Pace-Pacing and Clinical Electrophysiology最新文献

Background and aims: Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW.

Methods: This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of pulmonary vein isolation (PVI) + PWI (108 patients) or PVI-only (86 patients) using the CB. The cross-over technique was applied in all LAPWI.

Results: For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (right to left [R→L] 4.3 ± 1.1 and left to right [L→R] 4.3 ± 1.1) and 9.1 ± 1.2 (R→L 4.6 ± 1.6 and L→R 4.5 ± 1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI + PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow-up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI + PWI group and 72.9% of the PVI-only group (p = .011).

Conclusions: LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.

Background: The impact of the His bundle location and distance from the ablation site on ablation efficacy and complication risk remains unexplored. We determined the correlation between age, height, body mass index (BMI), and the His bundle location, and whether the distance between the His bundle and ablation target (D_HIS-ABL) affects ablation safety and efficacy.

Methods: Overall, 346 patients with atrioventricular nodal re-entrant tachycardia (AVNRT) and 96 with atrioventricular re-entrant tachycardia (AVRT) were retrospectively analyzed. The distance between the His bundle and the coronary sinus ostium (D_His-CS), the height of the His bundle (H_HIS), and D_HIS-ABL were measured. Electrocardiograms were obtained 3 months post-ablation to assess recurrence and complications.

Results: Multiple linear regression showed that H_HIS was negatively correlated with age in both groups. In AVNRT patients, D_HIS-ABL was associated with age, height, and BMI; D_HIS-CS was only negatively correlated with age. In AVRT patients, there was no significant correlation between the D_HIS-ABL and age, height, or BMI. The recurrence rates in the AVNRT and AVRT groups were 0.9% and 8.7%, respectively. Subgroup analysis showed that patients with D_HIS-ABL ≤ 10 mm had a higher recurrence rate than those with D_HIS-ABL > 10 mm (p = .013). The incidence of third-degree atrioventricular block (AVB) complications was 0.2%.

Conclusions: H_HIS was negatively correlated with age but not with height and BMI. The D_HIS-ABL correlated with age, height, and BMI in AVNRT patients. A short D_HIS-ABL led to a higher rate of supraventricular tachycardia recurrence; whether this affects AVB risk warrants further studies with larger sample sizes.

Background: Functional mitral regurgitation (FMR) and its severity are associated with adverse outcomes in heart failure patients. This study aims to analyze the predictors of FMR improvement after successful left bundle branch area pacing (LBBAP) in patients with LVEF < 50% and complete left bundle branch block (CLBBB).

Methods: Consecutive patients with LVEF < 50% and CLBBB who underwent successful LBBAP from July 2018 to July 2023 were retrospectively identified. Significant MR was defined as regurgitation of moderate severity or greater. Patients with significant FMR were included in the analysis. FMR improvement (FMRI) was defined as a reduction of at least one grade in regurgitation severity compared to baseline at 3 months or longer follow-up.

Results: Among the 81 identified patients, 42 patients with significant FMR preoperatively were included. After LBBAP, QRS duration significantly shortened from 170.6 ± 18.8 ms to 114.5 ± 20.2 ms (p < .001). Significant FMR improves in approximately 76.2%, and the patients were divided into an FMRI group (n = 32) and a non-FMRI group (n = 10). Univariate analysis showed that absence of persistent atrial fibrillation, typical CLBBB, and left atrium diameter at baseline were associated with improvement of FMR after LBBAP. Of these variables, only absence of persistent atrial fibrillation remains an independent predictor in the multivariate model (OR 12.436, p = .009).

Conclusion: LBBAP is able to improve FMR in heart failure patients who had CLBBB with LVEF < 50%. Meanwhile, the absence of persistent atrial fibrillation is an independent predictor of FMR improvement.

Background: Implantable Cardioverter Defibrillator (ICD) implantation has significantly modified the natural history of patients at high risk of sudden cardiac death (SCD) in various types of heart diseases. However there is a high rate of psychological distress and reduced quality of life in patients with an ICD, more evident in younger individuals. The ICD removal upon patient request is a very rare event and causes many clinical and ethical issues.

Methods: The article discusses the case of a young patient affected by hypertrophic obstructive cardiomyopathy, who underwent implantable cardioverter defibrillator (ICD) implantation as a primary prevention of sudden cardiac death (SCD). Two years after the implantation, the patient repeatedly requested removal of the ICD due to of a significant and untreatable psychological device intolerance.

Results: Intervention became possible only after extensive psychological evaluation, which excluded specific pathology, and the ratification of Italian law 219/2017 on informed consent and advance directives, which guarantees the patient's independent decisions on current and future medical treatment. The explantation was performed 7 years after the implant. The patient is alive and in good health.

Conclusions: The paper debates the issues related to establishing a patient-physician relationship based on respect for the patient's autonomy and experience of illness, in reference to principles such as beneficence and non-maleficence, and the conflicts that sometimes arise between them. If a paternalistic approach in the patient-physician relationship evolves into a patient-centered model, it is more certain that the patient's choice is realistically known and shared, and that it is consistent with the patient's values and life goals. The shared decision making (SDM) process and the use of pathology-specific decision aids are able to transform the informed consent tool, usually related to medical-legal issues, into an aid for true partnership between the patient and the medical care team.

