Pace-Pacing and Clinical Electrophysiology最新文献

Esophageal injury is a serious complication following atrial fibrillation catheter ablation procedures. It may manifest as atrio-esophageal fistula, pericardio-esophageal fistula (PEF), or restricted perforation, with high mortality rate if left unoperated. Chest computed tomography with intravenous contrast is the mainstay of diagnosis; however, a definite imaging diagnosis is often delayed and may worsen patient outcomes. This case demonstrates that pericardial fluid amylase detection may contribute to early differential diagnosis of PEF versus restricted esophageal perforation combined with inflammatory pericarditis, in patients with relevant symptoms who present with pericardial effusion and may guide either conservative-as our case-or surgical approach.

Background: The effectiveness of cryoballoon ablation (CBA) of the left atrial (LA) roof in addition to pulmonary vein isolation (PVI) using a novel cryoballoon catheter, POLARx, remains unclear.

Methods: This study compared the efficacy of LA roof line ablation and PVI using POLARx (Boston Scientific) or AFA-Pro (Medtronic) in 100 patients with persistent atrial fibrillation. The right superior pulmonary vein (PV) anchoring and raise-up techniques were consistently used for LA roof line ablation, and rapid right ventricular pacing was applied if the cryoballoon temperature did not reach -40°C.

Results: Complete conduction block at the LA roof could be obtained in all patients with POLARx and in 98.0% of patients with AFA-Pro. Rapid right ventricular pacing was needed in 64.0% of patients with AFA-Pro and in no patients with POLARx. During LA roof line ablation, the nadir cryoballoon temperature was significantly lower with POLARx than with AFA-Pro (right: -54.2°C ± 4.4°C vs. -46.0°C ± 5.4°C; central: -56.8°C ± 4.4°C vs. -45.7°C ± 4.8°C; left: -56.1°C ± 4.3°C vs. -46.1°C ± 5.7°C), and the cryoballoon temperature reached -40°C earlier with POLARx than with AFA-Pro (right: 30.8 ± 7.4 s vs. 74.1 ± 37.7 s; central: 28.2 ± 5.2 s vs. 62.9 ± 30.9 s; left: 29.8 ± 5.8 s vs. 69.6 ± 40.7 s).

Conclusion: The nadir cryoballoon temperature with POLARx was approximately 10°C lower than with AFA-Pro, consistently dropping below -40°C during LA roof line CBA. Thus, a complete conduction block of the LA roof line can be easily accomplished using right superior PV anchoring and the raise-up techniques without the need for rapid right ventricular pacing with POLARx.

Background: Asymptomatic nonvalvular atrial fibrillation is often suspected in patients with cryptogenic stroke which constitute 20%-30% of ischemic strokes. Detection of atrial fibrillation (AF) and treatment with anticoagulation can reduce the risk of stroke. We sought to investigate the prevalence of asymptomatic atrial fibrillation (aAF) in patients with a history of stroke or an acute stroke on admission.

Methods: From November 2011 until December 2014, 15,308 patients with a first episode of AF were enrolled in phase 2 of the international, prospective, multicenter global registry on long-term oral anticoagulation treatment in patients with AF (GLORIA-AF) Registry. For the present analysis, we focused on patients with aAF regarding the prevalence of stroke.

Results: One third of patients (n = 4892, 32%) had aAF. Of these, 611 (12.5%) had a history of stroke or an acute stroke on admission. In contrast, 519 of 10,416 (5.0%) patients with symptomatic AF (sAF) had a history of stroke or an acute stroke on admission. Higher age, male gender, permanent AF, stroke, and the combination of stroke, TIA or systemic embolism were associated with a higher prevalence of aAF on admission. In a multivariable analysis, patients with aAF had a 2.3-fold (95% confidence interval (CI), 2.02-2.54) risk for stroke compared to patients with sAF. Other independent risk factors for stroke were a history of prior bleeding (odds ratio 1.62, 95% CI, 1.34-1.92), chronic kidney disease (1.38, 1.21-1.56), and diabetes mellitus (1.24, 1.10-1.41).

Conclusion: aAF is reported in about one third of patients with newly diagnosed AF and is associated with a 2.3-fold risk for stroke compared to sAF. Therefore, screening for aAF in high-risk patients might be appropriate to prevent further embolic cerebrovascular events.

Introduction: The VDD-leadless pacemaker aims to maintain high atrioventricular (AV) synchrony, but proper sensing setup is crucial.

Methods and results: This case was an elderly woman with an AV block who received a dual-chamber pacemaker. Due to ventricular pacing failure, a Micra AV2 was implanted. However, postimplantation, high sinus rate, and frequent premature ventricular contractions were noted. Therefore, the auto + A3 threshold function was used in the atrial-sensing setup. A few days later, the MAM test confirmed good AV synchrony.

Conclusion: The auto + A3 threshold function equipped in the Micra AV2 may offer to maintain high AV synchrony.

