Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.05.032
Peter Khalil MD, FHRS , Mohammad Hossein Mohammadzadeh MS , Malli Barremkala MD , Brian Williamson MD
Background
Sudden cardiac death is a severe health issue, responsible for many deaths annually in the United States. It occurs unexpectedly in individuals without a prior diagnosis of a life-threatening condition. Implantable cardiac defibrillators (ICDs), introduced in the 1980s, have been pivotal in improving survival rates for high-risk patients by detecting and correcting dangerous cardiac rhythms. Traditional transvenous ICD implantation, involving leads threaded through veins, carries risks such as vascular damage and infection. Nontransvenous ICD options, such as subcutaneous ICDs (S-ICDs) and extravascular ICDs, present alternative approaches that may reduce these risks. Implantation techniques for S-ICDdevices have evolved greatly over the years, with the most recently recommended approach being an intermuscular technique. However, this anatomical space has not been adequately studied.
Objective
The purpose of this study was to better understand the anatomical variations associated with S-ICD implantation.
Methods
This investigation involved a detailed examination of 18 cadaveric specimens (12 females and 6 males) to map the anatomical relationships between the latissimus dorsi muscle (LDM), the serratus anterior muscle, and the long thoracic nerve (LTN), which are critical for refining nontransvenous ICD implantation techniques. Measurements included the distance from the anterior border of the LDM to the back, the anterior-posterior diameter of the chest at the fifth and seventh rib levels, and the positioning of the LTN relative to the chest wall.
Results
The analysis showed that at the fifth rib level, the average distance from the back to the LDM border was 7.5 cm, and at the seventh rib level, it was 7.6 cm. The overall average distance from the back to the LDM border across both rib levels was 7.5 cm. The LTN was positioned at an average distance of 8.5 cm from the back at the fourth rib, decreasing to 5.7 cm at the sixth rib. The LTN tended to be more anterior in males than in females, but this difference was not statistically significant.
Conclusion
The findings highlight the importance of accurate anatomical knowledge for the effective placement of nontransvenous ICDs. Understanding the specific anatomical layout of the LDM, the serratus anterior muscle, and the LTN is crucial to prevent complications such as LTN injury and to improve the safety and efficacy of ICD implantation. The results advocate for personalized assessment approaches to improve procedural success and patient outcomes in nontransvenous ICD implantation.
{"title":"Anatomical considerations for the nontransvenous implantable cardioverter-defibrillator implantation: A cadaver-based analysis","authors":"Peter Khalil MD, FHRS , Mohammad Hossein Mohammadzadeh MS , Malli Barremkala MD , Brian Williamson MD","doi":"10.1016/j.hroo.2025.05.032","DOIUrl":"10.1016/j.hroo.2025.05.032","url":null,"abstract":"<div><h3>Background</h3><div>Sudden cardiac death is a severe health issue, responsible for many deaths annually in the United States. It occurs unexpectedly in individuals without a prior diagnosis of a life-threatening condition. Implantable cardiac defibrillators (ICDs), introduced in the 1980s, have been pivotal in improving survival rates for high-risk patients by detecting and correcting dangerous cardiac rhythms. Traditional transvenous ICD implantation, involving leads threaded through veins, carries risks such as vascular damage and infection. Nontransvenous ICD options, such as subcutaneous ICDs (S-ICDs) and extravascular ICDs, present alternative approaches that may reduce these risks. Implantation techniques for S-ICDdevices have evolved greatly over the years, with the most recently recommended approach being an intermuscular technique. However, this anatomical space has not been adequately studied.</div></div><div><h3>Objective</h3><div>The purpose of this study was to better understand the anatomical variations associated with S-ICD implantation.</div></div><div><h3>Methods</h3><div>This investigation involved a detailed examination of 18 cadaveric specimens (12 females and 6 males) to map the anatomical relationships between the latissimus dorsi muscle (LDM), the serratus anterior muscle, and the long thoracic nerve (LTN), which are critical for refining nontransvenous ICD implantation techniques. Measurements included the distance from the anterior border of the LDM to the back, the anterior-posterior diameter of the chest at the fifth and seventh rib levels, and the positioning of the LTN relative to the chest wall.</div></div><div><h3>Results</h3><div>The analysis showed that at the fifth rib level, the average distance from the back to the LDM border was 7.5 cm, and at the seventh rib level, it was 7.6 cm. The overall average distance from the back to the LDM border across both rib levels was 7.5 cm. The LTN was positioned at an average distance of 8.5 cm from the back at the fourth rib, decreasing to 5.7 cm at the sixth rib. The LTN tended to be more anterior in males than in females, but this difference was not statistically significant.</div></div><div><h3>Conclusion</h3><div>The findings highlight the importance of accurate anatomical knowledge for the effective placement of nontransvenous ICDs. Understanding the specific anatomical layout of the LDM, the serratus anterior muscle, and the LTN is crucial to prevent complications such as LTN injury and to improve the safety and efficacy of ICD implantation. The results advocate for personalized assessment approaches to improve procedural success and patient outcomes in nontransvenous ICD implantation.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1575-1578"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327103","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.07.012
Catalin Pestrea MD, PhD, Ecaterina Cicala MD, Stefania Sisea-Polexa MD, Mircea Dobre MD, Roxana Enache MD, Florin Ortan MD
Background
Insights into right ventricle (RV) activation during left bundle branch pacing (LBBP) have postulated direct transseptal and retrograde physiological pathways, which may be absent in patients with infranodal conduction abnormalities.
Objective
This study compared the long-term impact of LBBP on the right heart in patients with atrioventricular block (AVB) according to the baseline QRS morphology.
Methods
Overall, 82 patients with successful LBBP for AVB were prospectively evaluated for changes in right atrial volume (RAV), RV diameter, tricuspid annulus peak systolic elevation (TAPSE), RV S' wave, and tricuspid regurgitation (TR).
Results
A total of 41.5% had a baseline narrow QRS, 29.3% had right bundle branch block (RBBB), and 29.3% had left bundle branch block (LBBB). RV activation time was similar between the 3 groups. The patients were followed over a mean period of 715.7 ± 194.8 days. In the narrow QRS group, there were no changes between the follow-up and the baseline values for RA volumes, RV diameter, RVS'W, and TR, with a significant improvement in the TAPSE. In the LBBB group, there were no differences in RA volumes, RV diameter, RVS'W, and TAPSE at follow-up, but TR worsened from 0.7 ± 0.7 to 1 ± 0.9 (P = .04). Same changes were seen in the RBBB group, with an increase in TR from 0.6 ± 0.5 to 1 ± 0.7 (P = .02). There was no inter-group difference in the magnitude of change for each right heart echocardiographic parameter.
