Journal of Innovations in Cardiac Rhythm Management最新文献

Bidirectional ventricular tachycardia (VT) is a rare arrhythmia characterized by alternating QRS morphologies and axis changes. Atrial flutter (AFL) can coexist with ventricular arrhythmias, complicating diagnosis. We present a case of a 56-year-old man with a history of ischemic heart disease and severe mitral regurgitation admitted with palpitations who was diagnosed with dual tachycardia (bidirectional VT and AFL).

Atrial fibrillation (AF) increases the risk of thromboembolic stroke, and oral anticoagulants (OACs) are an effective tool to reduce this risk. Previous studies have demonstrated that female, black, Hispanic, and Asian groups are less likely to be prescribed OACs. This study explores OAC rates by racial/ethnic group and assesses differences within sexes and between high and low CHA₂DS₂-VASc risk groups. Using a database of AF patients, we employed logistic regression models to assess the association between race/ethnicity and OAC rates among all individuals and according to CHA₂DS₂-VASc risk and sex subgroups. Black, Hispanic, and Asian individuals with AF had lower OAC rates compared to white individuals (adjusted odds ratio [aOR], 0.84; 95% confidence interval [CI], 0.77-0.91) (aOR, 0.92; 95% CI, 0.85-0.99) (aOR, 0.80; 95% CI, 0.72-0.88). Female patients with AF had lower OAC rates than male patients (aOR, 0.66; 95% CI, 0.64-0.68). Among male patients, black, Hispanic, and Asian patients had lower OAC rates while, among female patients, only black patients had a lower OAC rate. In the low-risk CHA₂DS₂-VASc group, only Asian individuals had a lower OAC rate compared to white individuals, while, in the high-risk group, this trend was observed only for black individuals. Women, particularly black women, are less likely to receive OACs compared to men and their white counterparts. High-risk black individuals face reduced OAC use, while low-risk white individuals have high OAC rates. Subjective decision-making may contribute to these disparities, with the most significant disparities observed in black individuals, particularly black women. This "double hit" affecting black women could be the target of equity-focused interventions.

The migration of an implantable loop recorder (ILR) is a rare complication. We aimed to perform a meta-summary of case reports to characterize patients who experienced an ILR migration. We searched for case reports published in PubMed, Google Scholar, Scopus, and Embase from January 2017 to 2023 using the following keywords: "migration ILR," "migration loop recorder," "complication loop recorder," and "complication ILR." Seven case reports/case series reporting ILR migration were included. Data about patients' characteristics, ILR implantation, time of onset, management, and clinical outcome of this complication were collected. Seven patients who experienced the migration of an ILR were examined. All patients experienced migration within 35 days following ILR implantation. The clinical suspicion of ILR migration mainly arose from patients' symptomatology. The migration of the ILR was confirmed by a radiological scan in all cases, and surgical removal, preferably by video-assisted thoracic surgery, was required. In conclusion, intrapleural migration is a rare complication of ILR implantation. It may occur in the early postprocedural period. Clinical suspicion arises from symptoms, but a radiological scan is necessary to confirm the diagnosis. Surgical removal is mandatory.

Left bundle branch area pacing (LBBAP) has shown promising outcomes at experienced centers; however, less is known about the learning curve with initial adoption of LBBAP implantation. We conducted a retrospective analysis (2020-2023) of the learning curve for LBBAP at an academic medical center. Procedural success and device-related adverse events in adult patients undergoing LBBAP by seven new operators with >5 years' experience in device implantation were compared between operators with a history of ≤10 (LBBAP_inexp) versus >10 (LBBAP_exp) LBBAP implant attempts. Successful LBBAP was defined as a left ventricular activation time (LVAT) of ≤80 ms. Seven operators implanted LBBAP devices in 288 patients (age, 73 ± 11 years; 38% women), including 68 (24%) in the LBBAP_inexp group versus 220 (76%) patients in the LBBAP_exp group with similar baseline characteristics. The median number of implants per operator was 22 (range, 8-83). Post-implant LVAT ≤ 80 ms was less frequent in LBBAP_inexp compared to LBBAP_exp (56.9% vs 72.4%; P = .04). There were no significant differences in paced QRS duration ≤ 130 ms (75.9% vs. 76.1%; P = 1.0) or operator self-identified success (85% vs. 91%; P = .2). With new single-/dual-chamber device implants, there was no difference in implant duration (103.4 ± 31.8 vs. 101.6 ± 38.5 min; P = .3), but there was longer fluoroscopy with LBBAP_inexp (12.6 ± 10.1 vs. 8.2 ± 8.0 min; P < .0001). The average number of attempts at LBBAP was lower with LBBAP_inexp versus LBBAP_exp (2.0 ± 1.5 vs. 2.9 ± 2.9; P = .03). There was no difference in device-related adverse events between the two groups (P = .3). Operators use less fluoroscopy, make more attempts at LBBAP, and more frequently achieve LVAT ≤ 80 ms after their first 10 implants.

Intracardiac echocardiography (ICE) is a common tool that has real-time impact in novel pulsed-field ablation (PFA). It is a feasible and efficient option due to zero-fluoroscopy, real-time tissue visualization of procedural maneuvers, and for the assessment of potential procedural complications. We present a case of zero-fluoroscopy-based PFA using four-dimensional (4D) ICE in a 68-year-old man with symptomatic atrial fibrillation. Using 4D ICE, we were able to achieve procedural success by visualization of direct tissue contact with the Farawave™ catheter (Boston Scientific, Marlborough, MA, USA) with each rotation and application of the basket and flower configurations and no edema or color change in tissue morphology after applications. Overall, zero fluoroscopy in PFA is feasible and efficient.

