Journal of Innovations in Cardiac Rhythm Management最新文献

Sick sinus syndrome (SSS) is a cardiac conduction disorder that often necessitates pacemaker implantation, especially in older adults. Emerging evidence suggests a potential association between coronavirus disease 2019 (COVID-19) infection and SSS, but the impact on SSS trends and permanent pacemaker (PPM) implantation rates remains unclear. This study compares the pre- and post-COVID-19 trends in SSS incidence and PPM implantation rates. Using the TriNetX Research Network, we analyzed the monthly incidence rate (IR) of SSS and the rate of PPM implantation in the overall population from January 2018 to December 2023. Additionally, we conducted a subgroup analysis focusing on patients >50 years of age to examine trends in IR and PPM implantations during the same period. To evaluate changes before and after COVID-19, we used interrupted time series analysis, with March 1, 2020, as the cutoff. In the overall SSS population, the IR increased significantly post-COVID-19 (IR, 1.80 cases/100,000 person-years [PY] per month; P < .001), which was accompanied by a significant rise in PPM implantation rates (119.16 cases/100,000 PY per month; P < .001). Among patients <50 years of age, the IR increased post-COVID-19 (IR, 0.355 cases/100,000 PY per month; P < .001), but PPM implantation rates in this subgroup remained unchanged (P = .897). Our findings suggest an increase in SSS incidence across all age groups post-COVID-19. However, the lack of increased PPM implantation in younger patients may reflect either a more transient disease course or a higher threshold for device implantation in this age group. Further research is needed to determine the prognosis of SSS in the recent era.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as an alternative to conventional ICD systems. Although not considered mandatory, short-time fluoroscopy is used in clinical practice, both preprocedurally and intraoperatively. The aim of this study was to compare totally fluoroless versus limited fluoroscopy-assisted S-ICD implantation in terms of clinical and technical efficacy and safety. In this non-randomized, single-center study, 49 patients (24.5% women; mean age, 43.2 ± 18.4 years) at high risk for arrhythmic cardiac death underwent S-ICD implantation in the context of either primary or secondary prevention between May 2016 and June 2024 with at least 6 months of follow-up thereafter. Patients were allocated to group A (n = 25), where a totally fluoroless implantation strategy was followed (January 2023-June 2024), or group B, where a limited fluoroscopy-guided S-ICD implantation process (first 24 cases) was followed. Following implantation, a pre-discharge chest X-ray confirmed an anatomically acceptable lead position in all cases. Further, our data revealed similar acute and long-term clinical efficacy with both approaches: the success rate of defibrillation testing at 60 J was 100%, the appropriate shock rate was low (8.2%) with defibrillation therapy successful in all cases, the mean PRAETORIAN score remained in the low-risk category, and no arrhythmic deaths were recorded. The rate of inappropriate shocks was similar between groups (8% vs. 8.3%; P = .97 for groups A and B, respectively). Finally, no major periprocedural complications were recorded with either approach. Compared to the limited fluoroscopy-guided technique, totally fluoroless S-ICD implantation showed comparable efficacy, reliability, and safety in the present study.

We present the case of a young man with cocaine intoxication whose electrocardiogram (ECG) on presentation showed a typical type 1 Brugada pattern. The patient had no personal or family history of unexplained syncope or sudden cardiac death. The ECG quickly normalized, and follow-up ECGs continued to be normal. Nevertheless, the patient and family members insisted on implantation of a cardioverter-defibrillator. The purpose of this case report is to discuss the somewhat unfounded fear of sudden cardiac death of asymptomatic patients with Brugada-type ECGs that has been termed "brugadaphobia" and to highlight the difficult and controversial decision-making process that should include discussions about the possible benefits and harms of an overly active diagnostic and therapeutic approach.

Cardiac resynchronization therapy (CRT) is a well-established treatment for patients with heart failure and wide QRS complexes. Successful left ventricular (LV) lead implantation is typically achieved through the coronary sinus (CS). However, congenital anomalies such as CS ostial atresia can complicate the procedure. We report a case of a 65-year-old man with a history of aortic valve replacement and heart failure who underwent successful CRT-defibrillator implantation. During the procedure, CS ostial atresia was unexpectedly encountered, preventing standard venous access. The LV lead was successfully implanted via the vein of Marshall.