Conclusion
LBBP showed a similar long-term protective effect on the right heart chambers’ dimensions and function in patients with AVB, regardless of the baseline QRS morphology.
{"title":"Lack of impact of baseline QRS morphology on the right heart during long-term left bundle branch pacing in patients with atrioventricular block","authors":"Catalin Pestrea MD, PhD, Ecaterina Cicala MD, Stefania Sisea-Polexa MD, Mircea Dobre MD, Roxana Enache MD, Florin Ortan MD","doi":"10.1016/j.hroo.2025.07.012","DOIUrl":"10.1016/j.hroo.2025.07.012","url":null,"abstract":"<div><h3>Background</h3><div>Insights into right ventricle (RV) activation during left bundle branch pacing (LBBP) have postulated direct transseptal and retrograde physiological pathways, which may be absent in patients with infranodal conduction abnormalities.</div></div><div><h3>Objective</h3><div>This study compared the long-term impact of LBBP on the right heart in patients with atrioventricular block (AVB) according to the baseline QRS morphology.</div></div><div><h3>Methods</h3><div>Overall, 82 patients with successful LBBP for AVB were prospectively evaluated for changes in right atrial volume (RAV), RV diameter, tricuspid annulus peak systolic elevation (TAPSE), RV S' wave, and tricuspid regurgitation (TR).</div></div><div><h3>Results</h3><div>A total of 41.5% had a baseline narrow QRS, 29.3% had right bundle branch block (RBBB), and 29.3% had left bundle branch block (LBBB). RV activation time was similar between the 3 groups. The patients were followed over a mean period of 715.7 ± 194.8 days. In the narrow QRS group, there were no changes between the follow-up and the baseline values for RA volumes, RV diameter, RVS'W, and TR, with a significant improvement in the TAPSE. In the LBBB group, there were no differences in RA volumes, RV diameter, RVS'W, and TAPSE at follow-up, but TR worsened from 0.7 ± 0.7 to 1 ± 0.9 (<em>P</em> = .04). Same changes were seen in the RBBB group, with an increase in TR from 0.6 ± 0.5 to 1 ± 0.7 (<em>P</em> = .02). There was no inter-group difference in the magnitude of change for each right heart echocardiographic parameter.</div></div><div><h3>Conclusion</h3><div>LBBP showed a similar long-term protective effect on the right heart chambers’ dimensions and function in patients with AVB, regardless of the baseline QRS morphology.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1579-1586"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.06.027
Beatrice Zanchi PhD , Ali Gharaviri PhD , Marco Bergonti MD, PhD , Simone Pezzuto PhD , Tardu Özkartal MD , Maria Luce Caputo MD, PhD , Esther Scheirlynck MD, PhD , Carlo de Asmundis MD, PhD , Francesca Faraci PhD , Giulio Conte MD, PhD
Background
An increased risk of atrial fibrillation (AF) has been reported in patients with Brugada syndrome (BrS). The pathophysiology of AF susceptibility in BrS is largely unknown.
Objective
This study aimed to characterize the atrial electrical properties of patients with BrS with and without AF based on P-wave and high-density atrial mapping analysis with a focus on conduction velocity (CV) and provide mechanistic insights on AF susceptibility using computer modeling.
Methods
Electrocardiographic signals were processed, and P-wave parameters were analyzed in a consecutive series of patients with and without BrS. High-density atrial mapping was performed in patients with BrS undergoing an electrophysiological procedure. CV vectors were numerically approximated at each recording point using polynomial surface fitting. AF initiation susceptibility was simulated in a 3-dimensional atrial model and compared with control simulations.
Results
A total of 133 subjects (89 patients with BrS and 44 controls) were included. AF history was present in 11% of patients with BrS. Patients with BrS had longer mean P-wave duration than controls (135 ms vs 124 ms, P < .01), whereas no P-wave parameter was able to discriminate between patients with BrS with and without AF. CVs correlated with total atrial activation time (TAAT) (R2 = 0.706), and TAATs mildly correlated with P-wave duration (R2 = 0.12). A significantly higher conduction pattern complexity, quantified as the number of coexisting fibrillation waves, was observed in BrS than in control simulations. In all simulations, regardless of the degree of fibrosis, AF initiation rates were significantly higher in BrS than in control simulations.
Conclusion
Conventional P-wave parameters do not identify patients with BrS prone to AF. Increased TAAT is related to reduced local CVs, explaining the prolonged P-wave duration observed in patients with BrS. Simulation studies showed significantly higher AF susceptibility initiation in patients with BrS than in controls.
背景：Brugada综合征（BrS）患者心房颤动（AF）的风险增加已被报道。BrS中AF易感性的病理生理学在很大程度上是未知的。目的基于p波和高密度心房电图分析，以传导速度（CV）为重点，研究伴有和不伴有房颤的BrS患者的心房电特性，并利用计算机建模提供房颤易感性的机制。方法对连续两组BrS患者的心电图信号进行处理，分析其p波参数。高密度心房测图在BrS患者进行电生理手术。利用多项式曲面拟合对每个记录点的CV向量进行数值逼近。在三维心房模型中模拟心房颤动起爆敏感性，并与对照模拟进行比较。结果共纳入133例受试者，其中BrS患者89例，对照组44例。11%的BrS患者有房颤史。BrS患者的平均P波持续时间比对照组更长（135 ms vs 124 ms, P < 01），而没有P波参数能够区分伴有和不伴有房颤的BrS患者。CVs与心房总激活时间（TAAT）相关（R2 = 0.706）， TAAT与P波持续时间轻度相关（R2 = 0.12）。与对照模拟相比，在BrS中观察到明显更高的传导模式复杂性，量化为共存颤动波的数量。在所有模拟中，无论纤维化程度如何，BrS中的房颤起始率明显高于对照模拟。结论常规p波参数不能识别BrS患者是否容易发生房颤，TAAT升高与局部cv降低有关，这解释了BrS患者p波持续时间延长的原因。模拟研究显示，与对照组相比，BrS患者的心房颤动易感性起始明显更高。
{"title":"High-density atrial mapping, P-wave analysis, and computational simulations in Brugada syndrome: Enhancing the understanding of atrial fibrillation","authors":"Beatrice Zanchi PhD , Ali Gharaviri PhD , Marco Bergonti MD, PhD , Simone Pezzuto PhD , Tardu Özkartal MD , Maria Luce Caputo MD, PhD , Esther Scheirlynck MD, PhD , Carlo de Asmundis MD, PhD , Francesca Faraci PhD , Giulio Conte MD, PhD","doi":"10.1016/j.hroo.2025.06.027","DOIUrl":"10.1016/j.hroo.2025.06.027","url":null,"abstract":"<div><h3>Background</h3><div>An increased risk of atrial fibrillation (AF) has been reported in patients with Brugada syndrome (BrS). The pathophysiology of AF susceptibility in BrS is largely unknown.</div></div><div><h3>Objective</h3><div>This study aimed to characterize the atrial electrical properties of patients with BrS with and without AF based on P-wave and high-density atrial mapping analysis with a focus on conduction velocity (CV) and provide mechanistic insights on AF susceptibility using computer modeling.</div></div><div><h3>Methods</h3><div>Electrocardiographic signals were processed, and P-wave parameters were analyzed in a consecutive series of patients with and without BrS. High-density atrial mapping was performed in patients with BrS undergoing an electrophysiological procedure. CV vectors were numerically approximated at each recording point using polynomial surface fitting. AF initiation susceptibility was simulated in a 3-dimensional atrial model and compared with control simulations.