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Clinical Cardiology Jan 2024Hypertrophic cardiomyopathy (HCM) is a common contemporary, treatable, genetic disorder that can be compatible with normal longevity. While current medical therapies are... (Review)
Review
Hypertrophic cardiomyopathy (HCM) is a common contemporary, treatable, genetic disorder that can be compatible with normal longevity. While current medical therapies are ubiquitous, they are limited by a lack of solid evidence, are often inadequate, poorly tolerated, and do not alter the natural disease course. As such, there has long been a need for effective, evidence-based, and targeted disease-modifying therapies for HCM. In this review, we redefine HCM as a treatable condition, evaluate current strategies for therapeutic intervention, and discuss novel myosin inhibitors. The majority of patients with HCM have elevated left ventricular outflow tract gradients, which predicts worse symptoms and adverse outcomes. Conventional pharmacological therapies for symptomatic HCM can help improve symptoms but are often inadequate and poorly tolerated. Septal reduction therapies (surgical myectomy and alcohol septal ablation) can safely and effectively reduce refractory symptoms and improve outcomes in patients with obstructive HCM. However, they require expertise that is not universally available and are not without risks. Currently, available therapies do not alter the disease course or the progressive cardiac remodeling that ensues, nor subsequent heart failure and arrhythmias. This has been regarded as an unmet need in the care of HCM patients. Novel targeted pharmacotherapies, namely cardiac myosin inhibitors, have emerged to reverse key pathophysiological changes and alter disease course. Their favorable outcomes led to the early Food and Drug Administration approval of mavacamten, a first-in-class myosin modulator, changing the paradigm for the pharmacological treatment of HCM.
Topics: United States; Humans; Cardiomyopathy, Hypertrophic; Heart; Disease Progression; Heart Failure; Myosins
PubMed: 38269637
DOI: 10.1002/clc.24207 -
Indian Pacing and Electrophysiology... 2024While atrial fibrillation (AF) ablation has proven beneficial for heart failure (HF) patients, most reports were performed with radiofrequency ablation. We aimed to...
INTRODUCTION
While atrial fibrillation (AF) ablation has proven beneficial for heart failure (HF) patients, most reports were performed with radiofrequency ablation. We aimed to evaluate the efficacy and safety of cryoballoon AF ablation in patients with HFrEF.
METHOD
We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to December 2022. Studies that reported the outcomes of freedom from atrial arrhythmia, complications, NYHA functional class (NYHA FC), and left ventricular ejection fraction (LVEF) after Cryoballoon AF ablation in HF patients were included. Data from each study were combined with a random-effects model.
RESULT
A total of 9 studies observational studies with 1414 HF patients were included. Five studies had only HF with reduced ejection fraction (HFrEF), 1 study with HF with preserved ejection fraction (HFpEF), and others with mixed HF types. Freedom from AA in HFrEF at 12 months was 64% (95% CI 56-71%, I 58%). There was a significant improvement of LVEF in these patients with a standard mean difference of 13% (95% CI 8.6-17.5%, I 99% P < 0.001. The complication rate in HFrEF group was 6% (95% CI 4-10%, I 0%). The risk of recurrence of atrial arrhythmia was not significantly different between HF and no HF patients (RR 1.34, 95% CI 0.8-2.23, I2 76%).
CONCLUSION
Cryoballoon AF ablation is effective in HFrEF patients comparable to radiofrequency ablation. The complication rate was low.
PubMed: 38218450
DOI: 10.1016/j.ipej.2024.01.001 -
Journal of Arrhythmia Dec 2023Inherited Primary Arrhythmias Syndromes (IPAS), especially Brugada syndrome (BrS), have been associated with arrhythmogenic substrates that can be targeted through...
BACKGROUND
Inherited Primary Arrhythmias Syndromes (IPAS), especially Brugada syndrome (BrS), have been associated with arrhythmogenic substrates that can be targeted through ablation. This meta-analysis evaluated the outcomes of catheter ablation (CA) in different types of IPAS based on procedural guidance and location.
METHODS
A systematic search was conducted across multiple databases to identify studies reporting on ventricular arrhythmia (VA) events before and after CA in IPAS, including BrS, Long-QT syndrome (LQTS), Early repolarization syndrome (ERS), and Idiopathic ventricular fibrillation (IVF). The primary outcomes were VA recurrence and VA burden, evaluated through conditional subgroup analysis. Procedural data were collected as secondary outcomes.