Marshall bundle ablation via retrograde ethanol infusion into the vein of Marshall (VoM) is one of the few adjunctive approaches complementary to the success of pulmonary vein (PV) isolation during catheter ablation for persistent atrial fibrillation (AF). VoM ablation also increases the success and durability of mitral isthmus block for the management of peri-mitral flutter. Despite its promise, the adoption of VoM ablation is limited due to anatomical variations that result in a steep learning curve. Successful Marshall bundle ablation requires accurate identification and successful cannulation of the VoM with an appropriate-size balloon to achieve adequate occlusion, followed by non-traumatic ethanol infusion. VoM ablation is often performed before wide-area circumferential ablation of the left-sided PVs. Mitral isthmus ablation to achieve mitral annular block is always recommended after VoM ablation to minimize the risk of peri-mitral flutter. This paper discusses a step-by-step approach for successful Marshall bundle ablation with tips and tricks for difficult cases based upon the performance of over 500 cases performed at the Ohio State University Medical Center.

Despite advancements in medical therapy, managing symptomatic inappropriate sinus tachycardia (IST) remains challenging. The role of catheter ablation in addressing this condition remains ambiguous according to multiple cardiac society guidelines. In this case study, we illustrate the efficacy of a hybrid approach involving sinus node modification and ablation in a patient with refractory symptoms, while also addressing the associated challenges and safety considerations of this procedure. A 58-year-old female patient was troubled with recurrent palpitations secondary to IST. Due to the proximity of the target ablation site to the phrenic nerve, this area was not amenable to complete ablation endocardially. To alleviate symptoms, an ablation procedure was planned, aiming for epicardial sinus node modification and displacement of the phrenic nerve from the target site. The procedure was completed under general anesthesia. The conventional subxiphoid technique was deemed challenging even with a surgical approach due to the patient's body habitus and significantly increased body mass index; hence, she underwent a 5-cm right anterior thoracotomy to establish access to the pericardium. The sinoatrial (SA) node was ablated surgically by direct application under vision of the right atrium around the area of the SA node to avoid the phrenic nerve. Modification and ablation of the sinus node in patients exhibiting features of IST may be considered to help alleviate patients' symptoms. Further follow-up and assessments with large cohorts and powered randomized controlled studies are needed. Our case represents an example where a hybrid invasive approach resulted in a safe procedure with immediate symptomatic benefit.

Catheter ablation has emerged as a first-line therapy for many arrhythmias. However, data on the safety and outcomes of catheter ablation in the elderly population remain limited. Here, we aimed to study the outcomes of catheter ablation in octogenarians. The data used in this study were obtained from the National Inpatient Sample database through years 2016-2019. We identified patients ≥80 years old who were diagnosed with atrial fibrillation (AF), atrial flutter (AFL), supraventricular tachycardia (SVT), or ventricular tachycardia (VT) as primary diagnoses. The patients' characteristics and common procedure complications were extracted. We investigated the predictors of mortality and in-hospital complications using multivariable logistic regression. A total of 18,595 patients were included in our analysis. The most common procedure performed was ablation for AF (46%), followed by AFL ablation (23%), VT ablation (18%), and SVT ablation (12%). Higher rates of tamponade (1.6%) were seen in patients undergoing VT ablation. A Charlson's comorbidity index (CCI) score of ≥3 points was used as an independent predictor for complications (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.4-3.3, P = .001). Mortality was higher in VT ablation (4.2%) compared to AFL (1.3%), AF (0.9%), and SVT (0.3%). After logistic regression analysis, a CCI score of ≥3 points (OR, 14.7; 95% CI, 1.88-114.9; P = .01) and tamponade (OR, 4.9; 95% CI, 1.65-14.8; P = .004) were independent predictors of mortality. We found a low incidence of procedural complication rates across all ablation groups in octogenarians. Those undergoing VT ablation were more likely to have complications and a higher mortality rate. Baseline comorbidities can be used to risk-stratify patients when deciding on the best treatment strategy.

Electrophysiology (EP) labs are fundamental in cardiovascular medicine, especially for the diagnosis and treatment of cardiac arrhythmias. Nowadays, continuous advances in technology have led to significant improvements in the design and functioning of EP labs, including the development of more sensitive and accurate sensors and algorithms as well as three- and four-dimensional imaging and guidance systems. However, there are still significant challenges related to the reduction of radiation exposure, space constraints, and the integration and compatibility between the different EP systems. Future advances in technology will lead to equipment and space improvements as well as the addition of advanced communication and collaboration tools, speech-recognition software, and the development of standardized data formats and centralized cloud-based data storage systems. The EP lab of the future will present multifunctional configurations that will integrate all the advances in technology, optimize workflows, and potentiate collaboration while assuring patient data protection.

We present a case of a 71-year-old woman with symptomatic paroxysmal atrial fibrillation and atypical atrial flutter (AFL), ultimately diagnosed with a rare type 3 macro-re-entrant biatrial tachycardia (BiAT). Despite initial pulmonary vein isolation and anterior line ablation for atypical AFL, she experienced recurrent AFL requiring a complex redo ablation. Successful termination of the tachycardia was achieved by extending ablation to the septal regions of both atria. This case highlights the complexity of managing BiAT.