Electrophysiological Procedures Research Articles

Same-day discharge strategy in a heart rhythm management clinic - what about patients' reported experience?

Abstract Background and aims Same-day discharge (SDD) has been adopted for many interventional cardiology procedures, however data on patients’ experience are scarce. The aim of this study was to investigate patient-reported experience of a SDD strategy following electrophysiology procedures (EP) in a Heart Rhythm Management Department. Methods Consecutive patients undergoing EP procedures in our centre, who fulfilled pre-defined eligibility criteria for SDD, were asked to complete the study questionnaire, right before hospital discharge. Procedures suitable for SDD ranged from non-invasive (electric cardioversion, tilt test) to invasive ones (EP studies, device replacement, rhythm recorders implantation, ablation of supraventricular tachycardias including atrial fibrillation). The questionnaire aimed to assess patients’ experience before and during the procedure, their satisfaction with the quality of the provided information and their comprehension of the given instructions regarding the post-discharge period and their medication. Results The study questionnaire was completed by 501 patients. The majority of participants described SDD as a good or a quite good experience (n=440, 87,8%), while 94,6% of them (n=474) would not hesitate to undergo a second SDD procedure, if necessary. A direct interview with a healthcare team member was viewed as the preferred method of obtaining information on the procedure. At discharge, 1 out of 10 patients were still unsure of the instructions given by the healthcare team, including their anticoagulation treatment. Patient reported satisfaction rates did not differ between invasive and non-invasive procedures. However, after an invasive procedure, patients seemed to significantly have a better understanding of post-discharge instructions. Conclusion Patients reported a high level of satisfaction with SDD EP procedures. However, significant efforts need to be made in order to ensure their understanding of post-discharge instructions.Figure : Patients' reported experience

Optimizing outcomes in catheter ablation for typical atrial flutter: a comparative study of intracardiac echocardiography versus fluoroscopy guidance

Abstract Background Catheter ablation is a standard intervention for typical atrial flutters, specifically targeting the cavotricuspidal isthmus (CTI). Intracardiac echocardiography (ICE) plays a pivotal role in providing real-time visualization of anatomical structures during the electrophysiology procedure, thereby enhancing safety and potentially reducing reliance on fluoroscopy, leading to improved procedural outcomes. We aimed to conduct a comparative analysis of procedural and follow-up outcomes between ICE-guided and fluoroscopy-only guided catheter ablations for CTI in patients undergoing treatment for typical atrial flutter. Methods A retrospective analysis was conducted at our university center, encompassing 376 consecutive patients in a single-center study. Of these, 158 underwent procedures guided solely by fluoroscopy, while 218 received ICE-guided CTI ablation. Results ICE-guidance demonstrated a statistically significant reduction in fluoroscopy time (72 [36; 170] s vs. 888 [578; 1184] s; p<0.01), total procedure time (70 [52; 90] min vs. 90 [60; 105] min; p<0.01), total ablation time (692 [435; 998] s vs. 920 [629; 1373] s; p<0.01), and the duration from the first to last ablation (20.5 [12; 37] min vs. 41.0 [26.8; 59.3] min; p<0.01). Both groups achieved a 100% acute success rate without major complications. The ICE-guided group exhibited a significantly superior long-term success rate (ICE-guided group: 95.74%, fluoroscopy-only group: 89.26%; p=0.048) compared to the fluoroscopy-only group at an average follow-up length of 34 months. Conclusion The utilization of ICE-guidance for CTI ablation significantly reduces fluoroscopy exposure, procedure time, and ablation time, ultimately contributing to enhanced long-term success rates when compared to the conventional fluoroscopy-only approach.

