Left Atrial Arrhythmias Research Articles

Left Atrial Low-Voltage Extent Predicts the Recurrence of Supraventricular Arrhythmias.

The incidence of left atrial (LA) supraventricular arrhythmias is increasing. Even after LA ablation, recurrence of these tachycardias is common. MRI studies show that LA cardiomyopathy is a significant risk factor for recurrence and correlates with low voltage areas detected via 3D electroanatomic mapping (EAM). There are limited data on the impact of low voltage extent detected by EAM on recurrence-free survival. Voltage thresholds defining low voltage vary across different studies. This study aims to investigate the impact of the extent of low voltage areas in the LA on recurrence-free survival and to assess whether defining low voltage areas using thresholds of 0.5, 0.4, or 0.3 mV offers better predictive performance. Patients with atrial arrhythmia who underwent LA EAM at Ulm University Heart Center between September 2018 and September 2022 were included from the ATRIUM registry. ROC analysis determined the voltage threshold for predicting recurrence-free survival. Kaplan-Meier and logistic regression models adjusted for patient variables were used to analyze recurrence-free survival. Of 1089 screened patients, 108 met the inclusion criteria. ROC analysis indicated that a 0.4 mV threshold for low voltage provided the best predictive performance. Logistic regression showed a 1.039-fold increase in recurrence risk per percent increase in LA low voltage area (odds ratio = 1.039, 95% CI 1.014-1.064). Low voltage extent in EAM correlates with 1-year recurrence rate after ablation of left atrial supraventricular arrhythmias. The threshold of 0.4 mV is the most suitable for predicting recurrences of those examined.

Combined left atrial appendage occlusion and catheter ablation procedure for left atrial arrhythmias: A real-world, propensity-matched analysis.

Real-world studies comparing safety and efficacy of combined percutaneous left atrial appendage occlusion (LAAO) and catheter ablation (CA) to LAAO alone are limited. Patients from a large US hospital system undergoing combined LAAO and left-atrial CA from 8/2020 to 2/2024 were retrospectively analyzed and compared to a control group undergoing LAAO alone. Controls were identified using a 1:2 propensity score match based on LAAO device type (Watchman FLX vs. Amulet), CHA2D2-VASc and Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio [INR], Elderly, Drugs/alcohol (HAS-BLED) scores and compared for safety, sealing performance and clinical outcomes at 6 months. Patients were younger in the combined (n = 72) than in the control group (n = 144, 70.2 ± 7.3 vs. 76.7 ± 6.9 years, p < 0.001) but otherwise comparable with a mean CHA2D2-VASc score of 4.2 ± 1.1 and 4.4 ± 1.2 (p = 0.26) and HAS-BLED score of 2.2 ± 0.8 and 2.3 ± 0.7 (p = 0.34). Successful LAAO implantation rates were the same (95.8% vs. 95.8%, p = 0.99) with longer procedure times seen in the combined group (156.5 ± 53 vs. 56 ± 26 min, p < 0.001). Both major (1.4% vs. 2.1%, p = 0.72) and minor (27.8% vs. 19.4%, p = 0.17) in-hospital complications were similar between the combined and control group, respectively. At 45 days, presence of peri-device leak (18.3% vs. 30.4%, p = 0.07) and device related thrombosis (4.5% vs. 4.5%, p = 0.96) on transesophageal echocardiogram did not differ. Finally, all-cause mortality (0% vs. 1.4%, p = 0.99), thromboembolic (0% vs. 0%, p = 0.99) and bleeding (6.1% vs. 4.4%, p = 0.73) events during follow-up were comparable. This large, real-world analysis indicates comparable safety and efficiency of combined LAAO and CA when compared with LAAO alone.

