Journal of Interventional Cardiac Electrophysiology最新文献

Introduction: Pulsed field ablation (PFA) is a non-thermal energy source for catheter ablation associated with shorter procedure time, less risk of esophageal injury, and less dependence on absolute catheter stability compared with radiofrequency ablation. Limited data are available on performing the procedure with deep sedation (DS) as an alternative to general anesthesia (GA) utilizing endotracheal intubation.

Methods: Patients who underwent PFA using DS between March and August 2024 were retrospectively included. DS was administered by anesthesia staff, consisting of propofol, dexmedetomidine, fentanyl, and midazolam, at the discretion of the practitioner. The primary endpoint was the rate of airway complications or requirement for conversion to GA. Secondary endpoints were the rate of acute procedural success, total time in the EP lab, procedure time, and non-procedure time.

Results: A total of 100 patients (mean age 71.9 ± 11.6 years, BMI 30.1 ± 7.1, 51% females) were included in the analysis. There were no instances of airway complications or conversion from DS to GA. There was a 100% rate of acute isolation of pulmonary veins. The average total time in the lab was 149.7 ± 44.7 min, consisting of a mean procedure time of 98.3 ± 40.5 min and a non-procedure time of 51.4 ± 12.2 min.

Conclusions: In this study conducted at a single health system, DS for PFA was feasible and associated with no instances of airway complications nor conversion to GA. The findings may not apply to patients with moderate or severe obstructive sleep apnea or other pulmonary diseases.

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: 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: Patients undergoing atrial fibrillation (AF) catheter ablation may require redo procedures involving pulmonary vein (PV) re-isolation and/or ablation of extra-PV sites. Pulsed field ablation (PFA) offers a highly selective energy source for cardiac tissue, with the potential to reduce collateral damage to adjacent structures. This study aimed to evaluate the feasibility and efficacy of redo ablation using a pentaspline PFA system.

Methods: Patients undergoing redo procedures with a pentaspline PFA system at three international centers were enrolled. A workflow was established based on rhythm at presentation: sinus rhythm (Group 1), atrial flutter/atrial tachycardia (Group 2), or AF (Group 3). Propensity score matching was used for comparison between PFA- and RF-based redo ablations.

Results: A total of 117 patients were included (Group 1: 64, Group 2: 18, Group 3: 35). PV re-isolation was required in 71.9% and 72.2% of Group 1 and 2 patients, respectively. PFA terminated all cases of non-cavotricuspid isthmus dependent flutter and 45.7% of cases of AF. One major complication (0.9%; frontal cerebral hematoma) was documented. Freedom from atrial tachyarrhythmias at 12 months was 78.3% (95% CI 69.6-84.8%) without statistically significant differences among groups (Group 1: 85.7%; Group 2: 77%; Group 3: 65.5%; p = 0.053). PFA led to similar arrhythmia freedom compared to RF, but with significantly shorter procedural and dwelling times.

Conclusion: The adoption of a pentaspline PFA system for repeat ablation procedures was feasible, safe, and effective at 1-year follow-up. No clinical differences were observed between PFA and RF; however, redo PFA cases were significantly shorter.

Introduction: A hybrid approach with very high-power short-duration (vHPSD) posteriorly and ablation-index guided HPSD (50 W) anteriorly seems to be an optimal balance between efficiency and effectiveness for point-by-point pulmonary vein isolation (PVI). The aim of the current study is to compare vHPSD/HPSD ablation to cryoballoon ablation (CBA) in patients with symptomatic atrial fibrillation (AF).

Methods and results: In this retrospective single-center study, we identified 110 consecutive patients who underwent their first PVI with either vHPSD/HPSD (n = 54) or CBA (n = 56). We compared procedural efficacy, efficiency, safety, and long-term outcomes. Baseline characteristics of both groups were comparable; however, patients in the vHPSD/HPSD group had larger left atrial volume index (35, IQR 27-45 vs. 28, IQR 21-36 ml/m², P = 0.005). Complete PVI was achieved in all patients except two CBA cases (100% vs. 96.4%, P = 0.50). First-pass isolation rate was 79.6% in the hybrid group. Procedure times were similar between groups (53, IQR 47-63 vs. 55, IQR 49-65 min, P = 0.35), but fluoroscopy time was shorter in the vHPSD/HPSD group (3.9 [2.7, 5.6] vs. 11.9 [9.3, 14.9] min, P < 0.001). There were 3 temporary phrenic nerve palsies (5.4%) in the CBA group which resolved within 1 year. The 1-year freedom from any atrial tachyarrhythmias after a single procedure was similar between groups (68.5% vs. 73.2%, P = 0.56). During repeat procedure, the durability of PVI was comparable.

Conclusions: The use of vHPSD/HPSD ablation renders point-by-point PVI as fast and effective as CBA. Furthermore, it has lower radiation exposure compared to CBA.

Background: Patients with transposition of the great arteries (TGA) who undergo atrial switch procedures may develop symptomatic atrial arrhythmias necessitating ablation. We present a single-centre retrospective analysis of a novel approach using jugular access for catheter ablation in this unique patient population.

