and LA stroke volume before and after ablation between groups, no statistically significant differences were identified.

Conclusion: Cardiac MRI did not demonstrate a significant change in left atrial mechanical function as measured by left atrial ejection fraction after pulmonary vein isolation alone nor after PVI plus posterior wall isolation.

Background: Left atrial appendage occlusion (LAA-O) with Amulet and Watchman FLX are approved for reducing stroke risk in patients with atrial fibrillation when oral anticoagulation is not tolerated. Real world clinical outcomes reported along with imaging data are needed to help clinicians choose between these two technologies and manage device-related complications.

Methods: The study retrospectively analyzed clinical, transesophageal (TEE), and available computed tomography (CT) data from 364 FLX and 292 Amulet procedures performed at an academic medical center over a 4-year period.

Results: LAA-O procedures were successful in 96.7% FLX and 97.3% Amulet cases. FLX implant success rate increased to 98.9% when only patients with LAA diameter to depth ratio < 1.8 and LAA area < 4.4 cm² were included. TTE LAA-orifice area correlated with CT-derived measurements. There were more late pericardial effusions for Amulet (3.1%) compared to FLX (0.3%), though the majority were conservatively managed. Mean procedure times were similar (FLX 64 ± 24, Amulet 65 ± 21 min) as were the rates of device related thrombus (FLX 1% and Amulet 1.4%). Clinically relevant peridevice leak (PDL) on follow-up TEE imaging was greater for FLX (16%) compared to Amulet (10%). Combined AF ablation-LAA-occlusion procedures exhibited lower rates of PDL and late pericardial effusions compared to solo procedures.

Conclusions: Based on retrospective analysis, an initial strategy with Watchman FLX in patients with favorable LAA anatomy would reduce the risk of late pericardial effusions at the expense of a higher rate of clinically relevant PDL compared to Amulet. Combined AF ablation and LAA-O procedures exhibit less PDL.

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: Bipolar radiofrequency catheter ablation (B-RFA) has shown promising results in refractory ventricular arrhythmias (VAs) of septal origin and underlying non-ischemic cardiomyopathy. However, its efficacy and safety in other locations, such as papillary muscles (PM) or with different underlying substrates has yet to be fully determined.

Objective: To describe the procedure data, safety, and efficacy of B-RFA in a cohort of patients with VAs of different locations and underlying substrates and to generate new hypotheses.

Methods: We prospectively enrolled 26 patients with VAs, of whom 21 ultimately underwent B-RFA during the ablation procedure. Of these, 17 were redo procedures. Thirteen patients presented ventricular tachycardia (VT), and eight patients had ventricular ectopy (VE). Procedure data, related complications and acute and long-term outcomes during follow-up were assessed.

Results: Of the 21 patients, 76.2% were male, and the mean age was 60.8 ± 15.4 years. Fourteen patients had underlying substrate, and 7 had no structural heart disease. The VA originated from the septum (n = 9), lateral wall (n = 7), and PM (n = 5). Acute success, defined as the absence of the clinical VE or non-inducibility of VT at the end of the procedure, was achieved in 20 patients (95.2%). At 12-month follow-up, 8 (61.5%) patients with VT did not present any sustained arrhythmia or ICD therapy, and 6 (75%) patients with VE had a > 90% reduction in their burden on the 24-h Holter. Papillary muscle VAs seemed to present lower acute and long-term success after B-RFA. The use of B-RFA in PM, compared to other cardiac locations, required a greater number of radiofrequency applications (p = 0.010) with lower mean contact force (p = 0.001) and impedance drop (p = 0.010). No major peri-procedural complications were observed.

Conclusions: Bipolar RF delivery can be used safely and successfully for VAs of septal and free wall origin but may have more limited use for PM arrhythmias. In this location, B-RFA exhibits reduced energy transfer, as does conventional ablation. No differences in procedural data or outcomes of B-RFA are observed based on the underlying substrate.

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.