Simulating left atrial arrhythmias with an interactive N-body model

BackgroundHeart disease and strokes are leading global killers. While atrial arrhythmias are not deadly by themselves, they can disrupt blood flow in the heart, causing blood clots. These clots can travel to the brain, causing strokes, or to the coronary arteries, causing heart attacks. Additionally, prolonged periods of elevated heart rates can lead to structural and functional changes in the heart, ultimately leading to heart failure if untreated. The left atrium, with its more complex topology, is the primary site for complex arrhythmias. Much remains unknown about the causes of these arrhythmias, and computer modeling is employed to study them. MethodsWe use N-body modeling techniques and parallel computing to build an interactive model of the left atrium. Through user input, individual muscle attributes can be adjusted, and ectopic events can be placed to induce arrhythmias in the model. Users can test ablation scenarios to determine the most effective way to eliminate these arrhythmias. ResultsWe set up muscle conditions that either spontaneously generate common arrhythmias or, with a properly timed and located ectopic event, induce an arrhythmia. These arrhythmias were successfully eliminated with simulated ablation. ConclusionsWe believe the model could be useful to doctors, researchers, and medical students studying left atrial arrhythmias.

Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter.

Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

The impact of ultrasound-guided vascular access for catheter ablation of left atrial arrhythmias in a high-volume centre.

Vascular complications are a common occurrence during atrial fibrillation ablation. Observational studies indicate that the utilization of ultrasound (US)-guided puncture may decrease the incidence of vascular complications; however, its routine use is not established in many centres. Patients undergoing catheter ablation for atrial fibrillation were included sequentially. All patients receiving US-guided punctures were prospectively enrolled (US group), while patients who underwent the procedure with standard puncture technique served as control group (No-US group). Periprocedural vascular complications requiring intervention within 30days of the procedure were defined as the primary endpoint. A total of 599 patients (average age: 69 ± 11years, 62.9% male) were analysed. The incidence of vascular complications was lower with the US-guided puncture than with the anatomic landmark-guided puncture (14/299 [4.7%] vs. 27/300 [9%], p = 0.036). The US-guided vascular access significantly reduced the rate of false aneurysms (3/299 [1%] vs. 12/300 [4%], p = 0.019). In addition, the occurrence of arteriovenous fistula (2/299 [0.7%] vs. 4/300 [1.3%], p = 0.686) and haematoma requiring treatment (9/299 [3%] vs. 11/300 [3.7%], p = 0.655) were also lower in the US group. US-guided puncture did not prolong the procedure time (mean procedure time: 57.48 ± 24.47min vs. 56.09 ± 23.36min, p = 0.478). Multivariate regression analysis identified female gender (OR 2.079, CI 95% 1.096-3.945, p = 0.025) and conventional vascular access (OR 2.079, CI 95% 1.025-3.908, p = 0.042) as predictors of vascular complications. The implementation of US-guided vascular access for left atrial catheter ablation resulted in a significant decrease of the overall vascular complication rate.

Renal function and periprocedural complications in patients undergoing left atrial catheter ablation: A comparison between uninterrupted direct oral anticoagulants and phenprocoumon administration.

Data regarding uninterrupted oral anticoagulation in patients with chronic kidney disease (CKD) during catheter ablation for left atrial arrhythmias is limited. This study aimed to evaluate the safety and efficacy of periprocedural uninterrupted direct oral anticoagulants (DOAC) compared with uninterrupted phenprocoumon in patients with CKD undergoing left atrial catheter ablation. We conducted a retrospective single-center study of patients who underwent left atrial catheter ablation between 2016 and 2019 with underlying chronic kidney disease (glomerular filtration rate (GFR) between 15 and 45ml/min). The primary objective of this study was to investigate whether direct oral anticoagulant (DOAC) therapy or warfarin presents a superior safety profile in patients with chronic kidney disease (CKD) undergoing left atrial catheter ablation. We compared periprocedural complications (arteriovenous fistula, aneurysm, significant hematoma (> 5cm)) and/or bleeding (drop in hemoglobin of >2g/dl, pericardial effusion, retroperitoneal bleeding, other bleeding, stroke) between patients receiving either uninterrupted DOAC or warfarin therapy. Secondary analysis included patient baseline characteristics as well as procedural data. A total of 188 patients (female n = 108 (57%), mean age 75.3 ± 8.1years, mean GFR 36.8 ± 6ml/min) were included in this study. Underlying arrhythmias were atrial fibrillation (n = 104, 55.3%) and atypical atrial flutter (n = 84, 44.7%). Of these, n = 132 patients (70%) were under a DOAC medication, and n = 56 (30%) were under phenprocoumon. Major groin complications including pseudoaneurysm and/or AV fistula occurred in 8.9% of patients in the phenprocoumon group vs. 11.3% of patients in the DOAC group, which was not statistically significant (p = 0.62). Incidence of cardiac tamponade (2.3% vs. 0%; p = 0.55) and stroke (0% vs. 0%) were low in both DOAC and phenprocoumon groups with similar post-procedural drops in hemoglobin levels (1.1±1g/dl vs 1.1±0.9g/dl; p= 0.71). The type of anticoagulation had no significant influence on bleeding or thromboembolic events as well as groin complications in this retrospective study. Despite observing an increased rate of groin complications, the uninterrupted use of DOAC or phenprocoumon during left atrial catheter ablation in patients with CKD appears to be feasible and effective.