Influence of audiovisual distraction on the feeling of stress, analgesic sedation and patient satisfaction during electrophysiological ablation procedures on the heart

Abstract Background Distraction using audiovisual stimuli has mostly been researched in a paediatric population with the results showing an inhibiting effect on stress and anxiety as well as the subjective perception of pain. Purpose We designed a study to test if audiovisual distraction may reduce the level of sedatives and analgesics by reducing anxiety and stress during electrophysiological intervention (EP). Methods We conducted a clinical intervention pilot study that was carried out in a randomized controlled manner. Consecutive 70 patients undergoing EP with subsequent ablation were randomized 1:1 to control (CTL) or intervention group (AVD). In addition to standardized sedation, all patients in AVD group received audiovisual glasses. Feeling of fear and stress was assessed through blood pressure changes. The patient satisfaction was assessed with Client Satisfaction Questionnaire, ZUF-8. Numeric scale (NRS) was used to quantify the perceived pain during the procedure. The difference between the subjective estimated duration of the procedure and the actual duration of the procedure was compared. Results The study included predominantly male patients (58.6%) with a mean age of 56 years. Technical aptitude was well balanced between both groups with the majority of patients in both groups owning a smartphone or a tablet (86.1% vs 85.7% for CTL and AVD respectively, p=0.92), and majority of patients in both groups using a computer, laptop or tablet on a weekly basis (58% vs 57.1% for CTL and AVD group respectively, p=0.97). The baseline feelings of anxiety were well balanced within both groups (Figure 1). Our analysis revealed no significant difference between the mean blood pressure values of the CTL and AVD groups (systolic: 135 vs. 141 mmHg; p = 0.32; diastolic: 74 vs. 72 mmHg; p = 0.45). Patient satisfaction score was comparable in both groups (26.5 vs. 26.8 points, p = 0.36). Average response for perceived pain using NRS scale as well as perceived procedure duration was similar between the groups (Figure 2). AVD group required a lower dose of Midazolam than CTL group (0.005 mg/kg/h vs 0.007 mg/kg/h, p = 0.07). Majority of patients (31.4%) in AVD group stated: "The audiovisual glasses made me feel distracted at times." 10% of the AVD patients stated: "The audiovisual glasses made me feel completely distracted and more relaxed." Conclusion The use of audiovisual glasses has no influence on the patients’ feelings of anxiety and stress during EP. The use of audiovisual glasses can temporarily induce distraction during EP, while they do not seem to be sufficient in reducing pain intensity during ablation therapy. Patients undergoing EP do not seem to be the target patient group for AVD use.

Non-invasive detection of cardiac arrhythmias using photoplethysmography signals

Abstract Cardiac arrhythmias (CAs) are associated with critical heart-related complications such as stroke or heart failure. Because of the intermittent and asymptomatic presentation of some CAs in their early stages, the screening remains limited using traditional methods based on ECG. Recent advances in photoplethysmography (PPG) have revealed substantial potential for wearable devices to detect CAs within large populations. Although PPG has demonstrated efficiency in discriminating atrial fibrillation (AF) from normal sinus rhythm, it remains unclear whether AF detection methods remains effective in the presence of CAs other than AF. In this study, we applied a recurrent neural network on a dataset containing eight different types of CAs (Table 1). The classifier processes sequences of interbeat intervals (IBIs) as input and discriminates between normal and abnormal rhythms. The algorithm was evaluated on 64 patients (45 males and 19 females , with a mean age of 55.9 ± 16.0) undergoing a diagnostic or therapeutic electrophysiological procedure. This dataset includes simultaneous recordings of PPG signals from a wrist-bracelet and 12-lead ECG, with the latter used as the gold-standard for annotating cardiac rhythms. The classifier achieved 84% accuracy, 77% sensitivity and 88% specificity in detecting abnormal rhythms. Table 1 shows that AF (99.6%), atrial tachycardia (100%) and AVRT (96.4%) were well classified as abnormal rhythm, whereas the reliability of the detection decreased for atrial flutter (65.4%), atrial or ventricular bigeminy (72.4%) and ventricular tachycardia (80.2%). Undetected abnormal rhythms were often characterized by a rather regular rhythm (illustrated by VT in Figure 1) and CAs for which PPG heartbeat detection was initially not optimal (Bigeminy in Figure 1). In conclusion, this study shows the capability of PPG-based technology to detect various CAs extending beyond AF. It highlights the merits and limitations of IBI-based detection of abnormal rhythms, highlighting the need for a better comprehension of the peripheral hemodynamic signature of CAs.

