Journal of Innovations in Cardiac Rhythm Management最新文献

Slow pathway modification via cryoablation is a common treatment of atrioventricular nodal re-entrant tachycardia (AVNRT) in pediatric patients. Sinus propagation mapping (SPM) is a tool that has been used to augment identification of the AVNRT slow pathway. We hypothesize that the use of SPM will decrease the total number of ablations performed and decrease the number of ablations until the slow pathway is successfully modified without a significant increase in procedure time. We conducted a retrospective review of patients who underwent cryoablation for AVNRT from August 2016 through March 2021. We excluded patients >21 years of age, those who underwent radiofrequency ablation; those with prior AVNRT ablation, additional pathways, or arrhythmias; and those with congenital heart disease. Out of 122 patients identified by the IMPACT database query, 103 met the inclusion criteria. Fifty-two patients (50.5%) had SPM completed during their procedures. The median number of ablations needed until successful slow pathway modification was two ablations in patients who underwent SPM and four ablations in the non-SPM group (P = .03). There was no significant difference in the total number of ablations between groups. The median total procedural time was longer in the SPM group (152 vs. 125 min; P = .01). SPM can be utilized to further improve the successful treatment of AVNRT with cryotherapy by lowering the number of ablations needed until successful slow pathway modification. However, the technique requires some additional time to collect sufficient data points to create the sinus map.

Although myocardial infarction (MI) is a reversible cause of atrioventricular (AV) block, the association of ischemia other than MI with AV block is unclear. The purpose of this study is to investigate this relationship. Among patients nominated for pacemaker implantation due to AV block in two centers from 2017-2020, 120 patients with significant coronary artery disease (CAD) in angiography were included in the study. Patients were divided into two equal groups based on their CAD treatment approach: drug therapy and revascularization. Coronary lesions were divided into three types based on location: left anterior descending artery (type 1), dominant coronary with AV node branch (type 2), and a combination of both (type 3). After coronary disease treatment, all patients were followed up with for 14 months, and AV block reversibility was assessed. There were 7 cases of block reversibility in the revascularization group (11.7%) and 1 case in the medical group (1.7%), which differed significantly (P = .02). A history of acute coronary syndrome, smoking, opium use, chronic kidney disease, hypertension, age, sex, and chronic obstructive pulmonary disease were not significantly associated with reversible block. Also, the type of coronary obstruction had no significant relationship with block reversibility (P = .3, .5, and .8 for type 1, type 2, and type 3, respectively). Hibernation due to ischemia can be a reversible cause of an AV blockage. Therefore, it is recommended that significant coronary artery lesions be revascularized before pacemaker implantation.

Pulmonary vein isolation via cryoballoon (CB) ablation is the cornerstone ablation strategy for the treatment of atrial fibrillation (AF). Acute intraprocedural hypotensive and/or bradycardic responses have been reported in patients undergoing CB ablation for AF. However, it remains unclear as to whether these are due to a true vagal response (VR), which can be used to predict long-term outcomes of CB ablation. We analyzed 139 freezes across 17 patients who received CB ablation for paroxysmal AF, measuring vital signs and freeze characteristics. Only one freeze was associated with both hypotension and bradycardia, constituting a true VR. Several freezes were associated with hypotension only that did not respond to atropine administration, suggesting that these responses are not associated with a VR. Hypotensive responses were significantly associated with ice bubble bursts during CB deflation. Unlike the true VR reported in patients undergoing conscious sedation, the presence of acute hypotension shortly after CB deflation cannot be used as a predictor for long-term ablation outcomes.

A 58-year-old man admitted for a cryoballoon ablation due to a history of symptomatic paroxysmal atrial fibrillation experienced pericardial effusion and cardiac tamponade intraoperatively. A longitudinal left superior pulmonary vein perforation was confirmed by emergency thoracotomy and repaired. He developed atrial fibrillation 2 days postoperatively, which was terminated with colchicine and oral steroids the following day.

