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European Journal of Preventive... Jun 2024The study investigates the prognosis of atrial fibrillation (AF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF).
OBJECTIVE
The study investigates the prognosis of atrial fibrillation (AF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF).
BACKGROUND
Data concerning the prognostic impact of AF in patients with HFmrEF is scarce.
METHODS
Consecutive patients with HFmrEF (i.e., left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. Patients with AF were compared to patients without with regard to the primary composite endpoint of all-cause mortality and HF-related rehospitalization at 30 months (median follow-up). Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching.
RESULTS
2,148 patients with HFmrEF were included with an overall prevalence of AF of 43%. The presence of AF was associated with higher risk of the primary composite endpoint all-cause mortality and HF-related rehospitalization at 30 months (HR = 2.068; 95% CI 1.802-2.375; p = 0.01), which was confirmed after propensity-score matching (HR = 1.494; 95% CI 1.216-1.835; p = 0.01). AF was an independent predictor of both all-cause mortality (HR = 1.340; 95% CI 1.066-1.685; p = 0.01) and HF-related rehospitalization (HR = 2.061; 95% CI 1.538-2.696; p = 0.01). Finally, rhythm control may be associated with lower risk of all-cause mortality compared to rate control for AF (HR = 0.342; 95% CI 0.199-0.587; p = 0.01).
CONCLUSION
AF affects 43% of patients with HFmrEF and represents an independent predictor of adverse long-term prognosis.
PubMed: 38825871
DOI: 10.1093/eurjpc/zwae185 -
International Heart Journal 2024This study aimed to clarify (1) the association among the atrial fibrillation (AF) type, sleep-disordered breathing (SDB), heart failure (HF), and left atrial (LA)...
Bidirectional Association Among the Type of Atrial Fibrillation, Sleep-Disordered Breathing Severity, Heart Failure Progression, and Left Atrial Enlargement, in Patients with Atrial Fibrillation.
This study aimed to clarify (1) the association among the atrial fibrillation (AF) type, sleep-disordered breathing (SDB), heart failure (HF), and left atrial (LA) enlargement, (2) the independent predictors of LA enlargement, and (3) the effects of ablation on those conditions in patients with AF. The study's endpoint was LA enlargement (LA volume index [LAVI] ≥ 78 mL/m).Of 423 patients with nonvalvular AF, 236 were enrolled. We evaluated the role of the clinical parameters such as the AF type, SDB severity, and HF in LA enlargement. Among them, 141 patients exhibiting a 3% oxygen desaturation index (ODI) of ≥ 10 events/hour underwent polysomnography to evaluate the SDB severity measured by the apnea-hypopnea index (AHI). The LA enlargement and HF were characterized by the LA diameter/LAVI, an increase in the B-type natriuretic peptide level, and a lower left ventricular ejection fraction.This study showed that non-paroxysmal AF (NPAF) rather than paroxysmal AF (PAF), the SDB severity, LA enlargement, and HF progression had bidirectional associations and exacerbated each other, which generated a vicious cycle that contributed to the LA enlargement. NPAF (OR = 4.55, P < 0.001), an AHI of ≥ 25.10 events/hour (OR = 1.55, P = 0.003), and a 3% ODI of ≥ 15.43 events/hour (OR = 1.52, P = 0.003) were independent predictors of an acceleration of the LA enlargement. AF ablation improved the HF and LA enlargement.To break this vicious cycle, AF ablation may be the basis for suppressing the LA enlargement and HF progression subsequently eliminating the substrates for AF and SDB in patients with AF.
Topics: Humans; Atrial Fibrillation; Male; Female; Sleep Apnea Syndromes; Heart Failure; Disease Progression; Middle Aged; Aged; Heart Atria; Severity of Illness Index; Catheter Ablation; Polysomnography; Atrial Remodeling; Echocardiography
PubMed: 38825490
DOI: 10.1536/ihj.23-493 -
Revista Portuguesa de Cardiologia :... Jun 2024
Topics: Humans; Cardiomyopathies; Tachycardia, Ventricular; Catheter Ablation
PubMed: 38825368
DOI: 10.1016/j.repc.2024.05.006 -
Heart Rhythm May 2024The potential risk of embolic events during ablation in the left ventricle (LV) with a heated saline-enhanced radiofrequency (SERF) needle-tip ablation catheter has not...