Methods: A 5-year retrospective analysis was conducted on patients referred for atrial arrhythmia ablation following atrial switch procedures. Procedures were performed by experienced operators, and data on patient demographics, procedural characteristics, and outcomes were collected. Statistical analysis was performed to compare outcomes between jugular and femoral access groups.

Results: Jugular access (N = 9) and femoral access (N = 13) cohorts were comparable in age, gender distribution, and clinical characteristics. Procedural success rates were high in both groups, with no significant difference in recurrence rates. Jugular access demonstrated a comparatively safe profile compared to femoral access.

Discussion: The jugular approach offers a viable alternative to femoral access for atrial arrhythmia ablation in patients with atrial switch procedures. The trajectory from the internal jugular vein to the baffle is straightforward, reducing vascular complications. Success rates and procedural times were comparable, highlighting the feasibility and safety of the jugular approach. The option for rapid post-procedural mobilisation adds to its appeal.

Conclusion: Atrial arrhythmia ablation with jugular access in patients with atrial switch procedures is safe and effective, providing an alternative in cases where femoral access may pose challenges. This approach warrants consideration in the management of atrial arrhythmias in this unique patient population.

Background: An electrophysiology (EP) recording system is recommended throughout the left bundle branch area pacing (LBBaP) procedure. However, the requirement of an EP recording system limits the wide adoption of LBBaP in non-EP laboratory settings. Thus, in this study, we proposed a novel set-up in non-EP laboratories using manufacturer pacing system analyzer (PSA)-derived electrogram guidance and fluoroscopy of the angiography system for LBBaP.

Methods: Our study prospectively enrolled consecutive patients who underwent LBBaP for bradyarrhythmia indications. LBBaP was performed using a stylet-driven lead (SDL) delivered through a dedicated delivery sheath. Procedural characteristics were recorded at the implant. The agreement of measurements on the modified 3-lead ECG of PSA and standard 12-lead ECG was analyzed.

Results: A total of 83 patients were enrolled (mean age 65.4 ± 11.8 years, 55.4% male). The LBBaP with an SDL was successful for all patients. The pacing response was observed as LBBP in 69.9% of cases, while 30.1% were classified as left ventricular septal pacing. The mean paced QRS duration (pQRSd) and the stimulus to left ventricular activation time (LVAT) were measured at 117.6 ± 11.4 ms and 68 ± 17 ms using a modified 3-lead ECG of PSA, compared to 118.5 ± 11.8 ms and 70 ± 13 ms using the standard 12-lead ECG, with agreements of 0.89 and 0.93, respectively. SDL-LBBaP resulted in low unipolar and bipolar pacing thresholds (0.7 ± 0.2 V at 0.4 ms and 0.8 ± 0.2 V at 0.4 ms), which remained stable at a median 12-month follow-up (p > 0.05). An atrial lead revision was needed for one (1.2%) patient during the first-month visit. Acute interventricular septal perforation occurred in two (2.4%) patients as a specific complication of LBBaP.

Conclusion: Our novel setting in non-EP laboratories, utilizing fluoroscopy from the angiography system and manufacturer-modified 3-lead ECG and EGM of PSA during LBBaP, is feasible, reliable, and widely available. LBB capture was confirmed by both the standard EP recording system and new modified PSA 3-lead ECG measurements, which showed good agreement. Further large-scale data is needed to validate our findings.

Background: Slow activation areas, characterized by decreased conduction velocities in the left atrium, are commonly observed in patients with persistent atrial fibrillation (PeAF). However, it remains unclear whether the ablation of slow activation areas combined with pulmonary vein isolation (PVI) improves clinical outcomes in these patients.

Methods: This single-center retrospective study included patients who underwent catheter ablation for PeAF. A total of 78 consecutive patients were included in the PVI + SAA group, while another 78 patients who underwent PVI with/without the roof line, matched 1:1 by propensity score, served as the control group. Slow activation area was defined as ≥ 4 10 ms-step isochrones within 10 mm distance. The endpoint was AF recurrence, atrial flutter, or atrial tachycardia (AT) lasting > 30 s after the blanking period.

Results: The mean mapping time was 10 ± 3 min in the PVI + SAA group. Slow activation areas were identified in 37 of the 78 patients, predominantly located in the anterior wall and often overlapping with the low-voltage areas. The proportion of atrial arrhythmia-free patients was significantly higher in the PVI + SAA group compared to the PVI group (Log-rank P = 0.024; hazard ratio [HR]: 0.40; 95% confidence interval [CI]: 0.19-0.85). Subgroup analysis showed no significant difference in AT/AF recurrence rates between patients who underwent additional ablation of slow activation area and those without identified slow activation areas in the PVI + SAA group (Log-rank P = 0.73; HR: 1.20; 95% CI: 0.42-3.42).

Conclusions: Slow activation areas can be efficiently identified using isochronal mapping. Targeted ablation of slow activation areas helps reduce AT/AF recurrence in patients with PeAF.