Revealing intracavitary catheter positions: artificial intelligence-enhanced localization with an electrogram-driven variational autoencoder model

Abstract Background The acquisition of electroanatomical (EA) maps in clinical electrophysiology procedures typically depends on locating intracardiac mapping catheters through magnetic triangulation with external patches placed on the patient's skin. However, this configuration is hampered by shifts in the reference system if the patient moves or if the setup changes during the procedure. Leveraging the feature extraction capabilities of artificial intelligence models, it becomes possible to assess catheter positions within the atria solely based on the information encoded in intracavitary electrograms (EGMs). Consequently, a neural network model could serve as an alternative or complementary system for locating EA mapping catheters, eliminating the need for external reference patches. Purpose We aimed to create a deep learning model utilizing a disentangled variational autoencoder (d-VAE) and unipolar EGM signals. The goal was to extract the precise position of a multi-electrode catheter within the left atrium and predict the specific atrial region in which it is situated, relying solely on the information derived from unipolar EGMs. Methods The model was trained using data from 51 patients with persistent atrial fibrillation who underwent pulmonary vein ablation. We exported 3D EA maps obtained with a 20-pole multi-electrode catheter, comprising a total of 40,000 unipolar EGMs with a duration of 30 seconds. Atrial geometries were segmented into 12 different areas (refer to the Figure). Subsequently, the d-VAE model was trained with unipolar EGMs to acquire encoded features, which were then input into a classifier model. The classifier was combined with atrial positions using one-hot encodings as the ground truth. The optimal architecture was selected through a grid search involving different layer numbers, sizes, and fine-tuning. For the encoding part, we assessed the negative evidence lower bound (ELBO) and Pearson’s correlation. Regarding the classifier, we evaluated accuracy, extended accuracy (indicating accuracy in predicting the region or an adjacent one), and the area under the curve (AUC). Results The best-performing autoencoder architecture presented a negative ELBO of -0.087 and a Pearson’s correlation of 0.971; and the classifier obtained an accuracy of 38.1%, an extended accuracy of 75.2%, and an AUC of 0.814. Conclusion We introduced an alternative method for localizing intracardiac catheters within the atrial chambers based on deep-learning techniques. In contrast to traditional hardware technologies, our proposed method eliminates the need for external magnetic or impedance reference patches. This approach is not limited to AF and can be extended to other supra-ventricular procedures. The results of our proposed method are promising, suggesting potential advancements in alternative systems for locating intracardiac catheters to complement existing classical hardware methods in the future.Variational autoencoder architecture

Atrial functional mitral regurgitation as a marker of atrial remodeling and ablation outcomes in atrial fibrillation patients

Abstract Background Atrial fibrillation (AF) triggers a cascade of atrial remodeling processes, significantly impacting atrial function and the efficacy of ablation therapies. This remodeling fosters the development of atrial cardiomyopathy and atrial dilation, which is linked to the emergence of mitral regurgitation, paving the way for the concept of atrial functional mitral regurgitation (aFMR). Our study delves into the intricate relationship between aFMR and the electrical architecture of the atrium, specifically focusing on left atrial bipolar voltage and the prevalence and extent of low-voltage areas (LVAs) in AF patients. By exploring these associations, this research aims to deepen our understanding of the interplay between the atrial substrate alterations and the development of aFMR. Methods A total of 282 patients were enrolled, who had presented for a redo PVI procedure after experiencing AF recurrence following a previous PVI. All patients received echocardiography prior to the electrophysiological procedure. All procedures were performed using 3D mapping and radiofrequency ablation. Reconnected pulmonary veins were detected in all patients and were re-isolated. The voltage of the electroanatomical points was documented on each of the atrial walls. LVAs were calculated in selected HD maps. Patients were followed-up for one year after the blanking period. Results Our cohort comprised 282 patients, predominantly male (69.4%), with a mean age of 64 years. 56% of the patients presented with persistent AF. LA area was larger in patients with aFMR ≥ 1+ as compared to aFMR < 1+ (17.0 [14.6-19.7] vs 20.6 [16.6-24.7] cm2, p<0.001). We observed significant differences in left atrial voltage and LVA extent between patients with varying degrees of aFMR (Table 1). Upon further investigation Patients with aFMR = 1+ showed significantly lower atrial voltage compared with aFMR < 1+ yet no significant increase in LVAs area. Patients with aFMR = 2 exhibited lower average voltage amplitudes in all atrial regions and larger LVA in the posterior wall, atrial roof, and septum compared to their aFMR < 1+ counterparts. Notably, the recurrence of AF was significantly higher in the AFMR ≥ 1+ (59% vs 46% p=0.027) group within one year of follow-up. aFMR was associated with AF recurrence even after adjusting for sex, age and AF types (HR:1.517, 95% CI: 1.057-2.184, p=0.025). Conclusion The presence of aFMR in AF patients may serve as a marker of progressive atrial remodeling and the onset of left atrial cardiomyopathy, characterized by reduced atrial voltage and increased LVAs. Additionally, aFMR is linked to the outcomes of PVI, suggesting that aFMR should be considered in the decision-making process for AF therapy. Further research is needed to explore the potential reversibility of these changes.Left atrial voltage and low voltage area