</div></div><div><h3>Results</h3><div>A total of 133 subjects (89 patients with BrS and 44 controls) were included. AF history was present in 11% of patients with BrS. Patients with BrS had longer mean P-wave duration than controls (135 ms vs 124 ms, <em>P</em> < .01), whereas no P-wave parameter was able to discriminate between patients with BrS with and without AF. CVs correlated with total atrial activation time (TAAT) (R<sup>2</sup> = 0.706), and TAATs mildly correlated with P-wave duration (R<sup>2</sup> = 0.12). A significantly higher conduction pattern complexity, quantified as the number of coexisting fibrillation waves, was observed in BrS than in control simulations. In all simulations, regardless of the degree of fibrosis, AF initiation rates were significantly higher in BrS than in control simulations.</div></div><div><h3>Conclusion</h3><div>Conventional P-wave parameters do not identify patients with BrS prone to AF. Increased TAAT is related to reduced local CVs, explaining the prolonged P-wave duration observed in patients with BrS. Simulation studies showed significantly higher AF susceptibility initiation in patients with BrS than in controls.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1621-1631"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.07.017
Farah Amrani BSc , Luuk H.G.A. Hopman PhD , Pieter G. Postema MD, PhD , Michiel J.B. Kemme MD, PhD , Cornelis P. Allaart MD, PhD , Jasper L. Selder MD , Ramon B. van Loon MD, PhD , Vokko P. van Halm MD, PhD , Marco J.W. Götte MD, PhD , Pranav Bhagirath MD, PhD
Background
Cardiac implantable electronic devices (CIEDs) can cause artifacts in late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (CMR), compromising diagnostic accuracy. No consensus exists on optimal CIED patient selection for LGE-CMR.
Objective
This study aims to identify predictors of LGE image quality in patients with CIEDS to optimize pre-scan selection.
Methods
Patients with CIEDs who underwent conventional 2D-LGE imaging were retrospectively identified from the Amsterdam UMC CMR database. Baseline clinical and device characteristics were collected, and generator-to-lead distance was measured on post-implantation chest X-rays. LGE quality was categorized as fully diagnostic, acceptable, or non-diagnostic. Multivariable regression and receiver operating characteristic (ROC) analysis determined independent predictors and exploratory generator-to-lead distance thresholds using a 90% sensitivity criterion.
Results
Overall, 80 patients (71.3% male, mean age 64 years) were included: 41.3% ICDs, 23.8% pacemakers (PMs), 23.8% cardiac resynchronization therapy defibrillators (CRT-Ds), and 2.5% cardiac resynchronization therapy pacemakers (CRT-Ps). LGE image quality was fully diagnostic in 48.8%, acceptable in 27.5%, and non-diagnostic in 23.8% of patients. PM/CRT-P patients had no non-diagnostic scans (92.9% fully diagnostic). Only 25.0% of ICD/CRT-D scans were fully diagnostic, while 36.5% were non-diagnostic (P < .001). Generator-to-lead distance was significantly associated with LGE quality, with thresholds of 10 cm in ICDs and 8 cm in PMs for acceptable LGE quality.
Conclusion
Device type and positioning significantly impact LGE image quality. ICDs were associated with poorer image quality, while PMs consistently yielded diagnostic-quality images. Generator-to-lead distance emerged as a key predictor, providing a practical tool for optimizing LGE-CMR referrals. This study defines generator-to-lead distance thresholds by device type and proposes a structured pre-scan workflow to support LGE-CMR referral decisions in patients with CIEDs.
{"title":"Predictors of late gadolinium enhancement cardiac MRI image quality in patients with cardiac implantable electronic devices","authors":"Farah Amrani BSc , Luuk H.G.A. Hopman PhD , Pieter G. Postema MD, PhD , Michiel J.B. Kemme MD, PhD , Cornelis P. Allaart MD, PhD , Jasper L. Selder MD , Ramon B. van Loon MD, PhD , Vokko P. van Halm MD, PhD , Marco J.W. Götte MD, PhD , Pranav Bhagirath MD, PhD","doi":"10.1016/j.hroo.2025.07.017","DOIUrl":"10.1016/j.hroo.2025.07.017","url":null,"abstract":"<div><h3>Background</h3><div>Cardiac implantable electronic devices (CIEDs) can cause artifacts in late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (CMR), compromising diagnostic accuracy. No consensus exists on optimal CIED patient selection for LGE-CMR.</div></div><div><h3>Objective</h3><div>This study aims to identify predictors of LGE image quality in patients with CIEDS to optimize pre-scan selection.</div></div><div><h3>Methods</h3><div>Patients with CIEDs who underwent conventional 2D-LGE imaging were retrospectively identified from the Amsterdam UMC CMR database. Baseline clinical and device characteristics were collected, and generator-to-lead distance was measured on post-implantation chest X-rays. LGE quality was categorized as fully diagnostic, acceptable, or non-diagnostic. Multivariable regression and receiver operating characteristic (ROC) analysis determined independent predictors and exploratory generator-to-lead distance thresholds using a 90% sensitivity criterion.</div></div><div><h3>Results</h3><div>Overall, 80 patients (71.3% male, mean age 64 years) were included: 41.3% ICDs, 23.8% pacemakers (PMs), 23.8% cardiac resynchronization therapy defibrillators (CRT-Ds), and 2.5% cardiac resynchronization therapy pacemakers (CRT-Ps). LGE image quality was fully diagnostic in 48.8%, acceptable in 27.5%, and non-diagnostic in 23.8% of patients. PM/CRT-P patients had no non-diagnostic scans (92.9% fully diagnostic). Only 25.0% of ICD/CRT-D scans were fully diagnostic, while 36.5% were non-diagnostic (<em>P</em> < .001). Generator-to-lead distance was significantly associated with LGE quality, with thresholds of 10 cm in ICDs and 8 cm in PMs for acceptable LGE quality.</div></div><div><h3>Conclusion</h3><div>Device type and positioning significantly impact LGE image quality. ICDs were associated with poorer image quality, while PMs consistently yielded diagnostic-quality images. Generator-to-lead distance emerged as a key predictor, providing a practical tool for optimizing LGE-CMR referrals. This study defines generator-to-lead distance thresholds by device type and proposes a structured pre-scan workflow to support LGE-CMR referral decisions in patients with CIEDs.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1594-1600"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327106","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.07.014
Robert Eckart MD,FHRS , Robert Brewer MD , Devi Nair MD, FHRS , Jonathan Dukes MD , John Costello MD , Matthew D. Martens PhD , Saja Al-Dujaili PhD , Brad S. Sutton MD , Jose Osorio MD, FHRS , Amin Al-Ahmad MD, FHRS , DISRUPT-AF Investigators
Background
Pulsed field ablation (PFA) has revolutionized catheter ablation procedures in terms of safety, efficiency, and efficacy. Streamlined zero-exchange workflows with therapy sheath integrated transseptal puncture (TSP) devices may offer further improvements. However, the impact of device exchanges on real-world PFA procedures remains unknown.