Corin and Left Atrial Cardiomyopathy, Hypertension, Arrhythmia, and Fibrosis

SummaryTwo siblings presented with cardiomyopathy, hypertension, arrhythmia, and fibrosis of the left atrium. Each had a homozygous null variant in CORIN, the gene encoding atrial natriuretic peptide (ANP)–converting enzyme. A plasma sample obtained from one of the siblings had no detectable levels of corin or N-terminal pro-ANP but had elevated levels of B-type natriuretic peptide (BNP) and one of the two protein markers of fibrosis that we tested. These and other findings support the hypothesis that BNP cannot fully compensate for a lack of activation of the ANP pathway and that corin is critical to normal ANP activity, left atrial function, and cardiovascular homeostasis.

Effect of body mass index (BMI) on electrocardiographic P-wave dispersion among healthy adults

Background: According to the results of an electrocardiogram (ECG), a higher body mass index (BMI) indicates body fat and is linked toa higher risk of cardiovascular illnesses. A noninvasive ECG signal called P-wave dispersion (Pd) can predict the likelihood of an atrialarrhythmia and reflects atrial remodeling. Pd is calculated by computing the difference between the maximum and minimum P-wavelengths captured from the 12 ECG lead recordings. To assess the early-stage risk of acquiring cardiovascular illnesses, we investigatedthe effect of BMI on P-wave dispersion in healthy, overweight, and obese adults. Materials and Methods: Depending on their body massindex (BMI), we divided 200 participants into three groups (normal weight, overweight, and obese) during a comparative cross-sectionalstudy. We measured 12-lead surface ECG and P-wave dispersion in study participants. Results: Mean P-wave lengths were 33.23(±6.08), 33.15(± 5.16), and 46.15 (± 5.37), respectively, for people who were normal weight, overweight, and obese. Between the normalweightand obese groups and the overweight and obese groups, there was a statistically significant difference (p &lt; 0.001), according toTukey’s post-hoc analysis. However, the normal-weight and overweight groups showed no statistically significant difference (P = 0.997).Pearson’s correlation analysis shows that P-wave dispersion and BMI showed a significant positive connection (r = 0.632). Conclusion:A higher BMI is linked to a longer P-wave duration and dispersion, even in healthy adults. The likelihood of left atrial hypertrophy andatrial arrhythmia increases with a prolonged P-wave duration. This study emphasizes the importance of raising awareness about theneed to adopt healthy lifestyles to avoid the harmful effects of obesity on the heart

Fenestration: Integrating Wings Into the Atrial Septal Occluder for Navigating a Challenging Terrain.