Diagnostic accuracy of smartwatches for automated atrial fibrillation detection over time: insights from the basel wearable study

Abstract Background The first smart-watch (SW) able to record a single lead ECG (SL-ECG) with automated atrial fibrillation (AF) detection algorithm was introduced 2018. Multiple other manufacturers followed. While manufacturers claim to continuously improve their devices’ algorithm, little is known about the impact on diagnostic accuracy on AF detection over time in a real-world cohort of patients. Purpose To assess if the diagnostic accuracy of algorithm-based AF detection of 5 smart devices has improved over time. Methods In this prospective study, consecutive patients undergoing electrophysiological procedures in a tertiary referral center were included between April 2021 to May 2023. Each participant received a 12-lead ECG and 5 SL-ECGs with different smart devices (AliveCor KardiaMobile, Apple Watch 6, Fitbit Sense, Samsung Galaxy Watch 3 and Withings ScanWatch). All SW were continuously updated for newest software or firmware as recommend by the manufacturers. The SW rhythm classification was compared to manual cardiologist-based interpretation of SL-ECGs. The change in number of inconclusive SL-ECGs by manufacturer’s algorithm were investigated over time via Cochran-Armitage test for trend and illustrated over time via logistic regression. Results 247 participants were included (30% female, mean age 66.3 [IQR: 57-74] years) resulting in a total of 1’235 SL-ECGs. Among these, 202 SL-ECGs (16%) were labeled as inconclusive by at least one smart-device. Inconclusive rates for individual SW ranged from 15% to 19%. When comparing the first and last quintile of patients in the study period, the inconclusive rates for the KardiaMobile were 14% vs. 6%, for the Apple Watch 14% vs. 6%, for the Fitbit Sense 20% vs. 14%, for the Samsung Galaxy 18% vs. 10% and for the Withings ScanWatch 22% vs. 14%, respectively. When assessed continuously over time, we observed a trend towards fewer inconclusive tracings, without reaching statistical significance (Figure 1). Conclusion Over 26 months, inconclusive tracings of 5 SW didn’t significantly decrease despite frequent software updates in a real-world patient cohort. Larger, long-term cohorts are needed to assess if automated AF detection has significantly improved over time.Figure 1

Digital health in the electrophysiological lab: Initial experience, safety and feasibility using remote support for arrhythmia ablation-Results of REMOTE-VA study