Obesity is a major risk factor for heart failure (HF). The relationship between adipokines and HF has been implicated in many previous studies and reviews. However, this review article summarizes the basic role of major adipokines, such as apelin, adiponectin, chemerin, resistin, retinol-binding protein 4 (RBP4), vaspin, visfatin, plasminogen activator inhibitor-1, monocyte chemotactic protein-1, nesfatin-1, progranulin, leptin, omentin-1, lipocalin-2, and follistatin-like 1 (FSTL1), in the pathogenesis of HF. Apelin is reduced in patients with HF and upregulated following favorable left ventricular (LV) remodeling. Higher levels of adiponectin have been found in patients with HF compared to in control patients. Also, high plasma chemerin levels are linked to a higher risk of HF. Serum resistin is related to the severity of HF and associated with a high risk for adverse cardiac events. Evidence indicates that RBP4 can contribute to inflammation and damage heart muscle cells, potentially leading to HF. Vaspin might stop the progression of cardiac degeneration, fibrosis, and HF according to experiments on rats with experimental isoproterenol-induced chronic HF. The serum concentrations of visfatin are significantly lower in patients with systolic HF. Leptin levels were found to be correlated with low LV mass and myocardial stiffness, both of which are significant risk factors for the development of HF with preserved ejection fraction (HFpEF). Measuring serum omentin-1 levels appears to be a novel prognostic indicator for risk stratification in HF patients. Increased expression of neutrophil gelatinase-associated lipocalin in both systemic circulation and myocardium in clinical and experimental HF suggests that innate immune responses may contribute to the development of HF. FSTL1 was elevated in patients with HF with reduced ejection fraction and associated with an increase in the size of the left ventricle of the heart. However, other adipokines, such as plasminogen activator inhibitor-1, monocyte chemotactic protein-1, nesfatin-1, and progranulin, have not yet been studied for HF.

A 69-year-old man with persistent atrial fibrillation (AF) experiencing recurrences of suspected paroxysmal atrial tachycardia was referred for repeat ablation. He had previously undergone pulmonary vein isolation in 2016. He was suspected to be experiencing a tachycardia involving the mitral isthmus or left-sided veins initially; however, electroanatomic mapping did not reveal a circuit involving these structures. Instead, a focal arrhythmia with the earliest signal on the anterolateral mitral valve annulus was noted. Catheter manipulation in this region consistently terminated the tachycardia.

The left atrial posterior wall (PW) is known to be a critical substrate for the initiation and perpetuation of atrial fibrillation (AF) and has been explored as a target for catheter ablation, particularly in persistent AF (PerAF). In this retrospective study, we investigate the clinical outcome of patients with PerAF who underwent PW isolation (PWI) restricted in predetermined lines in addition to pulmonary vein isolation (PVI). One hundred consecutive patients (64 ± 9.1 years, 66% male, 20% with previous PVI ablation) underwent PWI in a box lesion setting for PerAF lasting >3 months (34% long-standing PerAF). PW triggers were defined as either foci from the PW that repeatedly induced AF or as isolated AF or atrial tachycardia (AT) within the PW. After a mean follow-up period of 25.6 ± 6.7 months, 61% of the patients remained in sinus rhythm after the last procedure. In 79 patients, the PW was successfully isolated, while, in 21 patients, complete isolation was not possible due to failure in completion of the roof line (n = 16), the floor line (n = 7), or both (n = 2). Patients with incomplete isolation had similar AF/AT recurrence rates compared to those with complete PWI. In 12 patients, PW triggers were identified, and PWI in these patients was shown to have a significantly better prognosis in terms of sinus rhythm maintenance (P = .031). Failure of complete PWI does not predispose a patient to an inferior outcome nor is it responsible for iatrogenic ATs. The presence of AF triggers within the PW leads to a particularly favorable result after box lesion isolation.

Ablation of atrial fibrillation most commonly involves the pulmonary veins; however, the superior vena cava (SVC) is an important potentially arrhythmogenic structure that should not be overlooked. This case report demonstrates an excellent example of triggering activity localized to the SVC and the subsequent conversion to sinus rhythm with ablation of the SVC.

Sick sinus syndrome (SSS) is a condition of the sinoatrial node that arises from a constellation of aberrant rhythms, resulting in reduced pacemaker activity and impulse transmission. According to the World Health Organization, pulmonary hypertension (PH) is defined by a mean pulmonary arterial pressure of >25 mmHg at rest, measured during right heart catheterization. It can result in right atrial remodeling, which may predispose the patient to sinus node dysfunction. This study sought to estimate the impact of PH on clinical outcomes of hospitalizations with SSS. The U.S. National Inpatient Sample database from 2016-2019 was searched for hospitalized adult patients with SSS as a principal diagnosis with and without PH as a secondary diagnosis using the International Classification of Diseases, Tenth Revision, codes. The primary outcome was inpatient mortality. The secondary outcomes were acute kidney injury (AKI), cardiogenic shock (CS), cardiac arrest, rates of pacemaker insertion, total hospital charges (THCs), and length of stay (LOS). Multivariate regression analysis was used to adjust for confounders. A total of 181,230 patients were admitted for SSS; 8.3% (14,990) had underlying PH. Compared to patients without PH, patients admitted with coexisting PH had a statistically significant increase in mortality (95% confidence interval, 1.21-2.32; P = .002), AKI (P < .001), CS (P = .004), THC (P = .037), and LOS (P < .001). In conclusion, patients admitted primarily for SSS with coexisting PH had a statistically significant increase in mortality, AKI, CS, THC, and LOS. Additional studies geared at identifying and addressing the underlying etiologies for PH in this population may be beneficial in the management of this patient group.