Background Atrial septal defect (ASD) closure with significant left-to-right shunt and concurrent comorbidities poses challenges for intervention. A fenestrated atrial septal defect (FASD) device is a viable option for patients who cannot undergo complete occlusion due to hemodynamic and medical reasons. This study explores the use of FASD occluders in patients with secundum ASD and associated comorbidities where complete occlusion is difficult. Methodology This retrospective study collected the details of patients recommended for FASD closure diagnosed with significant secundum ASD and who had additional comorbidities between July 2015 and July 2023 in a tertiary cardiac center in eastern India. Among this cohort, patients who underwent FASD device placement were subjected to a comprehensive analysis. Results In total, 16 patients diagnosed with secundum ASD, characterized by significant left-to-right shunt and concurrent comorbidities, were considered for FASD closure during the study period. Ultimately, 13 patients (first group) underwent fenestrated atrial septal occluder implantation. The average age was 45.07 years, with the majority being females (n = 9). Comorbidities among this cohort included substantial left ventricular diastolic dysfunction (n = 7), left ventricular diastolic dysfunction coupled with moderate pulmonary hypertension (n = 1), severe pulmonary hypertension (n = 1), severe pulmonary valvular stenosis with right ventricular diastolic dysfunction (n = 2), and systemic lupus erythematosus (SLE) (n = 2). From this cohort, three patients did not undergo the intervention. The second group consisted of an elderly patient with severe left ventricular diastolic dysfunction, a young adult with a history of left atrial arrhythmia, and achild with Duchenne muscular dystrophy (DMD). The average ASD size among patients who underwent the intervention was 26.38 mm, with a thick-to-thick dimension measuring 31.15 mm. The procedure was successful in all 13 patients, with the most frequently used device being a 34 mm occluder (range = 28-40 mm). All devices, excluding the initial one, were custom-made atrial septal occluders (Lifetech Scientific). Among the patients, 12 exhibited left-to-right fenestration flow, while one patient experienced fenestration constriction, likely due to occluder overcrowding. The first patient hada handmade 5 mm fenestration in a 40 mm Amplatzer septal occluder, which got closed off at the one-year follow-up. The procedure was well-tolerated hemodynamically in all patients, with no major complications during the peri-procedural period. Short-term follow-up indicated favorable patient progress. Conclusions FASD closure emerges as a pivotal alternative for intricate scenarios involving secundum ASD coupled with concurrent comorbidities, offeringindividualized tailored solutions. Alongside the conventional associated comorbidities, such as left ventricular diastolic dysfunction and pulmonary hypertension, FASD devices hold the potential to extend their benefits to patients grappling with other complexities, including severe pulmonary valvular stenosis, SLE, predisposition to left atrial arrhythmia, and conditions like DMD. Ensuring meticulous evaluation of patient suitability and providing ongoing vigilant care becomes paramount for achieving optimal outcomes. The validation of these findings and the broadening of the comprehension of this approach necessitate further comprehensive investigations.

Comparing Inducibility of Re-Entrant Arrhythmia in Patient-Specific Computational Models to Clinical Atrial Fibrillation Phenotypes

BackgroundComputational models of fibrosis-mediated, re-entrant left atrial (LA) arrhythmia can identify possible substrate for persistent atrial fibrillation (AF) ablation. Contemporary models use a 1-size-fits-all approach to represent electrophysiological properties, limiting agreement between simulations and patient outcomes. ObjectivesThe goal of this study was to test the hypothesis that conduction velocity (ϴ) modulation in persistent AF models can improve simulation agreement with clinical arrhythmias. MethodsPatients with persistent AF (n = 37) underwent ablation and were followed up for ≥2 years to determine post-ablation outcomes: AF, atrial flutter (AFL), or no recurrence. Patient-specific LA models (n = 74) were constructed using pre-ablation and ≥90 days’ post-ablation magnetic resonance imaging data. Simulated pacing gauged in silico arrhythmia inducibility due to AF-like rotors or AFL-like macro re-entrant tachycardias. A physiologically plausible range of ϴ values (±10 or 20% vs. baseline) was tested, and model/clinical agreement was assessed. ResultsFifteen (41%) patients had a recurrence with AF and 6 (16%) with AFL. Arrhythmia was induced in 1,078 of 5,550 simulations. Using baseline ϴ, model/clinical agreement was 46% (34 of 74 models), improving to 65% (48 of 74) when any possible ϴ value was used (McNemar’s test, P = 0.014). ϴ modulation improved model/clinical agreement in both pre-ablation and post-ablation models. Pre-ablation model/clinical agreement was significantly greater for patients with extensive LA fibrosis (>17.2%) and an elevated body mass index (>32.0 kg/m2). ConclusionsSimulations in persistent AF models show a 41% relative improvement in model/clinical agreement when ϴ is modulated. Patient-specific calibration of ϴ values could improve model/clinical agreement and model usefulness, especially in patients with higher body mass index or LA fibrosis burden. This could ultimately facilitate better personalized modeling, with immediate clinical implications.

