Indian Pacing and Electrophysiology Journal最新文献

Lumen less leads (LLLs) and stylet-driven leads (SDL) are widely used for left bundle branch area pacing (LBBAP) and has become standard practice. The incidence of lead fracture is very rare with both leads. We report a case of delayed fracture in stylet driven lead producing syncope following exercise.

Background: This meta-analysis aimed to compare the effectiveness of early rhythm control to rate control, and whether catheter ablation derived more benefit compared to other methods of rhythm control.

Methods: A comprehensive literature search was conducted on PubMed, SCOPUS, and EuropePMC up to July 2, 2024. The primary outcome of this study was major adverse cardio-cerebrovascular events (MACCE), defined as a composite of mortality, stroke/systemic embolism, heart failure hospitalization (HFH), and acute coronary syndrome (ACS) during the follow-up period. Outcome measures were adjusted hazard ratios (aHR).

Results: A total of 504,124 patients from 11 studies were included in this systematic review and meta-analysis. Early rhythm control was significantly associated with reduction in MACCE (aHR 0.85 [95 % CI 0.80, 0.90], p < 0.001; I²: 23 %), stroke (aHR 0.79 [95 % CI 0.72, 0.86], p < 0.001; I²: 25 %), HFH (aHR 0.87 [95 % CI 0.78, 0.96], p = 0.008; I²: 48 %), and ACS (aHR 0.80 [95 % CI 0.66, 0.96], p = 0.018; I²: 40 %). No mortality benefit (aHR 0.93 [95 % CI 0.85, 1.01], p = 0.066; I²: 67 %) was observed; however, mortality benefit became evident (aHR 0.87 [95 % CI 0.85, 0.89], p < 0.001) upon removal of a study during a leave-one-out sensitivity analysis. Meta-regression analysis showed that the benefits of early rhythm control in terms of MACCE were more pronounced with ablation (coefficient -0.004, p = 0.010, R²: 100 %).

Conclusion: Early rhythm control was associated with better outcomes compared to rate control in AF, with a more pronounced benefit observed for ablation.

Cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) is difficult to manage with antiarrhythmic drugs, with radiofrequency (RF) ablation being the standard treatment. However, achieving a bidirectional CTI block can be challenging due to complex anatomy and epicardial-endocardial breakthrough (EEB). This case report illustrates that cryoablation can serve as an effective bail-out strategy to achieve a permanent CTI block when RF ablation fails, particularly in cases complicated by EEB. We present the case of a 66-year-old woman who underwent multiple catheter ablations for persistent atrial fibrillation (AF) and CTI-dependent AFL. Despite two prior sessions of RF-based CTI ablation, a durable bidirectional block was not achieved. During her fourth ablation, recurrent AFL persisted despite extensive RF applications. Cryothermal ablation, utilizing a Freezor MAX catheter with point-by-point freezing along the CTI line, successfully terminated the AFL and created a durable bidirectional CTI block. While RF ablation remains the primary treatment for CTI-dependent AFL, the formation of a durable bidirectional CTI block can be challenging due to complex CTI anatomy, EEB, and tissue edema. Cryothermal ablation offers a viable alternative in these difficult cases. The enhanced tissue adhesion and improved catheter stability provided by cryoablation, along with the reduced risk of steam pops, allow for more consistent lesion formation. This case underscores the utility of cryoablation as a bail-out strategy when RF ablation alone is insufficient.

Introduction: Three-dimensional (3D) maps are useful for premature ventricular contraction (PVC) ablation. However, positional information changes compared with sinus rhythm when PVCs appear, rendering ablation difficult. We aimed to understand the spatial displacement characteristics of PVC ablation in 3D maps and the therapeutic effect after correction using the LAT-Hybrid function.

Methods: Thirty-two consecutive patients who underwent PVC ablation from 2022 to 2024 were included. Parallel mapping was used to analyze the LAT-Hybrid function. Ablation was performed at the best Hybrid-LAT location. Characteristics according to PVC origin (right ventricular outflow tract, ventricular septum, and left ventricular outflow tract/left ventricular summit) were compared. Efficacy was evaluated by acute response and clinical outcome on 24-h Holter after 6 months.