Abstract Background In most electrophysiology (EP) labs, electroanatomical mapping (EAM) systems are operated on site by qualified staff or field technical engineers (FTE). Due to lack of skilled personnel, the FTE usually must travel between different hospitals and procedures must be planned in advance. Ablation of ventricular arrhythmias (VA) represents the most complex procedure in the field. The use of remote support (RS) to guide complex EP procedures has the potential to increase flexibility, reduce travel times and maximise healthcare resources. Purpose To evaluate the safety and feasibility of RS as compared to on-site support guided catheter ablation procedures for VA. Methods All patients undergoing ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation using remote support were included. The electronical system of the hospital was searched for 30 days postprocedural emergency department (ED) visits, unplanned ambulatory presentations, and readmissions. RS guided three-dimensional (3D) mapping was achieved by connecting the EAM software with an integrated audio-visual solution for remote support. Internet connection-based headphones and high-resolution cameras ensured the communication between the operator and the FTE, who worked exclusively from home office. The control group consisted of an equal number of patients matched for the type of procedure and undergoing on-site guided procedures. All ablations were performed using high density 3D mapping, as per institutional standard. Results Between October 2022 and October 2023, a total of 25 patients underwent VT (32%) or PVC ablation in our centre using RS and were compared to 25 patients undergoing the same procedures under on-site guidance. In the RS group one patient underwent epicardial VT ablation and another one bipolar ablation for VT Storm. The demographic data were similar between the groups. The median procedure time was 120 (93, 143) minutes in the RS group and 112 (95, 138) minutes in the control group (p=0.95), while the fluoroscopy time was 11.4 (7.0, 14.0) and 7.26 (5.0, 10.9) minutes respectively (p=0.08). The procedural success was achieved in 96% procedures in the RS group and in 100% in the control group. No technical issues or changes to on-site support were reported. One minor intraprocedural complication was noted among the control patients, while 24% of the patients in each group developed minor complications until discharge. Two patients in the RS group and one in the control group had ED visits, while only one patient in the control group had an unplanned ambulatory presentation. One unplanned readmission was reported in the control group (Table 1). Conclusions Even in the most complex procedures including epicardial ablation, the use of RS was feasible and safe in this single centre study. This approach has the potential to increase the feasibility in case of emergency procedures, reduce travel times, and maximise healthcare resources.

Delineation of intracavitary electrograms for the automatic quantification of decrement-evoked potentials in the coronary sinus with deep-learning techniques

Cardiac arrhythmias cause depolarization waves to conduct unevenly on the myocardial surface, potentially delaying local components with respect to a previous beat when stimulated at faster frequencies. Despite the diagnostic value of localizing the distinct local electrocardiogram (EGM) components for identifying regions with decrement-evoked potentials (DEEPs), current software solutions do not perform automatic signal quantification. Electrophysiologists must manually measure distances on the EGM signals to assess the existence of DEEPs during pacing or extra-stimuli protocols. In this work, we present a deep learning (DL)-based algorithm to identify decrement in atrial components (measured in the coronary sinus) with respect to their ventricular counterparts from EGM signals, for disambiguating between accessory pathways (APs) and atrioventricular re-entrant tachycardias (AVRTs). Several U-Net and W-Net neural networks with different configurations were trained on a private dataset of signals from the coronary sinus (312 EGM recordings from 77 patients who underwent AP or AVRT ablation). A second, separate dataset was annotated for clinical validation, with clinical labels associated to EGM fragments in which decremental conduction was elucidated. To alleviate data scarcity, a synthetic data augmentation method was developed for generating EGM recordings. Moreover, two novel loss functions were developed to minimize false negatives and delineation errors. Finally, the addition of self-attention mechanisms and their effect on model performance was explored. The best performing model was a W-Net model with 6 levels, optimized solely with the Dice loss. The model obtained precisions of 91.28%, 77.78% and of 100.0%, and recalls of 94.86%, 95.25% and 100.0% for localizing local field, far field activations, and extra-stimuli, respectively. The clinical validation model demonstrated good overall agreement with respect to the evaluation of decremental properties. When compared to the criteria of electrophysiologists, the automatic exclusion step reached a sensitivity of 87.06% and a specificity of 97.03%. Out of the non-excluded signals, a sensitivity of 96.77% and a specificity of 95.24% was obtained for classifying them into decremental and non-decremental potentials. Current results show great promise while being, to the best of our knowledge, the first tool in the literature allowing the delineation of all local components present in an EGM recording. This is of capital importance at advancing processing for cardiac electrophysiological procedures and reducing intervention times, as many diagnosis procedures are performed by comparing segments or late potentials in subsequent cardiac cycles.

Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology.

Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.

