Pace-Pacing and Clinical Electrophysiology最新文献

Background: Cryoballoon ablation has been widely performed in patients with paroxysmal atrial fibrillation (AF). In some challenging pulmonary veins (PVs), the procedure requires additional touch-up applications against the residual conduction gaps. It implies that there could exist difficult sites to cover with standard cryoballoon applications (CBAs), resulting in resistant conduction gaps (RCGs). This study aims to characterize the RCGs after initial CBAs.

Methods: We retrospectively enrolled 90 consecutive paroxysmal AF patients in our institute from January 2018 to December 2021 (66.5 ± 8.9 [SD] year-old, male/female 58/32). The RCGs after initial CBAs were mapped and analyzed with a high-resolution mapping (HRM) catheter. The PVs isolated using HRM were classified as HRM group. The PVs isolated without HRM, if isolated with a total of one or two CBAs, were classified as Control group.

Results: Whereas 325 PVs were isolated without HRM, 29 PVs had RCGs which were mapped and identified with HRM (HRM group): 15 right inferior pulmonary veins (RIPVs), 11 left superior PVs (LSPVs), and 3 left inferior PVs (LIPVs). In HRM group, the rate of broad RCGs in each PV extending over 2 or 3 segments of PV was almost double that of one-segment RCGs. The width of RCGs significantly correlated with nadir balloon temperature (R = 0.42; p = 0.021) and iTT₁₅ (R = -0.44; p = 0.015).

Conclusions: After standard CBAs, most RCGs were demonstrated to spread from the bottom to the posterior wall of RIPV and from the roof to the anterior wall of LSPV. The width of the RCGs was found to be correlated with parameters of balloon temperature, such as T_nadir and iTT₁₅.

Background: Predicting premature ventricular contraction (PVC) origin pre-ablation is a fundamental step, as right ventricular outflow tract (RVOT) PVC often leads to higher success rates.

Objective: To compare nine published ECG criteria to differentiate between RVOT and non-RVOT origins of PVCs and develop a stepwise algorithm using those criteria to better determine PVC origin to predict ablation success.

Methods: Two centers were involved in this study, the derivation group and the validation group. The derivation group included 65 patients with PVC left bundle branch block (LBBB) pattern morphology (predominantly negative in lead V₁) and inferior axis (predominantly positive in leads II and III), who underwent ablation at Cipto Mangunkusumo Hospital (RSCM) (2017-2022). The validation group included 291 patients who underwent ablation at the Taipei Veteran General Hospital (2020-2023). We calculated and compared six diagnostic accuracy measures from nine previously published ECG morphology criteria to develop an algorithm to enhance the accuracy of predicting RVOT PVC origin for successful ablation.

Results: Our multistep algorithm using Criteria 5, 8, and 1 enhanced diagnostic performance compared to using each criterion alone. The accuracy, sensitivity, and specificity in the derivation group were 86.2%, 93.6%, and 66.7%, respectively; those in the validation group were 85.9%, 90.8%, and 64.7%, respectively. The ROC curve AUCs were 0.802 and 0.775, respectively.

Conclusion: In cases of inferior axis and LBBB pattern PVCs, a multistep algorithm using multiple criteria increases the accuracy of predicting RVOT PVC origin instead of using a single criterion.

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.

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.