Objective
We aimed to describe and quantify procedural characteristics associated with different PFA workflows.
Methods
The DISRUPT-AF registry (NCT06335082) is an observational, prospective study assessing clinical experience with the pentaspline PFA system in the United States. Procedures are performed as per standard-of-care, where specific workflows and left atrial (LA) access devices were not mandated.
Results
A total of 873 cases (mean age, 68.0 ± 11.4 years; 38.6% women) with 62 unique operators across 20 centers were assessed. Of these, 10.1%, 63.1%, and 26.8% reported “0”-, “1–2”-, and “3+”-exchanges, respectively. Regardless of atrial fibrillation subtype, zero-exchange workflows were associated with significantly shorter and more consistent TSP times (0:5.7 ± 4.2 min; 1–2:15.3 ± 7.3 min; 3+:19.2 ± 9.3 min; P <0.001), left atrium dwell times (0:26.9 ± 10.2 min; 1–2:36.8 ± 13.2 min; 3+:50.8 ± 17.8 min; P < .001), and relative procedure times (0: 100%; 1–2: 152.7%; 3+: 209.4%; P < .001), when compared with 1–2 and 3+-exchange procedures. Despite this increased efficiency, there were no differences in TSP success rates, PFA lesion count, acute pulmonary vein isolation rates, and procedural complication rates between the 3 workflows.
Conclusion
The adoption of zero-exchange workflows enabled by therapy sheath-integrated TSP devices results in significant improvements in procedural efficiency and predictability without compromising patient safety or acute outcomes.
背景：脉冲场消融（PFA）在安全性、效率和疗效方面彻底改变了导管消融程序。简化的零交换工作流程与治疗鞘集成经间隔穿刺（TSP）设备可能提供进一步的改进。然而，设备交换对现实世界PFA程序的影响仍然未知。目的：我们旨在描述和量化与不同PFA工作流程相关的程序特征。方法DISRUPT-AF注册（NCT06335082）是一项观察性前瞻性研究，评估美国pentaspline PFA系统的临床经验。程序按照护理标准执行，没有强制规定特定的工作流程和左心房（LA）接入设备。结果共对20个中心62名手术人员共873例（平均年龄68.0±11.4岁，女性38.6%）进行了评估。其中，10.1%、63.1%和26.8%分别报告了“0”-、“1-2”-和“3+”-交换。无论何种房颤类型，与1-2和3+交换手术相比，零交换工作流程与更短且更一致的TSP时间（0:5.7±4.2 min; 1-2:15.3±7.3 min; 3+:19.2±9.3 min; P <0.001）、左心房停留时间（0:26.9±10.2 min; 1-2:36.8±13.2 min; 3+:50.8±17.8 min; P <0.001）和相对手术时间（0:100%;1-2:152.7%;3+:209.4%;P < 001）相关。尽管效率有所提高，但三种工作流程在TSP成功率、PFA病变计数、急性肺静脉隔离率和手术并发症发生率方面没有差异。结论：采用治疗套集成TSP设备实现的零交换工作流程显著提高了手术效率和可预测性，而不会影响患者安全或急性预后。
{"title":"The efficiency and safety of zero-exchange workflows in pulsed field ablation: Comprehensive insights from the DISRUPT-AF registry","authors":"Robert Eckart MD,FHRS , Robert Brewer MD , Devi Nair MD, FHRS , Jonathan Dukes MD , John Costello MD , Matthew D. Martens PhD , Saja Al-Dujaili PhD , Brad S. Sutton MD , Jose Osorio MD, FHRS , Amin Al-Ahmad MD, FHRS , DISRUPT-AF Investigators","doi":"10.1016/j.hroo.2025.07.014","DOIUrl":"10.1016/j.hroo.2025.07.014","url":null,"abstract":"<div><h3>Background</h3><div>Pulsed field ablation (PFA) has revolutionized catheter ablation procedures in terms of safety, efficiency, and efficacy. Streamlined zero-exchange workflows with therapy sheath integrated transseptal puncture (TSP) devices may offer further improvements. However, the impact of device exchanges on real-world PFA procedures remains unknown.</div></div><div><h3>Objective</h3><div>We aimed to describe and quantify procedural characteristics associated with different PFA workflows.</div></div><div><h3>Methods</h3><div>The DISRUPT-AF registry (NCT06335082) is an observational, prospective study assessing clinical experience with the pentaspline PFA system in the United States. Procedures are performed as per standard-of-care, where specific workflows and left atrial (LA) access devices were not mandated.</div></div><div><h3>Results</h3><div>A total of 873 cases (mean age, 68.0 ± 11.4 years; 38.6% women) with 62 unique operators across 20 centers were assessed. Of these, 10.1%, 63.1%, and 26.8% reported “0”-, “1–2”-, and “3+”-exchanges, respectively. Regardless of atrial fibrillation subtype, zero-exchange workflows were associated with significantly shorter and more consistent TSP times (0:5.7 ± 4.2 min; 1–2:15.3 ± 7.3 min; 3+:19.2 ± 9.3 min; <em>P <</em>0.001), left atrium dwell times (0:26.9 ± 10.2 min; 1–2:36.8 ± 13.2 min; 3+:50.8 ± 17.8 min; <em>P <</em> .001), and relative procedure times (0: 100%; 1–2: 152.7%; 3+: 209.4%; <em>P <</em> .001), when compared with 1–2 and 3+-exchange procedures. Despite this increased efficiency, there were no differences in TSP success rates, PFA lesion count, acute pulmonary vein isolation rates, and procedural complication rates between the 3 workflows.</div></div><div><h3>Conclusion</h3><div>The adoption of zero-exchange workflows enabled by therapy sheath-integrated TSP devices results in significant improvements in procedural efficiency and predictability without compromising patient safety or acute outcomes.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1508-1515"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327387","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.06.024
Vera Maslova MD , Marie Ahrens , Ole Rosenthal , Theodor Bau , Peter Magerfleisch , Fabian Moser MD , Adrian Zaman MD , Mohammed Saad MD , Martina Spehlmann MD , Derk Frank MD , Evgeny Lian MD
Background
Pulmonary vein isolation (PVI) in obese patients under deep sedation (DS) is anticipated to be more complex owing to challenging airway and hemodynamic management and dose adjustment of sedation drugs.