The case was a 15-year-old male with a history of paroxysmal supraventricular tachycardia refractory to medical therapy and prior catheter. A repeat electrophysiology study and catheter ablation were applied. Baseline AH and HV intervals were 100 and 55 ms during normal sinus rhythm (NSR), respectively. Programmed atrial stimulation induced a short RP narrow complex tachycardia (HV interval 22 ms) with an incomplete right bundle branch block configuration and right axis deviation. Tachycardia was terminated with ATP 5 mg injection. An atrial premature beat within the His refractory period advanced and reset tachycardia. Entrainment performed from the coronary sinus and left ventricle both showed a post-pacing interval minus tachycardia cycle length (TCL) of 90 ms. After confirming the diagnosis, left atrial mapping along mitral annulus was performed using trans-septal access and accessory pathway potentials were recorded during NSR and tachycardia at the superior mitral annulus. An irrigated ablation catheter guided by 3-D mapping was used to perform ablation during tachycardia. Tachycardia terminated immediately during the first RF application with ensuing automaticity exhibiting a warm-up during radiofrequency delivery and a cooling down upon the suspension of ablation. Therefore, all phenomena of Mahaim-fiber associated tachycardia were observed. In this case, we describe an antidromic atrio-ventricular reentry tachycardia using a left atrio-fascicular fiber inserting into the proximal left anterior fascicle.

Background: Pulmonary vein isolation (PVI) has been established as an effective management option for symptomatic paroxysmal atrial fibrillation (PAF). We aimed to explore the role of P-wave parameters in a 12-lead electrocardiogram (ECG) in predicting the success of repeat PAF ablation.

Methods: We enrolled consecutive patients who underwent a second AF ablation procedure for PAF in a UK tertiary center after an index ablation conducted between 2018 and 2019 and a repeat ablation up to 2021. A digital 12-lead ECG was recorded with a 1-50-Hz bandpass filter applied. P-wave duration (PWD), P-wave voltage (PWV), P-wave dispersion (PWDisp), and P-wave terminal force in V1 (PTFV1) were measured before and after the procedure. Changes were correlated with the 12-month clinical outcome. Procedural success was freedom from ECG-documented AF up to 12 months following ablation.

Results: Study criteria were satisfied by 72 patients, of which 43 (60%) had successful repeat PVI at 12 months. The mean age is 65, and 47 (65%) were males. The demographics were comparable between both study arms. PWD decreased after successful repeat ablations (136.7 to 124.6 ms, p = 0.01) and failed repeat ablations (135.4 to 125.3 ms, p = 0.009) without a significant change between both arms. PMV and PWDisp did not change significantly after both study arms. PTFV1 significantly decreased after successful repeat ablations (-3.1 to -4.4 mm.s, p = 0.005) without a significant change after failed ablations (-2.9 to -2.7 mm.s, p = 0.42). Changes were statistically significant between both arms (p = 0.004).

Conclusion: PTFV1 reduction following the second AF ablation was correlated with successful repeat AF ablation at 12 months.

Introduction: Right ventricular (RV) pacing can impair left ventricular function and cause heart failure, known as pacing-induced cardiomyopathy (PICM). Upgrade to cardiac resynchronization (CRT) is its usual treatment; recently left bundle branch area pacing (LBBAP) has emerged as a potential alternative. Deep septal pacing (DSP), a simplified alternative to LBBAP, is still able to achieve narrower paced QRS than during conventional RV pacing. The aim of this study was to assess the effect of DSP in a cohort of patients with PICM.

Methods and results: Consecutive patients diagnosed with PICM were included. The aim was to upgrade patients to DSP. The procedure was considered successful if a paced QRS duration ≤140 ms was obtained, in the absence of a terminal R wave in V1. Twelve patients were included. The mean baseline LVEF was 33% (SD 4%), and the mean percentage of RV pacing was 99% (SD 1%). All patients had symptomatic heart failure. The mean paced QRS duration was 172 ms (SD 14 ms) with RV pacing, and 130 ms (SD 7 ms) with DSP (mean difference 42 ms, p < 0.001). At 6 months, the mean LVEF after the upgrade was 46% (SD 9%), significantly superior to LVEF with RV pacing (p = 0.001), a mean improvement of 13% (SD 10%). All patients except one experienced an improvement in LVEF of at least 5%.

Conclusions: Our data suggest that DSP may be an effective and simpler alternative to biventricular or LBBAP in patients with PICM. Narrower paced QRS complexes can be achieved, which may lead to an improvement in left ventricular function.

A 58-year-old woman was referred for atrial flutter ablation after atrial fibrillation ablation. Linear and reinforcement mitral isthmus ablation failed to terminate the perimitral flutter. During vein of Marshall ethanol infusion (VOMEI), the flutter was terminated and followed by left atrial appendage (LAA) isolation. Voltage mapping showed that a large low voltage area was created in the superior and anterior wall of left atrium. During the waiting time, the LAA activation recovered. It would be necessary to keep in mind that VOMEI would lead to uncontrolled lesion of left atrium.

Introduction: Implantable cardioverter defibrillators (ICDs) lead fractures are rare but serious complications, often leading to inappropriate shocks. The early occurrence of such fractures post-implantation is exceptionally uncommon.

Methods and results: We present a case of a 53-year-old male with hypertrophic cardiomyopathy who experienced an inappropriate shock due to a lead fracture just 4 days after ICD implantation. The fractured lead was successfully extracted and replaced using a gooseneck snare passed through an oversized TightRail with no immediate complications.

Conclusion: Early lead fractures can occur shortly after ICD implantation, leading to inappropriate shocks. Successful management, including extraction and reimplantation, is possible even in these early cases. Clinicians should remain vigilant, and remote monitoring can play a crucial role in the timely detection of such complications.