Implementation and first outcomes of a novel standard operating procedure for preprocedural transoesophageal echocardiography screening in course of atrial arrhythmia ablation.

Preprocedural transoesophageal echocardiography (TEE) screening for left atrial (LA) thrombi is the standard of care in many centres performing atrial fibrillation (AF) ablation. However, TEE imposes procedural risks for patients and is often challenging to implement in daily practice, besides causing patient discomfort. At our centre, a novel standard operating procedure (SOP) was implemented, aiming to identify patients that can be exempt from TEE screening. We aimed to assess whether this screening approach may reduce preprocedural TEEs without imposing patients of higher risks for cerebrovascular events (CVEs). Data of 1874 consecutive patients treated by catheter ablation of LA arrhythmias between 2018 and 2022 were retrospectively analysed. A cohort of 937 patients, where decision to perform TEE screening was based on a new SOP (considering rhythm at admission, CHA2DS2-VASc score, and sufficient anticoagulation), was compared to a matched cohort receiving TEE before every procedure. Number of performed TEEs and incidences of CVEs were compared. Implementation of the new SOP led to a 67% reduction in TEEs performed (old SOP: 933 vs. new SOP: 305). No significant differences between the groups were detected regarding transitory ischaemic attack (old SOP: 5 vs. new SOP: 3; P = 0.48) and stroke (no events). No solid thrombi were detected during TEE screening. The number of preprocedural screening TEEs before AF ablation procedures can be safely reduced by applying risk stratification based on rhythm at admission and CHA2DS2-VASc score, if anticoagulation was performed properly.

Predictive value of clinical risk scores for determination of left atrial low voltage area and arrhythmia recurrences in patients undergoing atrial fibrillation ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background Presence of left atrial low voltage area (LVA) is an independent predictor of atrial tachyarhythmia (ATa) recurrences after atrial fibrillation (AF) ablation. Thus identifying patients with LVA by using non-invasive methods is an important endeavour. Purpose In this study; we investigated the predictors of LVA and postablation recurrences especially focusing on clinical risk scores. Methods We enrolled 328 consecutive patients who underwent initial AF ablation procedure using high density mapping. LVAs were assessed and segmental distribution was noted in each patient. CHA2DS2-VASc, HATCH, APPLE and SPEED scores were calculated. Predictive value and arrhythmia recurrences were evaluated. Results Two hundred and twenty one patients (67.37%) were paroxysmal AF and 107 (32.62%) patients were non-paroxysmal AF at the time of ablation. Mean CHA2DS2-VASc score was 1.88±1.66, mean APPLE score was 1.20±1.20, HATCH score was 0.93±1.00 and SPEED score was 1.54±1.27 in the whole study group. LVA was detected in 131 patients (39.93%). Female gender [OR:2.94, CI: 1.34-6.43, p=0.007), non-paroxsymal AF (OR: 2.49 CI:1.13-5.46, p=0.023), APPLE score ≥1 (OR:1.69 CI:1.12-2.55, p=0.012) and SPEED score ≥ 1 (OR: 1.47 CI:1.00-2.14, p=0.045] were independent predictors for the presence of LVA in multivariate analysis. Presence of LVA (OR:1.98; CI:1.13-4.15; p=0.017) and HT (OR:2.00; CI:1.19-3.38; p=0.009) were the independent predictors of recurrences. Conclusion Higher clinical scores are associated with more LVA which is associated with ATa recurrence. However the predictive value of these risk scores is limited. Better risk scoring systems are needed to precisely identify the underlying atrial substrate in this patient group.

