Journal of Innovations in Cardiac Rhythm Management最新文献

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Although its pathogenesis remains incompletely elucidated, accumulating evidence implicates oxidative stress (OS) as a key contributor to the development of the arrhythmogenic substrate. OS may facilitate atrial remodeling through modulation of calcium-handling proteins and ion channel function, potentially promoting the initiation and maintenance of AF. This article summarizes the role of OS biomarkers such as 8-hydroxydeoxyguanosine (8-OHdG), glutathione peroxidase (GPx), advanced glycation end-products (AGEs), superoxide dismutase (SOD), malondialdehyde (MDA), isoprostanes (IsoPs), derivatives of reactive oxidative metabolites that oxidize reduced glutathione (E_h GSH) and cysteine, and advanced oxidation protein products (AOPPs) in the pathogenesis of AF. Plasma 8-OHdG levels progressively increase with advancing low-voltage area stages, indicating a strong association between oxidative DNA damage and the severity of atrial fibrosis. Also, the reduction in GPx activity appears to contribute to arrhythmogenic electrochemical disturbances and oxidative lipid damage, independent of dyslipidemia. The receptor for the AGE axis plays a part in arrhythmogenic structural atrial remodeling. Patients who develop post-surgical AF demonstrate paradoxically elevated SOD activity, possibly reflecting a compensatory antioxidant response to heightened OS. As serum MDA levels were not linked to the development of postoperative AF (POAF), it is possible that lipid peroxidation is not the primary cause of POAF pathogenesis. Even when AF patients are receiving anticoagulant medication, elevated 8-isoprostane levels are linked to thromboembolic events, in part because of changes in the fibrin clot structure. Each 10% increase in E_h GSH was associated with a 40% increase in the risk of incident AF. Future research is required on AOPPs in AF pathogenesis. Future investigations should aim to identify and characterize novel OS markers and evaluate their potential therapeutic relevance in the prevention and management of AF.

Atrial fibrillation (AF), the most common arrhythmia worldwide, affects approximately 59 million people globally. It poses a significant health burden by increasing morbidity and mortality. Artificial intelligence (AI) is emerging as a potentially transformative technology across the AF care continuum. This review synthesizes current evidence and critically evaluates AI applications in AF management, including innovations in detection and screening using electrocardiography and wearables; advanced mapping techniques using signal processing and computational modeling to guide catheter ablation; machine learning-based prediction of treatment outcomes; and personalization of long-term therapy, such as anticoagulation. Key studies and trials illustrating AI's capabilities in improving diagnostic yield, refining ablation targets, and enhancing prognostic accuracy are analyzed. The potential for AI to facilitate integrated care pathways, such as the "AF Better Care" approach, is considered, balancing innovation against clinical practicality, rigorous validation, and workflow integration. While AI shows considerable potential to augment precision in AF management, significant challenges concerning data generalizability, model interpretability, clinical utility validation, and equitable implementation remain. Optimal integration requires careful alignment with clinical expertise and a focus on patient-centric outcomes. Addressing these challenges through collaborative efforts among clinicians, researchers, and technology developers will be essential to fully realize AI's promise in improving AF care. Future research should prioritize robust validation, transparent methodologies, and practical implementation strategies to ensure that AI effectively enhances patient outcomes.

While hemodynamically insignificant, a persistent left superior vena cava (PLSVC) draining to the coronary sinus (CS) may have important implications during an electrophysiology study and catheter ablation. Specifically, ablation of left-sided accessory pathways (APs) poses a special challenge secondary to the potential distortion of the mitral valve annulus (MVA) and the possibility of the AP comprising a discrete epicardial trunk involving CS musculature. Ablation of such pathways is more likely accomplished from within the CS rather than on the MVA after a transseptal puncture. We describe two pediatric cases with a PLSVC draining to a dilated CS in whom successful ablation of left-sided APs was accomplished from within the CS after failed ablation attempts on the MVA. Initial mapping and ablation in the CS after a careful evaluation of the coronary artery proximity may obviate the need for a transseptal puncture with its potential challenges.

Ventricular tachycardia termination by pacing with non-global capture is a specific criterion for identifying a critical component of the re-entrant circuit, regardless of whether concealed entrainment can be demonstrated at that site. It is usually observed almost by chance, but it can also be intentionally demonstrated by introducing a single extrastimulus during tachycardia.

Atrial fibrillation (AF) is a common comorbidity among patients with implantable cardioverter-defibrillators (ICDs). The presence of AF in this patient population is associated with increased mortality and morbidity. Dual-chamber ICDs allow for atrial arrhythmia detection; however, they have higher complication rates of implantation compared to single-chamber ICDs. Recent advances have enabled single-chamber ICDs to incorporate atrial electrogram (AEGM) sensing via a floating atrial dipole, potentially improving AF detection and arrhythmia discrimination. This study evaluates the effectiveness of AEGM-enabled single-chamber ICDs in detecting AF and differentiating tachyarrhythmias compared to single-chamber ICDs without AEGM and subcutaneous ICDs (S-ICDs). A retrospective analysis was done on 128 patients who received single-chamber ICDs between 2015 and 2024. Patients were stratified into three groups: (1) ICDs with AEGM, (2) ICDs without AEGM, and (3) S-ICDs. Baseline characteristics, comorbidities, arrhythmia events, and device data were collected. Numbers of ventricular tachycardia (VT), supraventricular tachycardia (SVT), and AF events were evaluated in all three devices. Outcomes measured included the detection of new and prior AF, tachycardia classification, initiation of anticoagulation, anticoagulants, AF ablation, congestive heart failure exacerbations, hospital admissions, and mortality. Statistical comparisons were made using logistic regression analysis. ICDs with AEGM (group 1, n = 69) detected AF in 42% (n = 29) of patients, including 13% (n = 9) with newly diagnosed, asymptomatic AF. In contrast, ICDs without AEGM (group 2, n = 34) detected AF only in patients with a prior history (n = 11), with no new cases identified. S-ICDs (group 3, n = 25) detected one new AF case, confirmed by external monitoring. The detection rate of new-onset subclinical AF was significantly higher in group 1 compared to groups 2 and 3 (P < .05). Among nine new AF patients in group 1, anticoagulation was started in four patients, anti-arrhythmics were initiated in four patients, two patients underwent AF ablation, and one patient underwent direct current cardioversion. VT events in all groups were analyzed, and the appropriateness of the therapy was confirmed in group 1 with the availability of AEGM and in groups 2 and 3 with EGM morphology and irregularity of the R-R intervals. There was no statistical difference among the groups with VT management (P > .05). In conclusion, single-chamber ICDs equipped with AEGM capabilities significantly enhance the detection of asymptomatic and new-onset AF. This has important implications for the management and prevention of AF-related complications in high-risk populations. Though there was no difference in VT defibrillation among all three groups, the validation of VT/SVT/AF was much more decisive in ICDs with AEGM.