Indian Pacing and Electrophysiology Journal最新文献

Preventing stroke is a key aspect of managing atrial fibrillation (AF). Non-vitamin K antagonist oral anticoagulants (NOACs) have become the preferred choice due to their improved safety profiles and ease of use compared to warfarin. At the same time, left atrial appendage occlusion (LAAO) has evolved from being an option only for patients unable to tolerate anticoagulation to a legitimate treatment supported by clinical trials, longer-term follow-up, and real-world data. As ongoing research progresses, clinicians are increasingly considering whether LAAO could potentially replace long-term anticoagulation. This review analyzes comparative evidence on NOACs versus LAAO through 2026, focusing on stroke prevention, bleeding complications, survival, procedural risks, long-term outcomes, and appropriate patient selection. Special attention is given to the Indian subcontinent, where bleeding tendencies, coexisting conditions, medication adherence, and access to medical care create unique challenges compared to Western populations. Available evidence shows NOACs remain the standard initial therapy for most AF patients. However, LAAO delivers an important alternative for selected individuals at elevated bleeding risk, those experiencing recurrent clots despite proper anticoagulation, or patients unable to maintain lifelong drug treatment.

Background: Ventricular arrhythmias arising from the left ventricular (LV) summit are technically challenging to ablate because of limited accessibility and proximity to the coronary arteries. Dual energy lattice-tip catheter (DLTC) could provide both very high-power temperature-controlled radiofrequency (RF) ablation and pulse field (PF) ablation.

Objective: To describe the use of combined radiofrequency (RF) and pulsed field (PF) ablation using a dual-energy large lattice-tip catheter for treatment of ventricular tachycardia originating from the LV summit region.

Methods: We report a 66-year-old man with atrial fibrillation, heart failure with reduced ejection fraction, and recurrent VT despite prior endocardial and epicardial radiofrequency ablation. Mapping localized the PVC/VT to a LV summit-adjacent region, with an endocardial target along the superior septum/LVOT consistent with an intramural or epicardial summit substrate. Given prior failed RF ablations compassionate-use ablation with the dual-energy lattice-tip catheter and Affera™ mapping system (Medtronic, Minneapolis, MN) was performed under intracardiac echocardiogram guidance. Interventional cardiology was directly involved, providing coronary angiography and intravascular imaging before and after ablation to ensure the absence of vasospasm or ischemia.

Results: At 6 week follow up, following dual-energy ablation with DLTC, there was significant suppression of ventricular arrhythmia off antiarrhythmic amiodarone. There was no evidence of coronary injury post ablation confirmed by coronary angiogram and intravascular ultrasound. This case highlights the feasibility of high-power temperature controlled-RFA and focal PFA for VT in anatomically regions where success with conventional energy sources is limited.

Conclusion: Combined RF and PF ablation using the DLTC achieved safe and effective ablation of LV summit ventricular tachycardia without coronary injury.

A young male presented with palpitations and wide complex tachycardia with a rate of 250/min. The differential diagnoses of wide complex tachycardia are discussed and the limitations of current diagnostic algorithms are highlighted.

It is crucial to analyze device stored electrograms (EGMs) to decipher whether the therapies were appropriate or inappropriate. We report a case of an inappropriate defibrillator therapy delivered during an obvious atrial tachyarrhythmia despite the dual chamber SVT discriminators being appropriately programmed for underlying rhythm abnormality. The therapy was delivered even though the tachycardia clearly satisfied V < A rate branch along with significant RR interval variability. The morphology match was misleading possibly due to malalignment of the peaks. On the other hand, the Abbott algorithm decides stability delta based on 2nd shortest and longest RR interval. This delta was <40 ms in spite of a irregular rhythm. The Atrio-Ventricular Association (AVA) algorithm, a second check-post designed for such situations, also got deceived due to variation of AV intervals. These led to fulfilment of stringent 'ALL' criteria programmed to make a diagnosis of VT and delivered therapy inappropriately.

Ventricular arrhythmias, either idiopathic or those associated with organic heart diseases, may originate from the epicardial side of the ventricular myocardium. Therefore, mapping and ablation via the coronary venous system offers a convenient, feasible, and effective option in such cases, considering the convenience of the epicardial location of the coronary venous system. Among epicardial idiopathic ventricular arrhythmias, the left ventricular summit is by far major region of interest closely associated with the coronary venous system. In this setting, the great cardiac vein/anterior interventricular vein or their tributaries serve as a convenient and practical route for the epicardial or intramural mapping of ventricular arrhythmias originating from this region, via endocardial access through the coronary sinus. In limited cases, where these veins are incidentally close enough to the arrhythmogenic focus and distant enough from the left coronary arteries, radiofrequency or ethanol ablation via these veins is also feasible and effective. Devices and techniques have been improved to facilitate transvenous epicardial and intramural mapping and ablation. Wide individual variations exist in terms of three-dimensional orientation of these veins relative to the left ventricular summit, coronary arteries, pulmonary root, and left atrial appendage. Therefore, discerning case-specific anatomy through careful review of periprocedural image findings is fundamental for estimating feasibility of transvenous epicardial procedures. In this review, comprehensive anatomy of the coronary venous system around the left ventricular summit as well as current clinical implications are summarized from the electrophysiologist's perspective.

Ibutilide is a class III antiarrhythmic drug used intravenously for the chemical cardioversion of atrial fibrillation (AF) and atrial flutter (AFL). It mainly acts by blocking the rapid component (I_kr) of delayed rectifier K⁺ channels, resulting in prolongation of action potential duration in the atrium. Ibutilide fumarate is a methanesulfonamide derivative that is structurally similar to sotalol without the β-adrenoreceptor blocking activity. The success rate of cardioversion of atrial flutter with ibutilide is in the range of 50-70%, whereas its efficacy for the conversion of atrial fibrillation is 30-50%. As compared to ibutilide monotherapy, coadministration with propafenone has a significantly higher success rate of AF termination. Ibutilide is also effective in pre-excited AF by reducing the risk of AF related ventricular tachycardia and thereby reducing the risk of sudden cardiac death. It is a safe drug to use for cardioversion in patients on chronic amiodarone therapy. The main side effect of dofetilide is torsade de pointes (tdp), which occurs in 4% patients, and monomorphic ventricular tachycardia, which occurs in 4.9% patients. Proadministration of magnesium reduces the risk of torsade de pointes. Patients should be monitored for at least 4 h for tdp. Targeting complex fractionated electrograms with the assistance of an ibutilide infusion during catheter ablation of persistent AF has shown mixed results. Conversion rate with an ibutilide infusion is only 30% in the presence of an enlarged left atrium (>5 cm) and 37.7% in the presence of mitral valve disease (MVD), whereas the conversion rate was 82.5% in the absence of MVD and 85% in the absence of both an enlarged left atrium and mitral valve disease (p = <0.001). Ibutilide can be used effectively in patients who are not a candidate for direct current cardioversion or who chose not to undergo electric cardioversion.