Arrhythmia & Electrophysiology Review最新文献

Aim: This study retrospectively investigated the clinical outcomes of patients with persistent AF treated with a combined approach of pulmonary vein isolation (PVI) and complex fractionated atrial electrogram (CFAE) ablation over a follow-up period of 10 years.

Methods: A total of 73 patients with persistent and long-standing persistent AF who underwent combined pulmonary vein isolation and CFAE ablation in the first procedure were included. A complete CFAE mapping of the left atrium and coronary sinus was performed with a 3D mapping system. All CFAEs defined as electrograms with continuous activity or mean cycle length detected by the system of <80 ms were excluded. Patients were controlled regularly during the first year followed by annual control. Any documented atrial tachyarrhythmia (ATA) was regarded as a recurrence.

Results: After index ablation, 18 (24.7%) were free of ATAs during 10-year follow-up. The proportion of atrial flutter (AFL) was 39.7%, with six typical AFL. A mean of 2.2 ± 1.2 ablation procedures were performed in each patient. After multiple procedures, 33 (45.2%) patients were free of ATA during the follow-up. The proportion of AFL was 23.2% with no typical AFL. Older age, female sex and a longer AF history were associated with ATA recurrence.

Conclusion: A high recurrence rate of ATA was observed after index procedure of pulmonary vein isolation plus CFAE ablation in patients with persistent AF. No significant difference in freedom of ATA was found between persistent and long-standing persistent AF groups beyond 1 year. The incidence of postablation AFL was particularly high, even after multiple ablations.

Arrhythmias and cancer are two pathological conditions that often coexist due to a patient's pre-existing comorbidities, or toxicity linked to anti-neoplastic drugs, and both are often characterised by poor prognosis. Cardio-oncology is a new interdisciplinary field that focuses on the cardiovascular health of cancer patients, especially those undergoing cancer treatment. Furthermore, cardiotoxicity can cause arrhythmias through primary and secondary mechanisms. Chemotherapy drugs have been shown to directly affect molecular pathways associated with arrhythmia development, as well as indirectly through mechanisms involving ischaemia or inflammatory injury to the heart. Understanding how to prevent and to treat these electrophysiological issues in cancer is an important challenge for cardio-oncologists. This review explores the intersection between cardio-oncology and electrophysiology, the various cardiac cell types implicated in the development of arrhythmias during cancer, the interplay between arrhythmias and cancer pathogenesis, and the need for the implantation of electronic devices along with their associated risks.

Soon after the rapid growth of the popularity of His bundle pacing (HBP), the use of this conduction system pacing modality was overshadowed by left bundle branch area pacing (LBBAP). This focused review on HBP addresses whether there are any advantages of HBP over LBBAP and what the current uses of HBP may be. We conclude that HBP must be considered as an alternative physiological pacing method with several potential applications, undoubtedly at least as a rescue option for failed CRT/LBBAP. For wider application of HBP, prospective studies are needed to document a reduction in the incidence of late threshold rise with modern implantation techniques. Nevertheless, HBP should be available in every modern pacing laboratory. This requires an active HBP program to maintain and develop the ability of operators to deliver HBP when it is most needed.

There are many factors contributing to the failure of conventional CRT with biventricular pacing, including coronary anatomy and an inability to stimulate diseased tissue. In this paper, we review evolving conduction system pacing (CSP), a physiological alternative to conventional CRT. CSP allows correction of bundle branch block and provides new opportunities to address multiple limitations of conventional CRT. Further studies are required to determine how the techniques are best applied in specific clinical situations.

Background: This study compared the efficacy and safety of temperature-controlled and conventional contact-force-sensing radiofrequency ablation catheters for pulmonary vein isolation (PVI) in AF.

Methods: Seven studies (1,138 patients) were included. Randomised controlled trials and observational (single-arm and two-arm) studies that reported freedom from AF ≥3 months after PVI with temperature-controlled radiofrequency ablation catheters (Biosense Webster QDOT MICRO operating in QMODE or Medtronic DiamondTemp) were included.

Results: Freedom from AF at a mean (± SD) follow-up of 9.0 ± 3.6 months did not differ significantly between temperature-controlled and conventional ablation (OR 1.22; 95% CI [-0.79, 1.64]; p=0.24). Total procedure duration (-13.5 minutes; 95% CI [-17.1, -10.0 minutes]; p<0.001) and total ablation duration (-8.9 min; 95% CI [-10.3, -7.5 min]; p<0.01) were significantly shorter for temperature-controlled ablation. There were no significant differences between temperature-controlled and conventional ablation in either the aggregated rates of procedural complications (OR 0.69; 95% CI [-0.15, 1.54]; p=0.11) or in the rate of any individual complication.