BACKGROUND
The potential risk of embolic events during ablation in the left ventricle (LV) with a heated saline-enhanced radiofrequency (SERF) needle-tip ablation catheter has not been characterized.
OBJECTIVE
This study aimed to investigate the formation of microemboli or other untoward events during SERF ablation.
METHODS
Ninety-three radiofrequency (RF) ablation procedures were performed in the LV of 14 pigs by using a SERF catheter (35 W, 70 seconds, and 60°C; normal or degassed saline [NS or DS] irrigation with a flow rate of 10 mL/min) vs a standard irrigated-tip radiofrequency (S-RF) catheter (30 or 50 W, 30 seconds, and 17 mL/min). Microbubble formation was graded on the basis of intracardiac echocardiography. Microbubbles, microembolic signals, and microparticles were monitored using our established model.
RESULTS
There was no significant difference in microbubble volume among SERF-NS, SERF-DS, and S-RF 30 W with "grade 1" intracardiac echocardiography microbubbles (median [quartiles] 0.201 [0.011-3.13], 0.455 [0.06-2.66], and 0.004 μL [0.00-0.16 μL], respectively). There was no significant difference in microembolic signals among SERF-NS, SERF-DS, and S-RF 30 W with grade 1 bubbles (n = 8.0 ± 5.8, n = 7.6 ± 4.2, and n = 6.1 ± 6.1, respectively). Both SERF-NS and SERF-DS created larger lesions than did both S-RF 30 W and S-RF 50 W deliveries (mean 1241.5 ± 658.6, 1497.7 ± 893.4, 75.0 ± 24.8, and 184.0 ± 93.8 mm; P < .001). There was no significant difference in microparticle incidence among groups (P = .675). No evidence of embolic events was found in the brain and other organs at the histology assessment.
CONCLUSION
In the setting of SERF ablation, significantly large LV lesions can be created without any increment in embolic microbubble or particle events. Grade 1 microbubble is related to the efficacy and safety.
PubMed: 38823665
DOI: 10.1016/j.hrthm.2024.05.050 -
Heart, Lung & Circulation May 2024Although there are evolving techniques and technologies for treating ventricular tachycardia (VT), the current landscape of clinical trials for managing VT remains...
BACKGROUND
Although there are evolving techniques and technologies for treating ventricular tachycardia (VT), the current landscape of clinical trials for managing VT remains understudied.
OBJECTIVE
The objective of this study was to provide a systematic characterisation of the interventional management of VT through an analysis of the ClinicalTrials.gov, clinicaltrialsregister.eu, anzctr.org.au and chictr.org.cn databases.
METHODS
We queried all phase II to IV interventional trials registered up to November 2023 that enrolled patients with VT. Published, completed but unpublished, terminated, or ongoing trials were included for final analysis.
RESULTS
Of the 698 registered studies, 135 were related to VT, with 123 trials included in the final analysis. Among these trials, 25 (20%) have been published, enrolling a median of 35 patients (interquartile range [IQR] 20-132) over a median of 43 months (IQR 19-62). Out of the published trials, 14 (56%) were randomised, and 12 (48%) focused on catheter ablation. Twenty-two (18%) have been completed but remain unpublished, even after a median of 36 months (IQR 15-60). Furthermore, 27 (22%) trials were terminated or withdrawn, with the most common cause being poor enrolment. Currently, 49 (40%) trials are ongoing and novel non-ablative technologies, such as radioablation and autonomic modulation, account for 35% and 8% of ongoing trials, respectively.
CONCLUSIONS
Our analysis revealed that many registered trials remain unpublished or incomplete, and randomised controlled trial evidence is limited to only a few studies. Furthermore, many ongoing trials are focused on non-catheter ablation-based strategies. Therefore, larger pragmatic trials are needed to create stronger evidence in the future.
PubMed: 38821759
DOI: 10.1016/j.hlc.2024.01.041 -
JACC. Clinical Electrophysiology May 2024A partial delineation of targets for ablation of ventricular tachycardia (VT) during a stable rhythm is likely responsible for a suboptimal success rate. The abnormal...
