Pace-Pacing and Clinical Electrophysiology最新文献

Behcet's disease is a systemic immune-mediated vasculitis predominantly affecting males. Cardiac involvement, termed cardiac Behcet's disease, is rare but potentially fatal, often mimicking infective endocarditis. This case presented with syncope as the initial symptom, leading to the identification of a non-coronary aortic sinus nodule, suspected as the cause of intermittent complete atrioventricular block. After pacemaker implantation, no recurrent syncope occurred, and immunosuppressive therapy reduced nodule size. This case underscores the importance of maintaining a high suspicion for cardiac Behcet's disease, as early diagnosis and intervention can be lifesaving.

Background: The need for transvenous lead extraction (TLE) is increasing worldwide. Since the course of the subclavian vein until the junction with the superior vena cava is a frequent place of lead adherences, we aim to assess the safety and efficacy of a short 13Fr bidirectional rotational mechanical sheath as first choice.

Methods and results: In this multicentric study, 202 carriers of a cardiac implantable electronic device (CIED) undergoing TLE using a short 13 Fr bidirectional rotational mechanical sheath were prospectively enrolled. All procedures were performed using a stepwise approach. The indication for TLE were infection (62%), malfunction (32%), and upgrade (6%). Overall, 471 leads were extracted: 65% pacing leads, 20% defibrillator leads, 9% coronary sinus leads, and 6% abandoned leads. Clinical success and complete lead extraction have been achieved in 97% and 95% of cases, respectively. The short sheath was always effective in gaining venous access at the start of the procedure and was sufficient for complete TLE in 67% of cases. Lead dwell time, defibrillator lead, number of leads per patient, and lead malfunction were predicting factors of long bidirectional rotational mechanical sheath use. There were no cases of intraprocedural death, and major complications were reported in 2% of patients. Overall survival was 97% at 1-year follow-up.

Conclusion: This multicentric experience using a short 13Fr bidirectional rotational mechanical sheath reported high safety and efficacy, demonstrating the utility of routine use of short extraction sheaths of higher caliper as the first choice.

Background: The subcutaneous implantable defibrillator (S-ICD) is an alternative to transvenous implantable defibrillators. The present analysis presents real-world data from patients with S-ICD and a follow-up duration of 10 years or more.

Methods and results: Between July 2010 and November 2013 76 S-ICD systems were implanted. After a follow-up duration of 10 years, data from 67 patients (88.1%) was available. Mean follow-up duration was 10.7 ± 1.3 years. Forty-seven patients (70.2%) were still alive with active S-ICD therapy. Eight patients (11.9%) died during follow-up. In eight patients (11.9%), conversion to a transvenous ICD system was necessary. This was either due to heart failure with indication for biventricular pacing (n = 2), bradycardia (n = 3), oversensing that could not be solved (n = 2), or pocket infection (n = 1). In four patients (6%), the S-ICD system was explanted without replacement for individual reasons. Sixteen patients already underwent two generator replacements, while one generator replacement was performed in the rest of the cohort. Therefore, generator longevity was documented to be within the predicted values. In 10 patients (14.9%), appropriate therapy delivery for ventricular arrhythmias was delivered. In 12 patients (17.9%), inappropriate shock delivery due to oversensing occurred. Of note, this could be resolved in all but two patients. Furthermore, the majority of these episodes occurred in the early years before the implementation of the Smart Pass algorithm.

Conclusion: S-ICD therapy can be successfully maintained over a long time. Incidence of oversensing significantly decreased with the implementation of novel algorithms and the new S-ICD generation. However, the present data also points out that in selected individuals conversion to transvenous systems is required.

Subcutaneous implantable cardioverter defibrillators (S-ICDs) are designed to avoid complications from transvenous leads, but patient selection requires careful screening, especially in conditions like hypertrophic cardiomyopathy (HCM) with frequent conduction abnormalities. A 27-year-old male with HCM underwent S-ICD implantation in 2015 after successful screening. In 2020, inappropriate shocks due to T-wave oversensing led to vector adjustments. By 2022, further shocks and failed re-screening revealed ineligibility for S-ICD due to low R/T ratios in multiple vectors. Imaging and ECG comparisons from 2015 to 2022 showed disease progression, with increased fibrosis and conduction abnormalities. As a result, a transvenous ICD was implanted. This case underscores how HCM progression, associated with fibrosis and ECG changes, can render S-ICD unsuitable over time. It highlights the importance of periodic reassessment in high-risk patients, as disease progression can compromise S-ICD eligibility, necessitating alternative solutions for inappropriate shocks.

Background: Conduction system pacing (CSP) is increasingly recognized for mitigating the adverse hemodynamic effects commonly associated with conventional ventricular pacing. However, there is limited data on the lead performance and echocardiographic outcomes for delayed bundle capture loss during CSP.

Objective: To evaluate the rate of complete loss of bundle capture/correction during CSP and assess the subsequent clinical outcomes.

Method: Patients who underwent successful CSP lead implantation with indications for ventricular pacing or cardiac resynchronization therapy (CRT) were screened. The reasons for complete loss of capture or failed LBBB correction were identified, and subsequent clinical outcomes were analyzed.

Result: Out of 2636 patients screened, nine experienced complete loss of bundle capture or LBBB correction during follow-up. Loss of capture was attributed to unexplained causes (n = 6), near-complete electrode dislodgement (n = 1), surgical damage (n = 1), and electrode malfunction (n = 1). The six patients with CRT indication and declining cardiac function underwent lead revision, with left ventricular ejection fraction (LVEF) improving from 40.6 ± 17.3% to 59.1 ± 6.0% at the last follow-up with the bundle capture threshold of 0.63 ± 0.14 V/0.5 ms. The remaining 3 atrioventricular block patients with stable cardiac function did not undergo lead revision and the local myocardium threshold of 0.58± 0.31 V/0.5 ms.