Objective
This study aimed to compare the complexity of de novo PVI in obese vs nonobese patients, with a particular focus on periprocedural sedation.
Methods
All patients undergoing de novo PVI under DS between January 2022 and January 2024 in our center were prospectively included. Data on detailed monitoring of respiratory and hemodynamic parameters during the procedure were collected. Two groups were defined (group 1, body mass index [BMI] of ≥30 kg/m2; group 2, BMI of <30 kg/m2) and compared in terms of DS tolerance, safety, and procedural success.
Results
Overall, 381 patients were included (61% male, median age 69 years); 120 were assigned to group 1 (BMI of 33 kg/m2 [32–38]) and 261 to group 2 (BMI of 25 kg/m2 [23–27]); 69% underwent cryoballoon ablation, 22% radiofrequency ablation, and 9% pulsed field ablation. The incidence of hypotension did not differ between groups. Hypoxic episodes were more frequent in group 1 (4 vs 2, P < .05), but none required mechanical ventilation. In multivariate analysis, obesity alone was not an independent risk factor for hypoxia or hypotension. Procedural duration, left atrial (LA) dwell time, and radiation dose were significantly higher in group 1. Overall complication rate was 3.4%, with no difference between groups. The 1-year success rate was comparable (71% vs 63%, P = .13). Subgroup analysis for persistent atrial fibrillation revealed a higher 1-year success rate (70% vs 57%, P = .048) for group 1.
Conclusion
Obesity was not an independent risk factor for periprocedural hypoxia or hypotension and did not affect safety or long-term success. Obesity alone should not be considered a reason to exclude patients from undergoing PVI under DS.
背景：由于具有挑战性的气道和血流动力学管理以及镇静药物的剂量调整，肥胖患者在深度镇静（DS）下的肺静脉隔离（PVI）预计将更加复杂。目的本研究旨在比较肥胖与非肥胖患者新生PVI的复杂性，并特别关注围手术期镇静。方法前瞻性纳入所有于2022年1月至2024年1月在本中心接受DS下PVI新生的患者。收集了手术过程中呼吸和血流动力学参数的详细监测数据。定义两组（1组，体重指数[BMI]≥30 kg/m2； 2组，体重指数[BMI]≥30 kg/m2），并在DS耐受性、安全性和手术成功率方面进行比较。结果共纳入381例患者（男性61%，中位年龄69岁）；1组120例（BMI为33 kg/m2[32-38]）， 2组261例（BMI为25 kg/m2 [23-27]）；69%接受低温球囊消融，22%接受射频消融，9%接受脉冲场消融。两组间低血压发生率无差异。组1缺氧发作更频繁（4 vs 2, P < 0.05），但没有人需要机械通气。在多变量分析中，肥胖本身并不是缺氧或低血压的独立危险因素。1组手术时间、左房停留时间、辐射剂量均显著增高。总并发症发生率为3.4%，两组间无差异。1年的成功率比较（71% vs 63%, P = 0.13）。持续性心房颤动的亚组分析显示，1组的1年成功率更高（70% vs 57%, P = 0.048）。结论肥胖不是围手术期缺氧或低血压的独立危险因素，也不影响手术的安全性和长期成功。肥胖本身不应被认为是排除患者在退行性椎体滑移下接受PVI的原因。
{"title":"De novo pulmonary vein isolation in obese vs nonobese patients under deep sedation: Does obesity increase procedure complexity?","authors":"Vera Maslova MD , Marie Ahrens , Ole Rosenthal , Theodor Bau , Peter Magerfleisch , Fabian Moser MD , Adrian Zaman MD , Mohammed Saad MD , Martina Spehlmann MD , Derk Frank MD , Evgeny Lian MD","doi":"10.1016/j.hroo.2025.06.024","DOIUrl":"10.1016/j.hroo.2025.06.024","url":null,"abstract":"<div><h3>Background</h3><div>Pulmonary vein isolation (PVI) in obese patients under deep sedation (DS) is anticipated to be more complex owing to challenging airway and hemodynamic management and dose adjustment of sedation drugs.</div></div><div><h3>Objective</h3><div>This study aimed to compare the complexity of de novo PVI in obese vs nonobese patients, with a particular focus on periprocedural sedation.</div></div><div><h3>Methods</h3><div>All patients undergoing de novo PVI under DS between January 2022 and January 2024 in our center were prospectively included. Data on detailed monitoring of respiratory and hemodynamic parameters during the procedure were collected. Two groups were defined (group 1, body mass index [BMI] of ≥30 kg/m<sup>2</sup>; group 2, BMI of <30 kg/m<sup>2</sup>) and compared in terms of DS tolerance, safety, and procedural success.</div></div><div><h3>Results</h3><div>Overall, 381 patients were included (61% male, median age 69 years); 120 were assigned to group 1 (BMI of 33 kg/m<sup>2</sup> [32–38]) and 261 to group 2 (BMI of 25 kg/m<sup>2</sup> [23–27]); 69% underwent cryoballoon ablation, 22% radiofrequency ablation, and 9% pulsed field ablation. The incidence of hypotension did not differ between groups. Hypoxic episodes were more frequent in group 1 (4 vs 2, <em>P</em> < .05), but none required mechanical ventilation. In multivariate analysis, obesity alone was not an independent risk factor for hypoxia or hypotension. Procedural duration, left atrial (LA) dwell time, and radiation dose were significantly higher in group 1. Overall complication rate was 3.4%, with no difference between groups. The 1-year success rate was comparable (71% vs 63%, <em>P</em> = .13). Subgroup analysis for persistent atrial fibrillation revealed a higher 1-year success rate (70% vs 57%, <em>P</em> = .048) for group 1.</div></div><div><h3>Conclusion</h3><div>Obesity was not an independent risk factor for periprocedural hypoxia or hypotension and did not affect safety or long-term success. Obesity alone should not be considered a reason to exclude patients from undergoing PVI under DS.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1524-1535"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327411","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.07.005
David Spreen MSc , Thomas Kueffer PhD , Salik ur Rehman Iqbal MD , Patrick Badertscher MD , Jens Maurhofer MD , Philipp Krisai MD , Corinne Isenegger MD , Behnam Subin MD , Nicolas Schärli MD , Beat Schaer MD , Vincent Schlageter PhD , Maurice Pradella MD , Corinne Jufer MSc , Gregor Thalmann MD , Helge Servatius MD , Hildegard Tanner MD , Felix Mahfoud MD , Michael Kühne MD , Laurent Roten MD , Tobias Reichlin MD , Sven Knecht DSc
Background
Cryoballoon ablation is an established therapy for pulmonary vein (PV) isolation (PVI).