Identification of the fossa ovalis by voltage mapping using a high-density mapping catheter

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transseptal puncture (TP) is routinely performed under fluoroscopy and/or echocardiography guidance. Additional methods to localize the fossa ovalis (FO) may decrease radiation exposure, as well as periprocedural risk. In the recent years, high-density mapping (HDM) catheters have been used for mapping and ablation of left atrial (LA) arrhythmias. Purpose The aim of this study is to determine whether a HDM catheter can reliably identify the specific FO electrogram (EGM) patterns. Methods During atrial fibrillation (AF) ablation, a voltage map of the right-sided atrial septum was created using a HDM catheter (Pentaray, Biosense Webster, USA, spacing 2-6-2 mm). The location of the FO was identified by transesophageal echocardiogram and fluoroscopy guidance prior to TP. At the end of the procedure, a 3D phantom was created during catheter retrieval from the left to the right atrium through the TP. Post ablation analysis was done to evaluate whether the HDM catheter was able to record EGM characteristics of the FO. Results Fifteen patients were included (male 63%, mean age 61.2±11.7 y. o.); 80% of the cases were in sinus rhythm, 53% had a normal LA size, and the mean CHADS2-VA2SC score was 1.5 ± 1.6. One patent fossa ovalis and one septal pouch of the left atrium were seen. In all patients, an area of low voltage could be identified in the vicinity of the transseptal puncture. In 74%, the location of transseptal puncture was inside of the area of low voltage. The mean voltage value of this area was 0.6 ± 0.3 mV, whereas the mean voltage value of the myocardium surrounding the "low voltage area" was 4.3 ± 2.1 mV (P&amp;lt;0.01). The surface of the low voltage could be best demarcated using a scale from 0.05 -1.5 mV with an area measured at 3.8 ± 2.6 cm2 [Figure 1]. At other voltage scales, the FO surface demonstrated smaller areas of low voltage (scale/surface [mV/cm2] : 0.05-0.5/ 0.8 ± 1.3; 0.05-1.0/2.2 ± 1.8; 0.5-1.0/2.3±1.6). In 63%, fractionated potentials were recorded in the area of the FO [Figure 1]. Conclusions Based on its EGM characteristics, the fossa ovalis can be accurately localized with a high-density mapping catheter. This finding will certainly help to implement radiation free procedure particularly when echocardiographic modalities are not available. Figure 1: Mapping of the region of the fossa ovalis with a high density mapping catheter revealed an area of low voltage with fractionnated electrogram. Fossa ovalis was identified by transseptal puncture. TP: phantom of the catheters, CS: coronary sinus, H: His, IVC: inferior vena cava, SVC: superior vena cava, * fractionnated electrogram

Clinical introduction of ultrasound-guided vascular access in catheter ablation of left atrial arrhythmias

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Vascular complications are a common occurrence during atrial fibrillation ablation. Observational studies show that the incidence of vascular complications can be reduced by using ultrasound (US)-guided puncture, however its routine use is not established in many centers. Purpose To compare the rate of vascular complications between ultrasound-guided and conventional anatomic landmark-guided vascular access during catheter ablation of left atrial arrhythmias. Methods Patients undergoing catheter ablation for atrial fibrillation were included sequentially. All patients receiving US-guided puncture were prospectively enrolled group A, while patients who underwent the procedure with standard puncture technique served as control group B. The primary endpoint were periprocedural vascular complications requiring intervention within 30 days of the procedure Results 599 patients (average age: 68 ± 11 years, 63,1% male) were analyzed, 299 in group A and 300 in group B. Demographic and clinical baseline characteristics were comparable between the two groups, except higher prevalence of pre-existing Diabetes mellitus in group A (14,7% vs. group B: 8,7%, p=0.022). The majority of patients were treated with radiofrequency ablation (51,5%), followed by pulsed-field ablation (20,4%) and cryoballoon (18,7%). Other ablation techniques were laserballoon and radiofrequency balloon ablation. The overall rate of vascular complications was lower with the ultrasound-guided puncture than the anatomic landmark-guided puncture (14/299 4,7% vs. 27/300 9%, p=0.036). The ultrasound-guided puncture resulted in a significantly reduced rate of false aneurysms (3/299 1% vs. 12/300 4%, p=0.019). In addition, arteriovenous fistula (2/0,7% vs. 4/1,3%, p=0.414) and hematoma requiring treatment (9/299 3% vs. 11/300 3,7%, p=0.655) were also lower in group A. Conclusion The use of ultrasound-guided vascular access for catheter ablation resulted in a significant reduction of the overall vascular complication rate.

