Arrhythmia & Electrophysiology Review最新文献

Idiopathic VF is a complex clinical entity that is characterised by an evolving scope over time. Arrhythmogenic cardiomyopathy and electrical diseases represent a significant proportion of diagnoses attributed during follow-up in patients with an initial diagnosis of idiopathic VF. Stepwise diagnostic workup and management are of paramount importance. We proposed that idiopathic VF can be split into two distinct phenotypes, with potential overlap in an individual patient. In patients with Purkinje-related idiopathic VF, short-coupled ventricular ectopy can be documented, and ablation of the culprit tissue is a reasonable strategy to avoid recurrence. In patients with microstructural idiopathic VF, localised myocardial alterations can be unveiled by thorough electro-anatomical mapping and are amenable to a substrate-elimination strategy. Idiopathic VF is also a dynamic and evolving field, with promising research, new diagnostic tools and ablation techniques being developed in the near future.

The 'ablate-and-pace' strategy, combining atrioventricular junction ablation with permanent pacing, has re-emerged as a valuable therapeutic option for patients with AF who are symptomatic, have poor rate control or develop AF-mediated cardiomyopathy. While historically considered a last-resort treatment, recent randomised trials and meta-analyses support its efficacy in improving functional status, reducing hospitalisations and potentially enhancing survival, particularly when paired with CRT or conduction system pacing. The success of this approach depends on careful patient selection and appropriate device choice. Candidates include patients with uncontrolled ventricular rates, tachycardia-bradycardia syndrome, symptomatic bradycardia or those with poor CRT response due to persistent AF. Right ventricular pacing should be avoided when possible, in favour of biventricular or conduction system pacing, which preserves synchrony and reduces pacing-induced cardiomyopathy. This review discusses clinical scenarios, prognostic considerations, and current device options - including leadless systems - offering a practical guide for tailoring atrioventricular junction ablation-based therapies to individual patient profiles.

Over the past several decades, substantial evidence has pointed to the role of the autonomic nervous system in the genesis and maintenance of ventricular arrhythmia. In particular, sympathetic activation has been shown to increase the risk of ventricular arrhythmia, particularly in the context of structural heart diseases, and is a key target of neuromodulatory therapies. Current peripheral sympathetic neuromodulatory approaches include temporary interventions, such as stellate ganglion block, proximal intercostal block, and thoracic epidural anaesthesia, as well as more definitive therapies, such as cardiac sympathetic denervation and renal denervation. Each of these approaches presents distinct strengths and limitations, as well as side effects that warrant careful consideration in clinical practice and highlight the need for more targeted strategies. Emerging interventions focusing on neuropeptide Y, sympathetic afferents ablation, high-frequency block of efferent nerves, and the restoration of sympathetic innervation after MI have shown promising potential. However, further research is needed to evaluate the feasibility and safety of these novel therapies prior to their implementation in patients with cardiovascular diseases.

Background: Transvenous lead implantation often faces challenges regarding venous access and lead-related complications. This study evaluated the feasibility and safety of a novel echocardiography-guided percutaneous transapical intraventricular septum (PTAIVS) pacing approach in an animal model.

Methods: Twelve adult dogs underwent PTAIVS lead implantation guided by transthoracic and transoesophageal echocardiography. Leads were introduced percutaneously through the apex and fixed in the mid-to-basal septum. The first six dogs were implanted with a pacing set with a coaxial introducer needle (CareFusion) and a Model 3830 lead (Medtronic), whereas an improved pacing set with an extended helix lead was used in the next six dogs. The first three dogs were used for evaluation of acute gross pathology, with the remaining nine followed up over a period of 4-12 weeks. Pathological examinations were performed at the end of the follow-up period.

Results: Successful lead placement without procedural complications was achieved in all dogs, with a mean (± SD) procedural time of 28.8 ± 4.8 min. At implantation, the median (interquartile range) capture threshold was 1.7 (0.85-2.50) V, the R-wave amplitude was 6.80 (6.13-13.00) mV and impedance was 536 (510-922) Ω. In the initial six dogs in which the unmodified pacing system was used, lead dislodgement occurred at the 1-month follow-up. Modifications to the system eliminated dislodgement at 1 month, but varying degrees of displacement were observed by 3 months.

Conclusion: This study demonstrates the initial technical feasibility of echocardiography-guided PTAIVS pacing, offering a potential alternative to traditional transvenous methods. However, further refinements are essential to improve long-term lead stability.

Background: Concomitant surgical ablation (SA) is recommended at the time of cardiac surgery in patients with AF but it remains widely underperformed. We sought to report on the safety and long-term efficacy of concomitant SA and the associated incidence of stroke and survival.