Objective
This study aimed to explore whether specific left atrial anatomical features are associated with both first-pass PVI success and long-term outcomes after cryoballoon ablation using 2 different cryoablation systems.
Methods
Left atrial reconstructions of patients with paroxysmal atrial fibrillation were analyzed. PVI was performed using either the Medtronic (Minneapolis, MN) Arctic Front Advance or the Boston Scientific (Marlborough, MA) POLARx cryoablation catheter. Anatomical features were assessed to predict first-pass PVI success after a single application and long-term outcomes on the basis of implantable cardiac monitor recordings.
Results
A total of 191 patients were enrolled (mean age 63.0 ± 9.8 years; 58 (30%) women). First-pass PVI was achieved in 69% of all procedures. Female sex was significantly associated with reduced first-pass isolation success, limited to the right superior PV (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.26–0.97; P = .04). Anatomical predictors of failure of first-pass PVI included the absence of an orthogonal orientation of the left superior PV (OR 0.20; 95% CI 0.05–0.88; P = .033) and the left inferior PV (OR 0.36; 95% CI 0.13–0.99; P = .047) as well as the presence of a right middle PV for the right superior PV (OR 3.58; 95% CI 1.18–10.9; P = .024). The absence of an orthogonal orientation of the left superior PV was associated with atrial tachyarrhythmia recurrence (OR 4.12; 95% CI 1.90–9.11; P < .001).
Conclusion
The absence of an orthogonal orientation of the left-sided PVs was significantly associated with lower first-pass isolation rates and a higher risk of recurrence. These findings highlight the importance of preprocedural anatomical assessment to identify potential challenges and tailor ablation strategies.
低温球囊消融是治疗肺静脉隔离（PV）的一种成熟的治疗方法。目的：本研究旨在探讨特定左心房解剖特征是否与使用两种不同的冷冻球囊消融后的首次PVI成功和长期结果相关。方法对阵发性心房颤动患者的左心房重建进行分析。PVI使用美敦力（Minneapolis， MN） Arctic Front Advance或Boston Scientific (Marlborough， MA) POLARx冷冻消融导管进行。评估解剖特征，以预测单次应用后的首次PVI成功和基于植入式心脏监护仪记录的长期结果。结果共纳入191例患者，平均年龄（63.0±9.8岁），女性58例（30%）。69%的手术实现了首次PVI。女性与首过分离成功率降低显著相关，仅限于右侧优越PV（优势比[OR] 0.50； 95%可信区间[CI] 0.26-0.97; P = 0.04）。首次通过PVI失败的解剖学预测因素包括左上PV （OR 0.20; 95% CI 0.05-0.88; P = 0.033）和左下PV （OR 0.36; 95% CI 0.13-0.99; P = 0.047）以及右上PV存在右中PV （OR 3.58; 95% CI 1.18-10.9; P = 0.024）。左上PV正交定位缺失与房性心动过速复发相关（OR 4.12; 95% CI 1.90-9.11; P < 0.001）。结论左侧pv的正交定向缺失与较低的第一次分离率和较高的复发率显著相关。这些发现强调了术前解剖评估对于识别潜在挑战和定制消融策略的重要性。
{"title":"Impact of left atrial anatomy on pulmonary vein isolation with cryoballoon ablation: Insights from the randomized controlled COMPARE CRYO study","authors":"David Spreen MSc , Thomas Kueffer PhD , Salik ur Rehman Iqbal MD , Patrick Badertscher MD , Jens Maurhofer MD , Philipp Krisai MD , Corinne Isenegger MD , Behnam Subin MD , Nicolas Schärli MD , Beat Schaer MD , Vincent Schlageter PhD , Maurice Pradella MD , Corinne Jufer MSc , Gregor Thalmann MD , Helge Servatius MD , Hildegard Tanner MD , Felix Mahfoud MD , Michael Kühne MD , Laurent Roten MD , Tobias Reichlin MD , Sven Knecht DSc","doi":"10.1016/j.hroo.2025.07.005","DOIUrl":"10.1016/j.hroo.2025.07.005","url":null,"abstract":"<div><h3>Background</h3><div>Cryoballoon ablation is an established therapy for pulmonary vein (PV) isolation (PVI).</div></div><div><h3>Objective</h3><div>This study aimed to explore whether specific left atrial anatomical features are associated with both first-pass PVI success and long-term outcomes after cryoballoon ablation using 2 different cryoablation systems.</div></div><div><h3>Methods</h3><div>Left atrial reconstructions of patients with paroxysmal atrial fibrillation were analyzed. PVI was performed using either the Medtronic (Minneapolis, MN) Arctic Front Advance or the Boston Scientific (Marlborough, MA) POLARx cryoablation catheter. Anatomical features were assessed to predict first-pass PVI success after a single application and long-term outcomes on the basis of implantable cardiac monitor recordings.</div></div><div><h3>Results</h3><div>A total of 191 patients were enrolled (mean age 63.0 ± 9.8 years; 58 (30%) women). First-pass PVI was achieved in 69% of all procedures. Female sex was significantly associated with reduced first-pass isolation success, limited to the right superior PV (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.26–0.97; <em>P</em> = .04). Anatomical predictors of failure of first-pass PVI included the absence of an orthogonal orientation of the left superior PV (OR 0.20; 95% CI 0.05–0.88; <em>P</em> = .033) and the left inferior PV (OR 0.36; 95% CI 0.13–0.99; <em>P</em> = .047) as well as the presence of a right middle PV for the right superior PV (OR 3.58; 95% CI 1.18–10.9; <em>P</em> = .024). The absence of an orthogonal orientation of the left superior PV was associated with atrial tachyarrhythmia recurrence (OR 4.12; 95% CI 1.90–9.11; <em>P</em> < .001).</div></div><div><h3>Conclusion</h3><div>The absence of an orthogonal orientation of the left-sided PVs was significantly associated with lower first-pass isolation rates and a higher risk of recurrence. These findings highlight the importance of preprocedural anatomical assessment to identify potential challenges and tailor ablation strategies.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1499-1507"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327386","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.07.011
Rahul Ahuja MD, Michael Von Bargen MBA, Howard Klemmer MD, Daniel Cheng MD, Mahdi Veillet-Chowdhury MD, Todd Seto MD, MPH, Bert Matsuo PharmD, Kailie Wong NP, Sara Hamele NP, David Singh MD
Background
Atrial fibrillation (AF) in the emergency department (ED) is a growing public health burden, marked by significant variability in management, particularly regarding oral anticoagulation (OAC). Care process models (CPMs), supported by real-time decision tools, may improve standardization and outcomes.