Results: In all cases, the PVC origin was spatially displaced by 5.6 ± 1.9 (right ventricular outflow tract, 6.0 ± 1.8; ventricular septum, 4.0 ± 1.4; left ventricular outflow tract/left ventricular summit, 6.0 ± 1.7) mm, and the septum area was significantly smaller. The voltage of origin was 60 % in the low voltage-transitional zone, which coincided with 80 % of the origin determined from the ripple map. The pace map at the location analyzed with LAT-Hybrid was high at 95.4 % ± 3.6 %, and ablation was successful in 96.9 % at the same site. The clinical outcome was good 6 months after ablation.

Conclusion: Spatial displacement of the 3D map caused by differences in excitation propagation can lead to misidentification of the origin. PVC ablation corrects spatial displacement and obtains accurate positional information, leading to successful ablation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and pulmonary vein isolation (PVI) by percutaneous transcatheter ablation is its pivotal treatment. Nowadays, several techniques using different energy sources are used, such as radiofrequency (RF), cryoablation and laser ablation. A new technology that combines the strengths of different techniques has been developed, in particular having both the speed of one-shot techniques and the selectivity and precision of point-by-point RF: the RF balloon (RFB). Recent clinical studies^1-3 have demonstrated its efficacy and safety, with good results in terms of first pass isolation, procedural duration and fluoroscopy time. However, real-world data regarding RFB ablation is scarce, therefore with this study we aimed to describe the experience of our center with this technology (one of the first adopting it in our country). We prospectively enrolled in a single-center a total of 20 consecutive patients who underwent AF ablation with RFB. The primary endpoint, i.e. PVI defined as stable absence of any electrical conduction from and into the veins, was met by 18 patient (90 %). Mean procedural and fluoroscopy times were 79 ± 30.68 min and and 15.36 ± 6.57 min, respectively, dwelling time was 30.3 ± 8.09 min. The only complication reported was a single case mild pericardial effusion 24 h after the procedure, likely of inflammatory nature, which was treated conservatively and resolved before discharge. With this study we demonstrated that PVI with RFB appears to be an effective and safe technique in a real world setting, with many upsides and a reduced atrial dwelling time that theoretically could reduce the risk of thromboembolic complications. Further studies on larger number of patients are needed to confirm the results we obtained.

Transthyretin Cardiac amyloidosis (ATTR-CA) is an increasingly recognised cause of heart failure in our elderly patients with preserved ejection fraction. Patients with ATTR-CA who require permanent pacemaker implantation often have preserved ejection fraction and do not meet the clinical indication for cardiac resynchronization therapy (CRT). In these patients, left bundle branch area pacing (LBBAP) can be a reasonable option to maximise physiological activation of the left ventricle. We describe a series of three patients with cardiac amyloidosis who have undergone LBBAP with the use of lumenless leads and successful capture of the myocardium and left bundle branch region.

Introduction: The advancement of medical technology has introduced leadless pacemakers (LPMs) as a significant innovation in cardiac pacing, offering potential advantages over traditional ventricular transvenous pacemakers. This report explores the application of LPMs in two patients with complex valvular histories, particularly those with mechanical tricuspid valves.

Case reports: The first case involves a 60-year-old male with a history of rheumatic heart disease and triple valve replacement who developed a high-grade AV block. Due to significant RV pacing, a single-chamber VVI pacemaker using the Micra Transcatheter Pacing System was successfully implanted, navigating the mechanical tricuspid valve with stable pacing parameters. The second case describes a 70-year-old female with HIV, diabetes, hypothyroidism, and multiple valve surgeries presenting with syncope and dyspnea. Given her complex medical history and recurrent conduction issues, the Micra pacemaker was chosen. Despite initial resistance, successful deployment was achieved at the lower septum with acceptable pacing thresholds.

Discussion: LPMs offer a promising alternative for patients with mechanical tricuspid valves, eliminating the risks associated with transvenous leads. The Micra system's minimally invasive approach and stable performance in these challenging cases suggest its potential viability in high-risk patients with complex valvular conditions.

Conclusion: These cases demonstrate the feasibility of LPM implantation through mechanical tricuspid valves; however, given the associated risks, careful evaluation and meticulous procedural planning are essential before considering this approach.