BACKGROUND
A partial delineation of targets for ablation of ventricular tachycardia (VT) during a stable rhythm is likely responsible for a suboptimal success rate. The abnormal low-voltage near-field functional components may be hidden within the high-amplitude far-field signal.
OBJECTIVES
The aim of this study was to evaluate the benefit and feasibility of functional substrate mapping using a full-ventricle S3 protocol and to assess its colocalization with arrhythmogenic conducting channels (CCs) on late gadolinium enhancement cardiac magnetic resonance.
METHODS
An S3 mapping protocol with a drive train of S1 followed by S2 (effective refractory period + 30 ms) and S3 (effective refractory period + 50 ms) from the right ventricular apex was performed in 40 consecutive patients undergoing scar-related VT ablation. Deceleration zones (DZs) and areas of late potentials (LPs) were identified for all maps. A preprocedural noninvasive substrate assessment was done using late gadolinium enhancement cardiac magnetic resonance and postprocessing with automated CC identification.
RESULTS
The S3 protocol was completed in 34 of the 40 procedures (85.0%). The S3 protocol enhanced the identification of VT isthmus on the basis of DZ (89% vs 62%; P < 0.01) and LP (93% vs 78%; P = 0.04) assessment. The percentage of CCs unmasked by DZs and LPs using S3 maps was significantly higher than the ones using S2 and S1 maps (78%, 65%, and 48% [P < 0.001] and 88%, 81%, and 68% [P < 0.01], respectively). The functional substrate identified during S3 activation mapping was significantly more extensive than the one identified using S2 and S1, including a greater number of DZs (2.94, 2.47, and 1.82, respectively; P < 0.001) and a wider area of LPs (44.1, 38.2, and 29.4 cm, respectively; P < 0.001). After VT ablation, 77.9% of patients have been VT free during a median follow-up period of 13.6 months.
CONCLUSIONS
The S3 protocol was feasible in 85% of patients, allows a better identification of targets for ablation, and might improve VT ablation results.
PubMed: 38819348
DOI: 10.1016/j.jacep.2024.04.023 -
JACC. Clinical Electrophysiology May 2024The boundaries of critical isthmuses for re-entrant ventricular tachycardia (VT) are formed by wave-front discontinuities (fixed lines of block, slow propagation, and...
BACKGROUND
The boundaries of critical isthmuses for re-entrant ventricular tachycardia (VT) are formed by wave-front discontinuities (fixed lines of block, slow propagation, and rotational propagation) seen during baseline rhythm. It is unknown whether wavefront discontinuities can be automatically identified and targeted for ablation using electroanatomic mapping systems.
OBJECTIVES
The purpose of this study was to assess the electrophysiologic characteristics of automatically projected wavefront discontinuity lines (WADLs) and outcomes of an ablation strategy targeting WADLs in a mixed cohort of VT patients.
METHODS
Late activation substrate maps were analyzed from 1 or more baseline rhythm wavefronts. WADLs were identified using the Carto Extended Early Meets Late module. Number, total length, and distance to critical VT sites were measured. VT recurrence and VT-free survival were followed.
RESULTS
In total, 49 patients underwent 52 ablations with 71 unique substrate maps analyzed (18.8% epicardial; 62.0% right ventricular paced, 28.2% sinus rhythm, 9.9% left ventricular paced). A total of 28 VT critical sites were identified in 24 patients. WADLs were present in 49 of 71 (69.0%) maps. WADLs were present regardless of cardiomyopathy etiology, mapping wavefront, or surface. At a WADL threshold of 30%, 73.9% of critical VT sites were in close proximity (≤15 mm) to a WADL. VT-free survival was 62% at 1 year, with a competing risk model estimating a 1-year risk of VT recurrence of 23%.
CONCLUSIONS
WADLs can be automatically projected in a majority of patients in a mixed cohort of cardiomyopathy etiology, mapped wavefronts, and myocardial surfaces mapped. Targeting WADLs results in low rate of VT recurrence at 1 year.
PubMed: 38819346
DOI: 10.1016/j.jacep.2024.03.023 -
JACC. Clinical Electrophysiology May 2024Catheter ablation of ventricular tachycardia (VT) typically requires radiation exposure with its potential adverse health effects. A completely fluoroless ablation...