Objective
This study aimed to evaluate the impact of a CPM on clinical outcomes, treatment patterns, and documentation for patients with AF presenting to EDs within a large integrated health care system.
Methods
We implemented a CPM in the Queen’s Health Systems (Hawaii), targeting ED patients with AF. Interventions included a structured treatment algorithm, an AF response team, best practice alerts (BPAs) for OAC and CHA2DS2-VASc documentation, and near-real-time data monitoring. Outcomes were assessed across 3 phases: pre-CPM, post-CPM/pre-BPA, and post-BPA. Primary outcomes included OAC compliance, documentation of OAC contraindications, cardioversion rates, length of stay (LOS), and admission rates.
Results
Among 3236 patients with AF (2020–2025), OAC compliance improved from 60.1% to 72.1% after BPA (P < .00001) and to 83% when excluding those with OAC contraindications. CHA2DS2-VASc documentation increased from 5% to 40% (P < .00001). Cardioversion rates increased from 11.9% to 16.8% (P < .0001). Hospital admissions declined from 44% to 38% (P = .004). ED LOS for discharged patients increased slightly (3.6–4.0 hours, P = .0005); inpatient LOS remained stable.
Conclusion
System-wide CPM implementation improved OAC use, documentation, and cardioversion rates, while reducing admissions. Despite a modest increase in ED LOS, the model supported more consistent, guideline-based AF care, reinforcing the value of multidisciplinary, algorithm-driven strategies in emergency settings.
{"title":"Impact of a care process model on outcomes in emergency department patients with atrial fibrillation","authors":"Rahul Ahuja MD, Michael Von Bargen MBA, Howard Klemmer MD, Daniel Cheng MD, Mahdi Veillet-Chowdhury MD, Todd Seto MD, MPH, Bert Matsuo PharmD, Kailie Wong NP, Sara Hamele NP, David Singh MD","doi":"10.1016/j.hroo.2025.07.011","DOIUrl":"10.1016/j.hroo.2025.07.011","url":null,"abstract":"<div><h3>Background</h3><div>Atrial fibrillation (AF) in the emergency department (ED) is a growing public health burden, marked by significant variability in management, particularly regarding oral anticoagulation (OAC). Care process models (CPMs), supported by real-time decision tools, may improve standardization and outcomes.</div></div><div><h3>Objective</h3><div>This study aimed to evaluate the impact of a CPM on clinical outcomes, treatment patterns, and documentation for patients with AF presenting to EDs within a large integrated health care system.</div></div><div><h3>Methods</h3><div>We implemented a CPM in the Queen’s Health Systems (Hawaii), targeting ED patients with AF. Interventions included a structured treatment algorithm, an AF response team, best practice alerts (BPAs) for OAC and CHA<sub>2</sub>DS<sub>2</sub>-VASc documentation, and near-real-time data monitoring. Outcomes were assessed across 3 phases: pre-CPM, post-CPM/pre-BPA, and post-BPA. Primary outcomes included OAC compliance, documentation of OAC contraindications, cardioversion rates, length of stay (LOS), and admission rates.</div></div><div><h3>Results</h3><div>Among 3236 patients with AF (2020–2025), OAC compliance improved from 60.1% to 72.1% after BPA (P < .00001) and to 83% when excluding those with OAC contraindications. CHA<sub>2</sub>DS<sub>2</sub>-VASc documentation increased from 5% to 40% (P < .00001). Cardioversion rates increased from 11.9% to 16.8% (P < .0001). Hospital admissions declined from 44% to 38% (P = .004). ED LOS for discharged patients increased slightly (3.6–4.0 hours, P = .0005); inpatient LOS remained stable.</div></div><div><h3>Conclusion</h3><div>System-wide CPM implementation improved OAC use, documentation, and cardioversion rates, while reducing admissions. Despite a modest increase in ED LOS, the model supported more consistent, guideline-based AF care, reinforcing the value of multidisciplinary, algorithm-driven strategies in emergency settings.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1556-1564"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327101","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.07.013
Akshar Patel BS, Stanley Joseph BS, Caryl Bailey MD, Ashish Sakharpe MD, Mallikarjuna Devarapalli MBBS
This article explores how Natural Language Processing (NLP) models and agentic AI can streamline workflows in electrophysiology (EP). It discusses fine-tuning models such as BioBERT for EP-specific tasks, Named Entity Recognition for identifying key terms, real-time guideline updates using web scraping, and the integration of these components into a unified agentic AI workflow. The Hugging Face Transformers library and its pipeline() function are leveraged for various NLP tasks, including summarization, text generation, and translation, to automate literature reviews, guideline monitoring, and report generation.
本文探讨了自然语言处理（NLP）模型和代理人工智能如何简化电生理学（EP）的工作流程。它讨论了微调模型，如用于ep特定任务的BioBERT，用于识别关键术语的命名实体识别，使用网络抓取的实时指南更新，以及将这些组件集成到统一的代理AI工作流中。hugs Face Transformers库及其pipeline（）函数用于各种NLP任务，包括摘要、文本生成和翻译，以自动进行文献审查、指导方针监控和报告生成。
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Pub Date : 2025-10-01DOI: 10.1016/j.hroo.2025.06.019
Haseeb Valli MBBS, MRCP, PhD , Mahmoud Ehnesh PhD , Sam Coveney PhD , David G. Jones MBBS, MD (Res), MRCP , Zhong Chen MBBS, FRCP, PhD , Wajid Hussain MBChB, FRCP , Vias Markides MD, FRCP , Kumaraswamy Nanthakumar MD , Tom Wong MD, FRCP , Caroline Roney PhD , Shouvik Haldar MBBS, MD (Res), FRCP, FESC, FHRS
Background
Left atrial (LA) fibrosis is a key component of arrhythmogenic remodeling in atrial fibrillation (AF). LA low-voltage areas (LVAs) are considered surrogates for fibrosis and novel targets for ablation. However, there are no established criteria for identifying such potential pathogenic areas, particularly when using omnipolar technology (OT) mapping.