Cardiac resynchronization therapy (CRT) via left bundle branch area pacing (LBBAP) has emerged as effective and safe as conventional CRT. Left-sided CRT implantation in patients with persistent left superior vena cava (PLSVC) is challenging and impossible in some patients. Right-sided CRT implantation, either conventional or LBBAP, is also tricky, as the delivery sheaths are feasible for left-sided implantations. Here, we present a patient with PLSVC who underwent successful right-sided CRT implantation via LBBAP.

Increased age is associated with increased frailty and often worse postoperative outcomes. We sought to assess the safety of leadless pacemaker (LPM) insertion in the very elderly population. We queried the National Readmission Database for patients who underwent LPM insertion from 2017 to 2020. Patients aged ≥90 years were included in the nonagenarian group and compared to patients aged <90 years. Patient comorbidities were queried using the appropriate International Classification of Diseases, Tenth Revision, codes. We compared outcomes using multivariate logistic and linear regression, adjusting for patient comorbidities. At baseline, nonagenarians had higher prevalence rates of hypertension, a history of stroke, atrial fibrillation, atrial flutter, dementia, and hypothyroidism. The control group had more diabetes, coronary artery disease, chronic kidney disease, chronic pulmonary disease, oxygen use, coagulopathy, anemia, obesity, substance abuse, and chronic liver disease. Compared to controls, nonagenarians were found to have a shorter length of stay (2.5 days; P < .001); lower mortality (adjusted odds ratio [aOR], 0.7; P = .02); and lower rates of post-procedural cardiac arrest (aOR, 0.3; P = .03), mechanical ventilation (aOR, 0.4; P < .001), and vasopressor use (aOR, 0.6; P = .001). Nonagenarians were only found to have an increased risk of pericardial complications (tamponade, pericardiocentesis, hemopericardium) (aOR, 1.6; P = .02). There was no significant difference in 30-day readmissions (aOR, 0.97; P = .7), postoperative bleed (aOR, 0.84; P = .07), or stroke (aOR, 0.586; P = .1). Our study demonstrates that LPM insertion could be safe in the very elderly population. However, our study likely demonstrates survivorship bias, as patients in the nonagenarian group had fewer overall comorbidities. Despite adjustment for known comorbidities, there remain confounders that are difficult to account for. Age itself does not seem to be a risk factor for worse outcomes in this population.

We sought to clarify the impacts of premature atrial contractions (PACs) and biochemical markers early after cryoballoon (CB) versus radiofrequency (RF) ablation for atrial fibrillation (AF) on the late recurrence of AF (LRAF). The study population included 138 patients who underwent first-time ablation for paroxysmal AF with CB (n = 69) or RF (n = 69). We compared the levels of the PAC burden on Holter monitoring, myocardial-bound creatine kinase (CK-MB), troponin T (TnT), and C-reactive protein (CRP) the day after ablation, and we assessed the incidence of LRAF, which was defined as AF after a 3-month blanking period. The postprocedural PAC burden was not significantly different between the CB and RF groups (P = .35), whereas the CK-MB and CRP levels were significantly higher in the CB group (both P < .01); the TnT levels of the groups were similar (P = .63). Among these, only a higher PAC burden was significantly associated with LRAF in both the CB (top quartile [≥2.16%]: 58% vs. others: 17%; log-rank P = .01) and RF (top quartile [≥3.05%]: 36% vs. others: 9%; log-rank P < .01) groups. A Cox regression analysis revealed two significant predictors of LRAF: in-hospital recurrence (CB group: hazard ratio [HR], 3.55 [1.67-11.80]; P = .04; RF group: HR, 7.55 [1.67-34.20]; P = .01) and a higher postprocedural PAC burden (CB: HR, 1.54 [1.06-2.22]; P = .02; RF: HR, 1.90 [1.16-3.35]; P = .01). In conclusion, irrespective of the ablation modality, the next-day PAC burden (but not the biochemical markers examined herein) is useful for predicting LRAF. Early AF recurrence should be considered a future risk even at the beginning of the blanking period.

Dofetilide is a class III anti-arrhythmic medication approved for patients with atrial fibrillation to maintain sinus rhythm. Excessive QTc interval prolongation, a potential side effect of dofetilide, increases the risk of torsades de pointes. This risk is mitigated by closely monitoring the QTc interval during an inpatient initiation protocol for the first five doses. Prior studies have demonstrated that dofetilide can be safely used in patients with heart failure after completing the initiation protocol. However, no studies have investigated risk factors associated with dofetilide-induced excessive QTc interval prolongation, resulting in discontinuation of the medicine. This single-center retrospective cohort study analyzed the association between dofetilide-associated excessive QTc prolongation during medication initiation and pertinent medical comorbidities as well as various echocardiographic values of interest. Risk factors found to be significantly associated with excessive QTc prolongation during dofetilide initiation included a clinical history of heart failure, reduced left ventricular ejection fraction, increased left ventricular end-diastolic diameter, increased left atrial diameter, and reduced right ventricular systolic function. Although some studies have demonstrated the safety of dofetilide use in patients with heart failure, our findings suggest that these patients are less likely to tolerate initiation of the medication due to excessive QTc prolongation.