OR12-2 | In-Practice Measurement of Radiation Exposure and Protection for (assumed) Pregnant Cardiologists Performing Cardiac Catheterization and Electrophysiology Procedures

OR12-2 | In-Practice Measurement of Radiation Exposure and Protection for (assumed) Pregnant Cardiologists Performing Cardiac Catheterization and Electrophysiology Procedures

The OEIS National Registry: Rationale, Context, and Current Status

Office based interventional procedures continue to increase in number and scope. An overview of the Outpatient Endovascular and Interventional Society (OEIS) National Registry (OEISNR) is described in this article. Currently there is one production module enrolling peripheral artery interventional procedures, and a new cardiac module encompassing both diagnostic catheterization/percutaneous coronary interventions and electrophysiology procedures is undergoing beta testing. A new embolization module with uterine fibroid embolization (UFE) as the initial modality is nearly initial development completion and expected to enter beta in 2024. The OEISNR has over 338 participating physicians and has enrolled over 42,000 cases since inception in 2017 with an extremely high rate of technical success (97%) and very low complication rates (2.15% overall, 1.65% minor complications, 0.53% major complications). More detailed data breakdowns including patient demographics and comorbidities, indications, lesion characteristics, treatment modalities and device utilization, complication details, and data integrity data are contained in this report. Sample analytics, sample dashboards, and structural details are illustrated and included.

Using AI to identify left ventricular ejection fraction from the ECG: The SOLOMAX (SOciaL NetwOrk of MedicAl Experiences) project

Aim: The interest in machine learning-based algorithms in the cardiovascular field is rapidly growing, especially for diagnostic and prognostic purposes. Recent evidence has demonstrated that certain electrocardiographic (ECG) parameters are predominantly associated with systolic function, estimated as left ventricular ejection fraction (LVEF) by echocardiography, albeit with still relatively low accuracy. Consequently, this study aims to develop an AI-based model capable of predicting LVEF from ECG data in an Italian population. Methods: Within the SOLOMAX project, we collected paired ECG-Echocardiography exams from 105 patients (64.82±16.02y;62.86%male). Precisely, we excluded patients with atrial fibrillation at the time of the ECG, PMK or electrostimulated rhythm, valve prostheses, previous cardiac surgery, O2 therapy or COPD, previous ablation or invasive electrophysiology procedures, currently hospitalized for Takotsubo or ACS, heart failure exacerbation, inotropic therapy, ACS over the last 3 months. We recorded anthropometric, clinical, biochemical, ECG, and Echocardiography parameters. The collected data was studied using AI-based techniques to create a new model to predict LVEF from ECG. Using an approach based on evolutionary algorithms, genetic programming was used. This approach solves a symbolic regression problem through genetic algorithms and provides a mathematical model of the relationship between ECG parameters and LVEF. The formula obtained was then used to build a simple explainable classifier, which provides a global interpretation of the link between ECG parameters and LVEF. Results: The performance of the proposed approach and the reliability of the results were assessed using the k-fold cross-validation method and by estimating standard metrics derived from the confusion matrix associated with a binary classifier, that is, accuracy, sensitivity, specificity, precision, and F-Measure. The proposed approach consistently demonstrated its ability to distinguish patients with preserved LVEF from those with reduced LVEF. Each metric averaged across all experiments scored approximately 95%. Furthermore, in the expression generated by the AI model, the axes of the P, QRS, and T waves play a prominent role, as they are likely to provide a better interpretation of the three-dimensional cardiac geometry and, consequently, cardiac function. Conclusions: AI applied to ECG data can be used to create cost-effective diagnostic and predictive tools for assessing LVEF. Indeed, the obtained formula highlights the relationship between ECG parameters and LVEF, as well as its complexity, which can aid in detecting heart diseases.

Transesophageal Echocardiography Improves Precision in Transseptal Puncture Compared to Fluoroscopy in Left Atrial Electrophysiological Procedures.