Methods: A retrospective observational study was performed on patients with AF undergoing cardiac surgery between April 2011 and March 2022 with grouping based on whether or not they received concomitant SA. Thirty-day complications and long-term atrial tachyarrhythmia recurrence, stroke and mortality were compared between groups after propensity score matching.

Results: A total of 1,205 patients were included; two groups were obtained after matching (n=326 each). Post-operative length of stay was slightly longer in matched patients receiving concomitant SA (median 10 versus 9 days; p=0.048) but length of stay on intensive care and complication rates were similar in both groups. Freedom from atrial tachyarrhythmia in the SA group was 74% at 1 year and 58% at 3 years compared with 10% and 8%, respectively, for the no-SA group. Ten-year survival was increased for matched patients in the SA group compared with patients in the no-SA group (adjusted HR 0.61; 95% CI [0.45-0.82]; p=0.001) but the incidence of ischaemic stroke was similar (subdistribution HR 1.11; 95% CI [0.53-2.30]; p=0.790).

Conclusion: In patients with AF undergoing cardiac surgery, concomitant SA was associated with improved long-term survival without increasing complications. Concomitant SA was not associated with an independent reduction in the long-term incidence of ischaemic stroke.

Ventricular arrhythmias after electrical cardioversion for AF are rare. Most of these arrhythmias are related to QT prolongation, resulting from marked and sudden slowing of heart rates, treatment with Class III antiarrhythmic drugs or other QT-prolonging medications, and the ventricular repolarisation remodelling effect of electrical cardioversion. A case of polymorphic ventricular tachycardia post-cardioversion of rapid AF in a patient with tachycardia-induced cardiomyopathy and the use of amiodarone is reported.

Background: While combined vein of Marshall ethanol infusion (EIVOM) and radiofrequency ablation improves acute left pulmonary vein (LPV) isolation and posterior mitral isthmus block in nonparoxysmal AF (non-PAF) ablation, its long-term efficacy remains unclear. This multicentre cohort study aimed to evaluate the chronic effect of EIVOM on LPV and mitral isthmus conduction recovery beyond 3 months post-initial ablation.

Methods: We retrospectively analysed consecutive non-PAF patients undergoing reablation across three tertiary centres, categorised by EIVOM use during initial ablation: the EIVOM cohort (n=41) versus the non-EIVOM cohort (n=50). Primary endpoints included the prevalence and anatomical distribution of conduction gaps at the LPV antrum and posterior mitral isthmus lines. Results: LPV reconnection rates were comparable (39% in the EIVOM cohort versus 28% in non-EIVOM cohort; p=0.27), with the EIVOM cohort showing more frequent conduction gaps at the inferior antrum of the LPV. Mitral isthmus conduction recovery was significantly reduced in the EIVOM cohort versus the non-EIVOM cohort (46.3% versus 80.8%; p=0.002). Absence of EIVOM use (OR 3.611; 95% CI [1.377-9.465]; p=0.009) and AF duration (OR 1.012; 95% CI [1.002-1.023]; p=0.021) were significant predictors for mitral isthmus conduction recovery. Mitral isthmus conduction gaps were commonly localised at the lateral ridge in both cohorts; endocardial mitral annulus conduction gaps were more frequent in the EIVOM cohort and epicardial vein of Marshall-related epicardial conduction gaps were predominant in the non-EIVOM cohort.

Conclusion: The combined EIVOM-radiofrequency ablation strategy significantly improved chronic mitral isthmus block durability but did not enhance long-term durability of LPV isolation compared with radiofrequency ablation alone. Distinct anatomical patterns of LPV and mitral isthmus conduction recovery provide useful clues for refining ablation strategies in non-PAF ablation.

AF is a common yet multifaceted cardiac arrhythmia with a far-reaching impact. The global burden of AF has been growing rapidly over the last few decades, partly related to the increasing overall burden of chronic illnesses in the setting of an ageing world population. Not only is AF common, but it also has significant implications for patients' health. There exist regional variations in the incidence, prevalence, morbidity and mortality of AF. Moreover, treatment strategies differ appreciably by global regions in a pattern influenced by regional differences in access to medications, the development of large-volume centres and the presence of clinical research. This review explores how AF epidemiology has evolved over time with distinct geographic heterogeneity, and it aims to provide an updated context for the global impact of AF.

An in-depth knowledge of the anatomy of the atrioventricular and ventriculo-arterial junctions of the heart is necessary for the safe implementation of transcatheter approaches for electrophysiological and structural intervention. In the first part of this review, the atrioventricular junctional areas are revisited from the perspective of their anatomy.

An in-depth knowledge of the anatomy of the atrioventricular and ventriculo-arterial junctions of the heart is necessary for the safe implementation of transcatheter approaches for electrophysiological and structural intervention. In the second part of this review, the ventriculo-arterial junctional areas are revisited from the perspective of their anatomy.