Conclusion: The incidence of complete capture loss during CSP is low recapturing/recorrecting the bundle significantly improves cardiac function in patients with CRT indications.

Catheter ablation (CA) is a recognized treatment for people experiencing symptomatic paroxysmal or persistent atrial fibrillation (AF). Pulmonary vein isolation (PVI) is the predominant therapeutic intervention for AF globally. According to PVI, some individuals may require supplementary ablation interventions. Literature has shown that the closeness of the esophagus to the posterior wall of the left atrium might result in injury to the vagal nerve branches during CA, causing conditions such as "gastroparesis" or "pyloric spasms." This report details a case of superior mesenteric artery compression syndrome following AF ablation, which did not improve with conservative management and was ultimately addressed by surgical procedure.

Background: Atrial fibrillation, which has increased in prevalence by 33% over the past two decades, affects 59 million people worldwide. It is treated using thermal and nonthermal techniques like radiofrequency, cryoballoon, laser, and pulsed-field ablation (PFA). This meta-analysis is the first to compare PFA with high-power short-duration radiofrequency ablation (HPSD-RFA).

Methods: We comprehensively searched PubMed, Cochrane Central, and ScienceDirect from inception to August 2024. In Review Manager 5.4.1, we pooled risk ratios (RRs) and weighted mean difference (WMD) along with 95% confidence intervals for dichotomous and continuous outcomes, respectively, and employed a random effects model. Study quality was assessed via the Newcastle-Ottawa Scale, and funnel plots were used to evaluate the risk of publication bias.

Results: Seven studies with a total of 1538 patients were analyzed in this meta-analysis. PFA was associated with a shorter total procedural time (MD = -36.39 min; 95% CI: [-46.23, -26.55]; p < 0.00001; I² = 90%), left atrial dwell time (MD = -33.22 min; 95% CI: [-53.21, -13.23]; p = 0.001; I² = 93%), and a longer fluoroscopy time compared to the HPSD-RFA (MD = 9.06 min; 95% CI: [6.13, 11.99]; p < 0.00001; I² = 96%). Other outcomes were comparable between the two arms.

Conclusion: PFA outperforms HPSD ablation in terms of procedural efficiency outcomes except for the total fluoroscopy time. Still, both techniques are comparable regarding safety and arrhythmia control outcomes.

Immune checkpoint inhibitor (ICI) has demonstrated promising results in treating various cancers, but its associated cardiotoxicity, especially ICI-associated myocarditis, presents a serious concern. We reported a case of a 63-year-old male who complained of progressive dyspnea after tislelizumab, a novel humanized anti-PD-1 monoclonal antibody, for hepatocellular carcinoma. Upon diagnosing ICI-related myocarditis, corticosteroid therapy was initiated immediately. The elevated biomarkers quickly decreased, but the atrioventricular block progressed from first-degree to third-degree, necessitating pacemaker implantation. This is the first report of complete AVB consecutive to tislelizumab-induced myocarditis, highlighting the importance of early corticosteroid therapy and continuous electrocardiography monitoring.

Background: The factors contributing to sustained ventricular arrhythmias (VAs) >30 days after left ventricular assist device (LVAD) implantation are not well-established.

Objectives: This study aimed to predict the factors associated with late sustained VAs after LVAD implantation and develop a predictive score to identify patients with an increased risk of late sustained VAs after the procedure.

Methods: We performed a retrospective cohort study on a training cohort of 623 patients and a validation cohort of 157 patients who underwent LVAD implantation at the Mayo Clinic (Rochester, Phoenix, and Jacksonville) from January 1, 2000, to December 30, 2020. Late sustained VAs were defined as ventricular tachycardia (VT) and ventricular fibrillation (VF) occurring >30 days after the LVAD procedure. Detailed chart reviews of the electronic health records within the Mayo Clinic and outside medical records were performed.

Results: A total of 780 patients were included in our study. Late sustained VAs occurred in 30% (n = 232) of the patients. The significant factors associated with late sustained VAs after LVAD were the history of VAs prior to LVAD (34.1% vs. 23.0%, p < 0.01), implantable cardiac defibrillator (ICD) (87.9% vs. 77.6%, p < 0.01) or cardiac resynchronization therapy (CRT) in situ (43.5% vs. 33.6%, p = 0.008), VT ablation prior to LVAD (5.2% vs. 1.8%, p = 0.010), use of amiodarone (49.1% vs. 38.7%, p = 0.007), use of mexiletine (15.5% vs. 5.7%, p < 0.01), and higher left ventricular end-diastolic diameter (LVEDD) on echocardiography prior to LVAD implantation (71.4 vs. 68.7 mm, p = 0.002). During follow-up, the patients who developed late sustained VAs after LVAD had lower survival than those who did not (HR = 1.96, 95% CI:156-2.4, p < 0.001). The average time from LVAD to orthotopic heart transplant was longer among late sustained VAs patients (23 vs. 14 months, p < 0.01). The "VIN" risk score was created to identify four risk groups: low (scores 0), intermediate (score 1), high (score 2), and very high (score 3). The rates of late VA's in the training cohort at 1 year were 9.5%, 14%, 18%, and 25% which was almost similar to the risk of late VA's at validation cohort 10%, 12%, 20%, and 63%, respectively.

Conclusions: Late sustained VAs occurred in 30% of the patients who received LVAD and were associated with lower survival. The VIN risk score was developed and validated to stratify patients into low, intermediate, high, and very high risk of late sustained VAs.