Background: Complex arrhythmias often arise from the left side of the heart, necessitating established electrophysiological (EP) procedures like 3D-mapping-assisted radiofrequency (RF) ablations or pulmonary vein isolation (PVI). These procedures typically require transseptal access, emphasizing the critical role of achieving an optimal catheter position through a precise transseptal puncture (TSP). Commonly employed imaging methods for TSP guidance include fluoroscopy and interventional echocardiography. Despite their routine use, there is limited evidence on which imaging modality offers superior catheter positioning for EP procedures, and safety concerns regarding transseptal punctures with imaging remain underexplored. This study aims to systematically evaluate the feasibility, safety, and accuracy of echo-guided TSP compared to fluoroscopy-guided TSP. Methods: In this prospective study, 150 consecutive patients undergoing left atrial EP procedures were enrolled between October 2023 and February 2024 at the Ulm University Heart Center. Following optimal fluoroscopy-guided transseptal needle positioning at the interatrial septum, the catheter placement was further verified using transesophageal echocardiography (TEE). Adjustments were made in cases of suboptimal needle positioning observed in TEE. The fluoroscopically achieved septal positions were categorized based on TEE images as optimal, suboptimal, poor, or dangerous. Results: Among the 150 patients included (58.0% male), fluoroscopy achieved optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0%, respectively. After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, respectively. No instances of poor or dangerous transseptal needle positions were observed under TEE guidance. Conclusions: TEE-guided TSP emerges as a feasible, more accurate, and safer imaging method for transseptal punctures in EP procedures.

A real-time signal processing software package for the electrophysiology laboratory.

Real-time signal processing has to date been difficult to implement in the clinical electrophysiology laboratory. To date, no open access software solutions are available in electrophysiology (EP) laboratories to facilitate real-time intraprocedural signal analysis. We aimed to develop an open access, scalable Python plug-in to allow real-time signal processing during human EP procedures. A Python-based plug in for the widely available EnsiteX mapping system was developed. This plug-in utilized the LiveSync feature of the system to allow real-time signal analysis. An open access library was developed to allow end-users to implement real-time signal analysis using this platform, implemented in the Python programming language https://github.com/anand9176/WaveWatch5000Public. We have developed and demonstrated the feasibility of a readily scalable and open-access Python-based plug in to an electroanatomic mapping system (EnSiteX) to allow real-time processing and display of electrogram (EGM) based information for the procedural electrophysiologist to view intraprocedurally in the electrophysiology laboratory. The availability, to the clinician, of traditional and novel EGM-based metrics at the time of intervention, such as atrial fibrillation ablation, allows for key mechanistic insights into critical unresolved questions regarding arrhythmia mechanism.

Trends in safety of catheter-based electrophysiology procedures in the last 2 decades: A meta-analysis.

Rapid technologic development and expansion of procedural expertise have led to widespread proliferation of catheter-based electrophysiology procedures. It is unclear whether these advances come at cost to patient safety. This meta-analysis aimed to assess complication rates after modern electrophysiology procedures during the lifetime of the procedures. A comprehensive search was performed to identify relevant data published before May 30, 2023. Studies were included if they met the following inclusion criteria: prospective trials or registries, including comprehensive complications data; and patients undergoing atrial fibrillation ablation, ventricular tachyarrhythmia ablation, leadless cardiac pacemaker implantation, and percutaneous left atrial appendage occlusion. Pooled incidences of procedure-related complications were individually assessed by random effects models to account for heterogeneity. Temporal trends in complications were investigated by clustering trials by publication year (2000-2018 vs 2019-2023). A total of 174 studies (43,914 patients) met criteria for analysis: 126 studies of atrial fibrillation ablation (n = 24,057), 25 studies of ventricular tachyarrhythmia ablation (n = 1781), 21 studies of leadless cardiac pacemaker (n = 8896), and 18 studies of left atrial appendage occlusion (n = 9180). The pooled incidences of serious procedure-related complications (3.49% [2000-2018] vs 3.05% [2019-2023]; P < .001), procedure-related stroke (0.46% vs 0.28%; P = .002), pericardial effusion requiring intervention (1.02% vs 0.83%; P = .037), and procedure-related death (0.15% vs 0.06%; P = .003) significantly decreased over time. However, there was no significant difference in the incidence of vascular complications over time (1.86% vs 1.88%; P = .888). Despite an increase in cardiac electrophysiology procedures, procedural safety has improved over time.

Prominent crista terminalis mimicking a right atrial mass: a systematic literature review and meta-analysis.