RESULTS
A total of 21 studies involving 584 IPAS patients who underwent CA were included. Following a mean follow-up duration of 33.5 months, substrate-based ablation demonstrated efficacy in reducing VA recurrence across all types of IPAS [RR 0.23; 95% CI (0.13-0.39); < .001; = 74%]. However, activation guidance ablation was found to be effective only in IVF cases. Although recurrences still occurred, CA was successful in reducing VA burden [MD -4.70; 95% CI (-6.11-(-3.29); < .001; = 74%]. The mean size of arrhythmogenic substrate was 15.70 cm [95% CI (12.34-19.99 cm)], predominantly distributed in the epicardial right ventricular outflow tract (RVOT) in BrS cases and LQTS [Proportion 0.99; 95% CI (0.96-1.00) and Proportion 0.82; 95% CI ( 0.59-1.00), respectively].
CONCLUSION
Substrate-based CA has demonstrated effective prevention of VA and reduction in VA burden in IPAS cases.
PubMed: 38045449
DOI: 10.1002/joa3.12947 -
Clinical Cardiology Jan 2024The coexistence of atrial fibrillation (AF) with heart failure (HF) is prevalent, leading to severe complications. This review aimed to investigate the success rate and... (Meta-Analysis)
Meta-Analysis Review
The coexistence of atrial fibrillation (AF) with heart failure (HF) is prevalent, leading to severe complications. This review aimed to investigate the success rate and efficacy of cryoballoon ablation (CBA) by measuring the improvement in the New York Heart Association (NYHA) classification and the effect on the left ventricular systolic function in patients with AF accompanied by heart failure with reduced ejection fraction (HFrEF). Electronic databases search included PubMed, Web of Science, and Scopus in January 2023. Outcomes addressed the following: left ventricular ejection fraction (LVEF) improvement, AF recurrence, NYHA classification improvement, and mortality. STATA 17.0 software was used for data analysis. The effect size for the studies was a standard mean difference (SMD) with a 95% confidence interval (CI) for outcomes. Proportion analysis with 95% CI was used for freedom from early AF and AF after 2 years and all-cause death. We included six studies, including 1699 HF patients with 365 HFrEF patients. The SMD of postoperative LVEF compared to preoperative LVEF in HFrEF was 0.99 ([95% CI: 0.60, 1.39], p = .00), and for NYHA was -1.12 ([95% CI: -1.36, -0.87], p = .00). The analysis results in HFrEF patients for freedom from AF after 1 year was 65% ([95% CI: 0.55, 0.75], and after 2 years was 39% ([95% CI: 0.10, 0.67]). Proportional analysis was conducted for all-cause death, resulting in 3% mortality ([95% CI: -0.01, 0.07]). Cryoablation of AF accompanied by HFrEF appeared safe as it reduced AF recurrence and enhanced clinical outcomes.
Topics: Humans; Atrial Fibrillation; Stroke Volume; Ventricular Function, Left; Heart Failure; Treatment Outcome; Catheter Ablation
PubMed: 37877802
DOI: 10.1002/clc.24177 -
Clinical Research in Cardiology :... Dec 2023Patients with Brugada syndrome (BrS) may experience recurrent ventricular arrhythmias (VAs). Catheter ablation is becoming an emerging paradigm for treatment of BrS.
BACKGROUND
Patients with Brugada syndrome (BrS) may experience recurrent ventricular arrhythmias (VAs). Catheter ablation is becoming an emerging paradigm for treatment of BrS.
OBJECTIVE
To assess the efficacy and safety of catheter ablation in BrS in an updated systematic review.
METHODS
We comprehensively searched the databases of Pubmed/Medline, EMBASE, and Cochrane Central Register of Controlled Trials from inception to 11th of August 2021.
RESULTS
Fifty-six studies involving 388 patients were included. A substrate-based strategy was used in 338 cases (87%), and a strategy of targeting premature ventricular complex (PVCs)/ventricular tachycardias (VTs) that triggered ventricular fibrillation (VF) in 47 cases (12%), with combined abnormal electrogram and PVC/VT ablation in 3 cases (1%). Sodium channel blocker was frequently used to augment the arrhythmogenic substrate in 309/388 cases (80%), which included a variety of agents, of which ajmaline was most commonly used. After ablation procedure, the pooled incidence of non-inducibility of VA was 87.1% (95% confidence interval [CI], 73.4-94.3; I = 51%), and acute resolution of type I ECG was seen in 74.5% (95% CI [52.3-88.6]; I = 75%). Over a weighted mean follow up of 28 months, 7.6% (95% CI [2.1-24]; I = 67%) had recurrence of type I ECG either spontaneously or with drug challenge and 17.6% (95% CI [10.2-28.6]; I = 60%) had recurrence of VA.
CONCLUSION
Catheter ablation appears to be an efficacious strategy for elimination of arrhythmias or substrate associated with BrS. Further study is needed to identify which patients stand to benefit, and optimal provocation protocol for identifying ablation targets.
Topics: Humans; Brugada Syndrome; Ventricular Fibrillation; Ventricular Premature Complexes; Catheter Ablation; Tachycardia, Ventricular; Treatment Outcome; Electrocardiography
PubMed: 35451610
DOI: 10.1007/s00392-022-02020-3