Arrhythmia & Electrophysiology Review最新文献

Cardioneuroablation is a relatively new method to treat asystolic reflex syncope. The short- and mid-term efficacy ranges between 70% and 94%. Although the method is increasingly used worldwide, there are many unresolved issues associated with the use of this technique. One such issue is the correct identification of optimal candidates for cardioneuroablation. This article reviews the demographic, clinical and procedural parameters that may be of value in predicting the efficacy of cardioneuroablation.

Fasciculoventricular accessory pathways (FVAPs), once considered rare variants of pre-excitation syndrome, are now recognised as ubiquitous in both humans and murine. Nonetheless, most FVAPs are likely electrically silent. However, they can become evident, as reported for some glycogen storage diseases (such as Danon disease and PRKAG2) and during high-voltage septal pacing. Typically, FVAPs only exhibit antegrade and non-decremental conducting properties. A block at the FVAP results in a normal His-to-ventricle interval and a narrow QRS complex without signs of pre-excitation. Decremental conduction over FVAP was once reported in a setting of PRKAG2 mutation. However, in the present case, incremental atrial pacing revealed varying His-to-ventricle intervals, with functional decremental conduction that was accompanied by varied QRS morphologies. These findings underscore the diagnostic challenges posed by FVAPs, and highlight the need for meticulous electrophysiological assessment to accurately distinguish them from other pre-excitation syndromes. This case exemplifies the nuanced behaviour of FVAPs, emphasising their clinical and diagnostic complexity in electrophysiological practice.

Objectives: The occurrence of new conduction abnormalities necessitating permanent pacemaker implantation (PPI) is a complication of transcatheter aortic valve replacement (TAVR). Previous studies have shown inconsistent results about the clinical impact of new PPI after TAVR.

Methods: CONDUCT was a prospective observational registry that enrolled 295 patients undergoing TAVR at four European centres. The primary goal of this registry was to compare 1-year clinical outcomes in TAVR patients with or without PPI, using one-to-four propensity score matched (PSM) analysis. It also assessed major adverse cardiac events (MACE) in patients undergoing right ventricular pacing after PPI.

Results: Out of 160 PSM patients, 36 underwent PPI and the other 124 had no PPI within 30 days post-TAVR. The median age of the patients was 80 years, with more men (80.6% and 84.7% in patients with and without PPI, respectively) and similar EuroSCORE II and Society of Thoracic Surgeons scores. Patients with PPI had higher diabetes prevalence (p=0.055) and lower left ventricular ejection fraction percentages (p=0.034), but higher systolic pulmonary artery pressure (p=0.013) than those without PPI. However, these differences diminished after PSM. At 1 year, PPI patients had a nonsignificant but slightly higher incidence of MACE (22.2% versus 13.7%; p=0.216) (HR 1.63; 95% CI [0.72-3.71]) driven by increased heart failure (11.1% versus 2.4%; p=0.046) (HR 5.05; 95% CI [1.09-23.4]). Freedom from all-cause mortality, cardiovascular death, stroke and endocarditis at 1-year follow-up was comparable between groups.

Conclusion: Despite a higher incidence of congestive heart failure rehospitalisation in patients undergoing PPI, 1-year clinical outcomes were similar in both groups.

Inappropriate sinus tachycardia (IST) is a clinical syndrome that generally affects young patients and is associated with distressing symptoms. Cardioneuroablation (CNA) is a promising method for the treatment of asystolic reflex syncope, functional bradycardia or atrioventricular block. Because CNA involves parasympathetic denervation, one potential adverse effect may be IST. We present an educational case of a patient with mixed vasovagal syncope and symptomatic sinus bradycardia who underwent CNA, as a result of which bradycardia converted to IST and the patient required subsequent pacemaker implantation. We also review the incidence of IST after CNA and difficulties around the definition and treatment of post-CNA IST.

Anatomical investigations aiming to delineate the 3D anatomy of the conduction system have been limited. Hierarchical phase-contrast tomography now provides the ability for 3D imaging at the micron-level spatial resolution. In this report, we present 3D reconstructions of the atrioventricular conduction axis within a structurally normal autopsied heart.

Arrhythmias originating from the specialised cardiac conduction system and papillary muscles can occur in both structurally normal and diseased hearts. Conduction system associated arrhythmias include bundle branch re-entry, fascicular re-entry, non-re-entrant fascicular ventricular tachycardia and idiopathic ventricular fibrillation. Each type of arrhythmia requires a unique diagnostic and therapeutic approach. The papillary muscles may also be a source of ventricular arrhythmias. Ablation of papillary muscle associated arrhythmias may be difficult due to the complexities of mapping, structural abnormalities and potentially the deep location of arrhythmia foci. Tools, such as intracardiac echocardiography, can be valuable.

Obesity independently increases AF risk and negatively affects the outcomes of catheter ablation. This review examines the relationship between obesity and AF, focusing on structural and electrical remodelling. Multiple studies demonstrate worse ablation outcomes in patients with obesity. Pre-ablation weight loss improves outcomes and maintaining weight loss post-ablation is equally important. Risk factor modification programmes show promise, however they require a large investment in resources. Less intensive strategies focusing on diet and exercise have shown mixed results. Glucagon-like peptide-1 receptor agonists have been identified as potential adjunct therapies. They have multiple effects, including preferential reduction of epicardial adipose tissue and an anti-inflammatory action. Further research is needed to establish their efficacy in improving ablation outcomes. This review highlights the importance of weight management in AF treatment and suggests potential monitoring strategies using cardiac imaging. Future studies may shift the paradigm for the management of AF patients with obesity who are undergoing ablation.

Three patients, two women and one man, aged 50.0 ± 9.8 years, who underwent catheter ablation for typical atrioventricular nodal re-entrant tachycardia, were studied during sinus rhythm. An electroanatomic system suitable for high-resolution mapping and recording of both bipolar and unipolar electrograms was used. Recording of potentials from the area of the right inferior extension was feasible in all patients with bipolar signals. Using unipolar signals, the electrical activity of the atrioventricular node was recorded in all patients. This preliminary report supports the existing evidence that the activity of the atrioventricular node and its right inferior extension can be successfully mapped in the electrophysiology lab.

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.