The crista terminalis is an anatomical structure localized on the posterolateral wall of the right atrium (RA). We performed a systematic review of the literature and meta-analysis concerning cases of unusual prominent crista terminalis mimicking RA mass. Moreover, we described the differential diagnosis of cardiac masses with the use of echocardiography, computed tomography, and cardiac magnetic resonance (CMR). We also emphasize the potential importance of this structure in electrophysiological procedures, including its role in exaggerated arrhythmias. Prominent crista terminalis may be a potential obstacle during invasive cardiac procedures or catheter ablation target. In analyzed cases, the crista terminalis was often erroneously interpreted as pathologic and at first confused with a thrombus or tumor during transthoracic echocardiography examination. The correct final diagnoses were mostly made with used transesophageal echocardiography or CMR. The most important imaging findings suggestive of prominent crista terminalis rather than tumor were a similar echogenicity/intensity with adjacent myocardium, the location on posterolateral wall of the RA, the phasic change in size, and no enhancement after contrast injection. We describe up to date and detailed imaging features for the differential diagnostics of selected intracardiac masses using various imaging techniques, including multimodality cardiac imaging. Familiarity with the anatomy and the imaging findings of the prominent crista terminalis will reduce misdiagnosis and avoid additional tests and unwarranted clinical interventions, while in patients considered for invasive cardiac procedures it might increase their efficacy and safety.

Evidence-based guideline for anticoagulant management of Electrophysiology procedures

Evidence-based guideline for anticoagulant management of Electrophysiology procedures

X-ray Doses in Relation to Body Mass, Indication, and Substrate During Pediatric Electrophysiological Procedures on the Heart.

The main goal of this study is to determine typical values of dose area product (DAP) and difference in the effective dose (ED) for pediatric electrophysiological procedures on the heart in relation to patient body mass. This paper also shows DAP and ED in relation to the indication, the arrhythmia substrate determined during the procedure, and in relation to the reason for using radiation. Organ doses are described as well. The subjects were children who have had an electrophysiological study done with a 3D mapping system and X-rays in two healthcare institutions. Children with congenital heart defects were excluded. There were 347 children included. Significant difference was noted between mass groups, while heavier children had higher values of DAP and ED. Median DAP in different mass groups was between 4.00 (IQR 1.00-14.00) to 26.33 (IQR 8.77-140.84) cGycm2. ED median was between 23.18 (IQR 5.21-67.70) to 60.96 (IQR 20.64-394.04) µSv. The highest DAP and ED in relation to indication were noted for premature ventricular contractions and ventricular tachycardia-27.65 (IQR 12.91-75.0) cGycm2 and 100.73 (IQR 53.31-258.10) µSv, respectively. In arrhythmia substrate groups, results were similar, and the highest doses were in ventricular substrates with DAP 29.62 (IQR 13.81-76.0) cGycm2 and ED 103.15 (IQR 60.78-266.99) µSv. Pediatric electrophysiology can be done with very low doses of X-rays when using 3D mapping systems compared to X-rays-based electrophysiology, or when compared to pediatric interventional cardiology or adult electrophysiology.

Liberating Electrophysiology Preprocedure NPO Status

BackgroundFasting at midnight is standard practice for patients undergoing inpatient electrophysiological (EP) procedures, creating discomfort and dissatisfaction. MethodsThis single-center, cross-sectional observational study utilized a standard-of-care (SOC) group who remained nil per os at midnight and an evidence-based (EB) group who received clear liquids up to 2 hours before their procedure. Each participant completed a Likert scale survey assessing fasting satisfaction and a retrospective chart review was completed to assess adverse outcomes. ResultsSubjects’ hunger in the SOC group (M = 4.067) differed significantly from the EB group (M = 3.167), U = 254.5, z = 2.883, p = .004, r = 0.372. Subjects' thirst in the SOC group (M = 4.367) differed significantly from the EB group (M = 3.1), U = 186, z = 3.896, p = <.001, r = 0.503. Hypoglycemia in the SOC group was statistically significant from the EB group. ConclusionAllowing clear liquids 2 hours before EP procedures reduced patient thirst and hunger without adverse outcomes.