Objective
This study aimed to evaluate the correlation between OT and conventional bipolar voltage (BiV) in AF and regular rhythms.
Methods
Bipolar and OT mapping was performed in 17 patients undergoing de novo ablation for persistent AF. Mapping was performed in AF and coronary sinus pacing (CSP) at 600 ms. BiV of <0.5 mV was defined as low voltage.
Results
LA voltage in AF correlated poorly with CSP using either BiV (r = 0.15) or OT (r = 0.16). OT yielded higher voltages than BiV in AF (0.62 ± 0.24 vs 0.49 ± 0.18 mV, P < .050) and during CSP (1.85 ± 0.78 vs 1.60 ± 0.80 mV, P < .050). LVA burden, as a percentage of LA surface area, varied significantly depending on the atrial rhythm and mapping approach (AF-bipolar 65.0 ± 15.6%, AF-OT 56.2 ± 17.0%, CSP-bipolar 34.2 ± 18.9%, CSP-OT 24.56 ± 13.5%, P < .050). BiV thresholds of 0.5 mV during CSP and 0.3 mV in AF corresponded to an OT voltage of 0.84 mV and 0.40 mV, respectively.
Conclusion
The mapping tool and atrial rhythm significantly influence LA voltage and LVA burden for both bipolar and OT mapping. Applying a universal bipolar or OT cutoff for low voltage in AF and sinus rhythm will not accurately reflect the arrhythmogenic substrate. OT yields higher voltage than corresponding bipolar measurements; thus, threshold adjustments are required when using OT.
背景左心房（LA）纤维化是心房颤动（AF）致心律失常重构的关键组成部分。LA低压区（LVAs）被认为是纤维化的替代品和消融的新靶点。然而，尚无确定这些潜在致病区域的既定标准，特别是在使用全极技术（OT）制图时。目的探讨OT与房颤常规双极电压（BiV）及心律的相关性。方法对17例顽固性房颤从头消融患者进行双极和OT定位，并在房颤和冠状动脉窦起搏（CSP） 600 ms时进行定位。0.5 mV的BiV定义为低压。结果使用BiV （r = 0.15）或OT （r = 0.16）时AF的sla电压与CSP的相关性较差。OT在AF（0.62±0.24 vs 0.49±0.18 mV, P < 0.050）和CSP（1.85±0.78 vs 1.60±0.80 mV, P < 0.050）时产生的电压高于BiV。LVA负担占LA表面积的百分比，根据心房节律和测图方法的不同而有显著差异（AF-bipolar 65.0±15.6%,AF-OT 56.2±17.0%,CSP-bipolar 34.2±18.9%,CSP-OT 24.56±13.5%,P < 0.050）。CSP时BiV阈值为0.5 mV， AF时为0.3 mV，对应的OT电压分别为0.84 mV和0.40 mV。结论测图工具和心房节律对双极和OT测图的LA电压和LVA负荷均有显著影响。对房颤和窦性心律的低电压应用通用双极或OT切断不能准确反映致心律失常的底物。OT产生比相应双极测量更高的电压；因此，在使用OT时需要调整阈值。
{"title":"High-density evaluation of the arrhythmogenic substrate in persistent atrial fibrillation","authors":"Haseeb Valli MBBS, MRCP, PhD , Mahmoud Ehnesh PhD , Sam Coveney PhD , David G. Jones MBBS, MD (Res), MRCP , Zhong Chen MBBS, FRCP, PhD , Wajid Hussain MBChB, FRCP , Vias Markides MD, FRCP , Kumaraswamy Nanthakumar MD , Tom Wong MD, FRCP , Caroline Roney PhD , Shouvik Haldar MBBS, MD (Res), FRCP, FESC, FHRS","doi":"10.1016/j.hroo.2025.06.019","DOIUrl":"10.1016/j.hroo.2025.06.019","url":null,"abstract":"<div><h3>Background</h3><div>Left atrial (LA) fibrosis is a key component of arrhythmogenic remodeling in atrial fibrillation (AF). LA low-voltage areas (LVAs) are considered surrogates for fibrosis and novel targets for ablation. However, there are no established criteria for identifying such potential pathogenic areas, particularly when using omnipolar technology (OT) mapping.</div></div><div><h3>Objective</h3><div>This study aimed to evaluate the correlation between OT and conventional bipolar voltage (BiV) in AF and regular rhythms.</div></div><div><h3>Methods</h3><div>Bipolar and OT mapping was performed in 17 patients undergoing de novo ablation for persistent AF. Mapping was performed in AF and coronary sinus pacing (CSP) at 600 ms. BiV of <0.5 mV was defined as low voltage.</div></div><div><h3>Results</h3><div>LA voltage in AF correlated poorly with CSP using either BiV (r = 0.15) or OT (r = 0.16). OT yielded higher voltages than BiV in AF (0.62 ± 0.24 vs 0.49 ± 0.18 mV, <em>P</em> < .050) and during CSP (1.85 ± 0.78 vs 1.60 ± 0.80 mV, <em>P</em> < .050). LVA burden, as a percentage of LA surface area, varied significantly depending on the atrial rhythm and mapping approach (AF-bipolar 65.0 ± 15.6%, AF-OT 56.2 ± 17.0%, CSP-bipolar 34.2 ± 18.9%, CSP-OT 24.56 ± 13.5%, <em>P</em> < .050). BiV thresholds of 0.5 mV during CSP and 0.3 mV in AF corresponded to an OT voltage of 0.84 mV and 0.40 mV, respectively.</div></div><div><h3>Conclusion</h3><div>The mapping tool and atrial rhythm significantly influence LA voltage and LVA burden for both bipolar and OT mapping. Applying a universal bipolar or OT cutoff for low voltage in AF and sinus rhythm will not accurately reflect the arrhythmogenic substrate. OT yields higher voltage than corresponding bipolar measurements; thus, threshold adjustments are required when using OT.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 10","pages":"Pages 1536-1545"},"PeriodicalIF":2.9,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145327412","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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