A 51-year-old woman presented with recurring palpitations. Electrocardiography revealed narrow QRS tachycardia with short RP configuration. Computed tomography showed coronary sinus (CS) ostial atresia along with a small persistent left superior vena cava (PLSVC). Electrophysiological study identified the retrograde earliest atrial activation site (EAAS) at the CS ostium without decremental properties, and para-Hisian pacing suggested retrograde atrioventricular nodal conduction. Using a 1.6-Fr microelectrode catheter distally placed in the CS via the PLSVC, EAAS was confirmed within the left atrium, not the CS ostium. Transseptal approach revealed a left lateral accessory pathway, which was successfully eliminated.

Background: Transvenous lead extraction (TLE) for cardiovascular implantable electronic device (CIED)-related infections has increased. The incidence of TLE in nonagenarians is low, with limited reports outlining the outcomes of this procedure. Therefore, in this study, we aimed to clarify the outcomes of TLE in nonagenarians.

Methods: Patients with TLE treated at our hospital between 2014 and 2023 were retrospectively examined; patient characteristics, device type, indications, procedures, complications, and clinical data of nonagenarians were analyzed.

Results: Of 12 patients with 24 leads (active fixation lead, n = 11; passive fixation lead, n = 13) who underwent TLE, the indication for TLE was infection (pocket infection, n = 8; sepsis, n = 4). Methicillin-resistant Staphylococcus epidermidis was the most frequently identified causative agent (n = 4). The median patient age was 91 years; five patients were female. The median lead dwell time was 9 years. Excimer laser sheath (16 leads), mechanical sheath (five leads), Evolution RL (one lead), and manual traction (two leads) were employed in TLE. The procedure was successful in all patients, and only one had a minor complication. Six patients required CIED re-implantation, and leadless pacemakers were selected for five patients. The 30-day mortality after TLE was 0%.

Conclusion: TLE can be safely performed in nonagenarians. The decision to perform TLE should not be based on old age alone; the suitability of removing infected CIEDs should be determined based on each patient's condition.

The importance of treating non-pulmonary vein (PV) foci is increasing with improvements in the durability of PV isolation. We describe two cases wherein non-PV foci were induced by mechanical irritation and conventional induction in the same area, which was impossible to induce after ablation, suggesting a relationship between mechanical irritation and induction of non-PV foci. In a recurrent case of non-PV foci, atrial fibrillation (AF) was induced only by mechanical irritation. No recurrence has been observed since the ablation of the area. Thus, treatment of the AF induction site with mechanical irritation could be considered an effective therapy for non-PV foci.

Persistent left superior vena cava (PLSVC) is one of the anatomical variations, which can make device implantation more challenging and lead to incorrect lead placement, dislodgement, and procedure failure. Conduction system pacing (CSP) can be an alternative to traditional CRT implantation. Herein, we describe a brief case report of successful LBBAP-optimized CRT (LOT-CRT) via an innominate vein in a patient with PLSVC.

A left bundle pacing stimulation pacemaker was implanted using stylet driver lead. The screw incarceration occurred after positioning of the lead. The screw rupture occurred during lead retraction; the distal portion of the screw remained incarcerated at the interventricular septum.

Background: Global longitudinal strain (GLS) and atrial voltage are acknowledged markers for worse rhythm outcome after ablation of persistent atrial fibrillation (PeAF). The majority of research efforts have been directed towards the left atrium (LA), with relatively fewer studies focusing on the right atrium (RA). The aim of this study was to investigate the effect of the biatrial substrate on the outcome following radiofrequency catheter ablation (RFCA).

Methods: All patients underwent two-dimensional speckle tracking echocardiography (2D-STE) and high-density mapping (HDM) on LA and RA in preoperative and postoperative stages of RFCA. Atrial substrate was assessed by GLS, average voltage, and low voltage zone (LVZ).

Results: This retrospective study enrolled 48 patients. With a follow-up of 385.98 ± 161.78 days, 22.92% (11/48) of all patients had AF recurrence and 63.64% in low strain group. Left atrial-low voltage zone (LA-LVZ) prior to RFCA was 67.52 ± 15.27% and 54.21 ± 20.07%, respectively, in the recurrence group and non-recurrence group. Multivariate regression analysis showed that preoperative LA-GLS (OR 0.047, 95%CI 0.002-0.941, p = .046) was independent predictors of AF recurrence. Biatrial average voltage in preoperative and postoperative stages were positively correlated (preoperative: r = 0.563 p < .001; postoperative: r = 0.464 p = .002). There was no significant difference in the proportion of RA in the recurrence group except the septum in preoperative and postoperative stages.

Conclusions: Low LA-GLS and high LA-LVZ may be predictors of RFCA recurrence in PeAF patients. Biatrial average voltage were positively correlated in preoperative and postoperative stages.