BACKGROUND
Catheter ablation of ventricular tachycardia (VT) typically requires radiation exposure with its potential adverse health effects. A completely fluoroless ablation approach is achievable using a combination of electroanatomical mapping and intracardiac echocardiography. Nonetheless, data in patients undergoing VT ablation are limited.
OBJECTIVES
This study aimed to determine the feasibility, efficacy, and safety of VT ablation in patients with structural heart disease using a zero-fluoroscopy approach.
METHODS
This multicenter study included consecutive patients with ischemic and nonischemic cardiomyopathy undergoing fluoroless VT ablation. Patients requiring epicardial access or coronary angiography were excluded.
RESULTS
Between 2017 and 2023 a total of 198 patients (aged 66.4 ± 13.4 years, 76% male, 48% ischemic) were included. Most patients (95.4%) underwent left ventricular (LV) mapping and/or ablation, which was conducted via transseptal route in 54.5% (n = 103), via retrograde aortic route in 43.4% (n = 82), and using a combined approach in 2.1% (n = 4). Two-thirds of patients had a cardiac device, including a biventricular device in 15%; 2 patients had a LV assist device, and 1 patient had a mechanical aortic valve prosthesis. The mean total procedural time was 211 ± 70 minutes, and the total radiofrequency time was 30 ± 22 minutes. During a follow-up period of 22 ± 18 months, the freedom from VT recurrence was 80%, and 7.6% of patients underwent a repeated ablation. Procedural-related complications occurred in 6 patients (3.0%).
CONCLUSIONS
Fluoroless ablation of VT in structural heart disease is feasible, effective, and safe when epicardial mapping/ablation is not required.
PubMed: 38819345
DOI: 10.1016/j.jacep.2024.03.011 -
Europace : European Pacing,... Jun 2024We aimed to assess the acute and midterm efficacy of premature ventricular contraction (PVC) ablation guided by multielectrode and point-by-point (PbP) mapping.
AIMS
We aimed to assess the acute and midterm efficacy of premature ventricular contraction (PVC) ablation guided by multielectrode and point-by-point (PbP) mapping.
METHODS AND RESULTS
This is a retrospective, international multicentre study of consecutive patients referred for PVC ablation in 10 hospital centres from January 2017 to December 2021. Based on the mapping approach, two cohorts were identified: the 'Multipolar group', where a dedicated high-density mapping catheter was employed, and the 'PbP group', where mapping was performed with the ablation catheter. Procedural endpoints, safety, and acute (procedural) and midterm efficacies were assessed. Of the 698 patients included in this study, 592 received activation mapping [46% males, median age of 55 (41-65) years]-248 patients in the Multipolar group and 344 patients in the PbP group. A higher number of activation points [432 (217-843) vs. 95 (42-185), P < 0.001], reduced mapping time (40 ± 38 vs. 61 ± 50 min, P < 0.001), and shorter procedure time (124 ± 60 vs. 143 ± 63 min, P < 0.001) were reported in the Multipolar group. Both groups had high acute success rates (84.7% with Multipolar mapping vs. 81.3% with PbP mapping, P = 0.63), as well as midterm efficacy (83.4% vs. 77.4%, P = 0.08), with no significant differences in the risk of adverse events (6.0% vs. 3.5%, P = 0.24). However, for left-sided PVC ablation specifically, there was a higher midterm efficacy in the Multipolar group (80.7% vs. 69.5%, P = 0.04), with multipolar mapping being an independent predictor of success [adjusted OR = 2.231 (95% CI, 1.476-5.108), P = 0.02].
CONCLUSION
The acute and midterm efficacies of PVC ablation are high with both multipolar and PbP mapping, although the former allows for quicker procedures and may potentially improve the outcomes of left-sided PVC ablation.
Topics: Humans; Ventricular Premature Complexes; Male; Middle Aged; Female; Catheter Ablation; Retrospective Studies; Aged; Adult; Treatment Outcome; Electrophysiologic Techniques, Cardiac
PubMed: 38818846
DOI: 10.1093/europace/euae148 -
Journal of Cardiovascular... May 2024
PubMed: 38818575
DOI: 10.1111/jce.16332