Conclusion: Temperature-controlled ablation was found to be at least non-inferior to conventional ablation in all measures of efficacy and safety. Further randomised controlled trials are warranted to evaluate long-term rates of freedom from AF and patient comfort.

Background: Left ventricular systolic dysfunction (LVSD) can improve after catheter ablation (CA) in many patients with AF. However, prospective prediction of response can be challenging. The aim of this study was, therefore, to perform a systematic literature review of features associated with improvement in left ventricular ejection fraction (LVEF) in patients with AF and LVSD undergoing first CA.

Method: Systematic search of Ovid MEDLINE, Embase and Cochrane Library databases up to 24 January 2024, for studies involving adult patients with LVSD receiving treatment for AF. The focus was on research articles and clinical trials reporting features associated with changes in LVEF following CA. The review followed PRISMA guidelines.

Results: A total of 789 unique articles were reviewed and 20 were included in the systematic review. Sixty-nine per cent (range, 54-79%) of included patients met the criteria for responder status, which were based on LVEF improvement (usually an increase in LVEF >10% or to >50% at follow-up). Baseline surrogates of myocardial fibrosis on MRI (R²=-0.67), electroanatomical mapping (R²=-0.93) and biochemical surrogates have shown the strongest association with LVEF change. Left atrium and LV chamber size, diastolic dysfunction ECGbased parameters and a known heart failure aetiology have shown prognostic value independently and in combination.

Discussion: Imaging, clinical and ECG-based surrogates of LV fibrosis may be pre-CA markers of LVEF improvement in patients with AF and LVSD. However, the confounding effect of procedural outcomes should be considered. A composite risk stratification tool would have clinical utility in risk stratification and patient selection; however, prospective studies are needed.

Vasovagal syncope (VVS) is the most common cause of syncope, and significantly impacts quality of life despite its benign nature. For some patients, conventional management strategies such as lifestyle changes, pharmacotherapy and pacemaker implantation, fail to prevent recurrence. Cardioneuroablation (CNA), a novel intervention targeting the cardiac autonomic nervous system's ganglionated plexi, has shown promise in addressing refractory VVS. This review examines the therapeutic potential of CNA, exploring the anatomy and physiology of the cardiac autonomic nervous system, the role of ganglionated plexi in cardiac regulation and the rationale behind their selection as ablation targets. The review also discusses diverse strategies for ganglionated plexi identification and ablation. The gateway ganglionated plexi hypothesis is used to explain the success of CNA across varied procedural methods, despite the absence of a standardized technique. These gateway ganglionated plexi, located near the sinoatrial and atrioventricular nodes, potentially serve as central nodes influencing heart rhythm and rate, thus explaining the high success rates in VVS treatment using different approaches.

Functional substrate mapping has emerged as an essential tool for electrophysiologists, overcoming many limitations of conventional mapping techniques and demonstrating favourable long-term outcomes in clinical studies. However, a consensus on the definition of 'functional substrate' mapping remains elusive, hindering a structured approach to research in the field. In this review, we highlight the differences between 'functional mapping' techniques (which assess tissue response to the 'electrophysiological stress' using short coupled extrastimuli) and those highlighting regions of slow conduction during sinus rhythm. We also address fundamental questions, including the optimal degree of electrophysiological stress that best underpins the critical isthmus and the role of wavefront activation in determining the most effective ablation site.

In this review, we summarise the ongoing debate surrounding the anatomy of the atrioventricular conduction axis and its relevance to pacing. We highlight previous disagreements and emphasise the importance of understanding the anatomical location of the axis. We give credit and support to the initial descriptions by His and Tawara, in particular their attention to the relationship of the atrioventricular conduction axis with the membranous septum. We express our disagreements with recent diagrams that incorrectly, in our opinion, depict the left bundle and right bundle branches. We offer our own latest understanding of the location and relationships of the atrioventricular conduction axis, including details of its development, and differences between human and animal hearts. We also emphasise the importance of understanding the relationship between the inferior pyramidal space and the inferoseptal recess so as appropriately to place the axis within the heart. We conclude by emphasising the need to consider the heart in the context of the body, describing its component parts by using attitudinally appropriate nomenclature.

Permanent cardiac pacing in children with congenital complete atrioventricular block (CCAVB) and/or congenital heart disease (CHD) is challenging. Conduction system pacing (CSP) represents a novel pacing strategy aiming to preserve physiological ventricular activation. Patients with CCAVB or CHD are at high risk of developing pacing-induced cardiomyopathy with chronic conventional right ventricular myocardial pacing. CSP may be a valuable pacing modality in this particular setting because it can preserve ventricular synchrony. In this review, we summarise implantation techniques, the available clinical evidence and future directions related to CSP in CCAVB and CHD.