Arrhythmia & Electrophysiology Review最新文献

Pulsed field ablation (PFA) is a novel, non-thermal technology used in catheter ablation procedures. Despite its growing clinical adoption, a standardised sedation protocol has not yet been established. Well-coordinated anaesthesia management is essential for procedural success, patient safety and comfort. This review examines various sedation strategies, highlighting their respective benefits and risks, and offers practical recommendations to optimise anaesthesia management during PFA procedures. PFA enables selective myocardial ablation while preserving surrounding structures such as the oesophagus and phrenic nerve. However, inadequate sedation may lead to complications such as haemodynamic instability or airway issues. This article provides an overview of sedation protocols, monitoring strategies and anaesthetic challenges to enhance the safety and efficiency of PFA procedures. Proper anaesthesia planning plays a crucial role in ensuring the safe and successful execution of PFA and contributes to the development of standardised protocols in cardiac electrophysiology.

Pulsed field ablation (PFA), recently introduced as a non-thermal and selective method for cardiac ablation, was associated with great promise, hope and expectation, but also raised some concerns and left some questions unanswered, in particular with respect to waveform. To better understand the challenges associated with the design and development of safe and efficient PFA systems, the underlying mechanism of electroporation at the membrane, cellular and tissue levels is described. The three interdependent components of each system, that is, the waveform, the catheter and the generator, are then addressed. The effect of the different waveform parameters on treatment outcomes is reviewed, and the consequences of a potential mismatch of the three components in the development of a safe and efficient PFA system are highlighted.

Pulsed field ablation (PFA) represents a paradigm shift in the catheter-based treatment of AF, offering myocardial-selective ablation through the non-thermal mechanism of irreversible electroporation. Despite promising early outcomes, the durability of PFA lesions, particularly over mid-and long-term follow-up, remains a critical area of investigation. This review incorporates preclinical and clinical data on PFA lesion durability, explores biophysical underpinnings, evaluates procedural variables influencing outcomes, and identifies ongoing challenges and future research priorities.

AF is the most common cardiac arrhythmia, affecting millions worldwide. Catheter ablation has evolved into a cornerstone treatment for AF, offering better rhythm control and symptom relief than antiarrhythmic medications in selected patients. Over the past few decades, AF ablation has evolved significantly. Initially, right atrial approaches were explored before shifting to the left atrium, with pulmonary vein isolation emerging as the principal strategy. Attempts at substrate modification, including complex fractionated atrial electrograms ablation, linear lesions and rotorbased approaches, have been explored, but yielded inconsistent results. Recent studies reaffirm pulmonary vein isolation as the cornerstone of AF ablation. This review critically evaluates the evolution of AF ablation, the scientific rationale behind different strategies, technological advancements and future directions in the field.

Conduction system pacing, particularly left bundle branch area pacing (LBBAP), has become a popular form of lead implantation for patients with ventricular pacing indications. Success rates are reportedly high, and complication rates are relatively low. However, complications with LBBAP are unique and follow-up and troubleshooting need to be more meticulous. This paper reviews some of the short- and longer-term complications that one may see with LBBAP. Guidance on device programming, follow-up and tips on troubleshooting for LBBAP is also provided.

Background: Elevated CHA₂DS₂-VASc scores are considered to be predictors of left atrial appendage (LAA) thrombus (LAAT); however, individuals with low scores remain at risk. Studies have indicated that aortic atherosclerosis (AA) is associated with increased stroke risk. AA on transoesophageal echocardiography (TOE) has been overlooked as a 'vascular' variable in the CHA₂DS₂-VASc score.

Aims: Determine the prevalence of LAAT in patients with low thromboembolic risk and the correlation of AA with LAAT.

Methods: We performed a retrospective review of all TOEs performed for patients who underwent electrophysiology procedures at the McGill University Health Centre from 2012 to 2017 and collected pertinent clinical and echocardiography variables. We reviewed all TOEs to evaluate the presence and severity of AA using the Katz score, American Society of Echocardiography (ASE) grade and the Ferrari score. In patients with a CHADS₂ of 0 and CHA₂DS₂-VASc score of ≤1, logistical regression and receiver operating characteristic curves were used to identify predictors for LAAT.

Results: 592 patients underwent a pre-procedure TOE and were included in the analysis. Among 249 patients with CHA₂DS₂-VASc scores ≤1, 7.5% had LAA. AA burden by Katz score was an independent predictor of LAAT (area under the curve (AUC) 0.76 95% CI [0.60-0.92]) for CHA₂DS₂-VASc ≤1.

Conclusion: AA visualised on TOE was significantly associated with an increased risk of LAAT development in patients with low CHA₂DS₂-VASc scores. Incorporating AA assessment into risk stratification may enhance clinical decision-making for the use of anticoagulation for patients with AF. Future studies are warranted to evaluate the use of other imaging modalities for AA detection.

Sudden cardiac death (SCD) is one of the leading causes of death worldwide. Coronary artery disease (CAD) is the predominant cause of SCD in older individuals, while inherited cardiomyopathies and channelopathies are more common in younger individuals under the age of 35 years. Genetic disorders associated with SCD have traditionally been perceived as monogenic disorders. However, increasing evidence suggests that many of these disorders have complex genetic architecture with contributions from multiple genetic variants, known as polygenic inheritance, along with environmental factors. Improved understanding of genetic contributions and variants in SCD may help elucidate the cause of SCD, enable risk stratification, and identify novel disease mechanisms to guide preventative and therapeutic strategies in SCD. This review provides an overview of the genetic risk factors and clinical implications for the most common cardiac disorders related to SCD in both old and young individuals: specifically CAD, as well as the inherited cardiomyopathies and channelopathies, respectively.

Background: Myocardial connections of left ventricular (LV) papillary muscles (PM) are determinants of QRS variability in the case of PM arrhythmias. We investigated the anatomical substrate of monomorphic versus polymorphic LV PM arrhythmias in patients with apparently normal hearts, as well as ablation outcomes.

Methods: Thirty-two patients were eligible for analysis. Thirteen patients underwent ablation. With advanced cardiac imaging (cardiac MRI or multidetector CT), we determined the number of PM-PM and PM-surrounding myocardium connections, PM architecture according to the number of strands and the level of LV trabeculation.

Results: Combinations of unifocal (monomorphic premature ventricular complexes [PVCs]), multiform PVCs and/or runs of polymorphic PM arrhythmias (≥3 beats) were recorded in 24 patients. The remaining eight patients had only unifocal monomorphic PVCs. The mean [± SD] number of PM connections was higher than that of PM-PM or PM-myocardial connections in patients with multiform PVCs (30 ± 1.5 versus 4 ± 1, respectively) or polymorphic arrhythmias (136 ± 4 versus 26 ± 3, respectively; p=0.004). Compared with the unifocal group, the frequency of multistranded PMs was higher (1 versus 22, respectively; p<0.001) and LV trabeculation was more pronounced in the group with multiform arrhythmia (multiform PVCs and/or polymorphic arrhythmias). All patients ablated for unifocal PVCs remained free of recurrence, compared with only half of those ablated for multiform PVCs.

Conclusion: Patients with multiform PM arrhythmias have more PM connections, PM strands and trabeculation than patients without QRS variability. The long-term effectiveness of catheter ablation in this patient group is limited.