Impact of Systematic Use of Intracardiac Ultrasound during Transseptal Catheterization in the Electrophysiology Laboratory

To explore the impact of the use of intracardiac echocardiography (ICE) in the ablation of supraventricular arrhythmias requiring transseptal catheterization (TSC), whilst analyzing the reduction in periprocedural complications and complications specifically related to TSC. A retrospective multicenter study collecting data from consecutive atrial fibrillation (AF) and supraventricular ablation procedures that required TSC was performed in five Italian centers. Based on physician discretion, TSC was performed with or without ICE. Periprocedural complications, separating all complications from complications directly related to TSC, were collected. Independent predictors of periprocedural complications and TSC-related complications were investigated. A total of 2181 TSCs were performed on 1862 patients at five Italian centers from 2006 to 2021, in 76% of cases by AF ablation and in 24% by ablation of other arrhythmias with a circuit in the left atrium. Overall, 1134 (52%) procedures were performed with ICE support and 1047 (48%) without ICE. A total of 67 (3.1%) complications were detected, 19 (1.7%) in the ICE group and 48 (4.6%) in the no ICE group, p < 0.001. A total of 42 (1.5%) complications directly related to TSC: 0.9% in the ICE group and 3.1% in the no ICE group (p < 0.001). The independent predictors of all complications were age (OR 1,02 95% C.I 1.00-1.05; p = 0.036), TSC with the use of ICE (OR 0.27 95% C.I 0.15-0.46; p < 0.001) and AF ablation (OR 2,25 95%C.I 1.05-4.83; p = 0.037). The independent predictors for TSC complications were age (OR 1.03 95% C.I 1.01-1.06; p = 0.013) and TSC with the use of ICE (OR 0.24 95% C.I 0.11-0.49; p < 0.001). ICE reduced periprocedural and TSC-related complications during electrophysiological procedures for ablation of left atrial arrhythmias.

Ultrasound-Guided Access Reduces Vascular Complications in Patients Undergoing Catheter Ablation for Cardiac Arrhythmias.

Femoral vascular access using the standard anatomic landmark-guided method is often limited by peripheral artery disease and obesity. We investigated the effect of ultrasound-guided vascular puncture (UGVP) on the rate of vascular complications in patients undergoing catheter ablation for atrial or ventricular arrhythmias. The data of 479 patients (59% male, mean age 68 years ± 11 years) undergoing catheter ablation for left atrial (n = 426; 89%), right atrial (n = 28; 6%) or ventricular arrhythmias (n = 28; 6%) were analyzed. All patients were on uninterrupted oral anticoagulants and heparin was administered intravenously during the procedure. Femoral access complications were compared between patients undergoing UGVP (n = 320; 67%) and patients undergoing a conventional approach (n = 159; 33%). Complication rates were also compared between patients with a BMI of &gt;30 kg/m2 (n = 136) and patients with a BMI &lt; 30 kg/m2 (n = 343). Total vascular access complications including mild hematomas were n = 37 (7.7%). In the conventional group n = 17 (10.7%) and in the ultrasound (US) group n = 20 (6.3%) total vascular access complications occurred (OR 0.557, 95% CI 0.283-1.096). UGVP significantly reduced the risk of hematoma &gt; 5 cm (OR 0.382, 95% CI 0.148, 0.988) or pseudoaneurysm (OR 0.160, 95% CI 0.032, 0.804). There was no significant difference between the groups regarding retroperitoneal hematomas or AV fistulas (p &gt; 0.05). In patients with BMI &gt; 30 kg/m2, UGVP led to a highly relevant reduction in the risk of total vascular access complications (OR 0.138, 95% CI 0.027, 0.659), hematomas &gt; 5 cm (OR 0.051, 95% CI 0.000, 0.466) and pseudoaneurysms (OR 0.051, 95% CI 0.000, 0.466). UGVP significantly reduces vascular access complications. Patients with a BMI &gt; 30 kg/m2 seem to particularly profit from a UGVP approach.

Left Atrial Function and Arrhythmias in Relation to Small Vessel Disease on Brain MRI: The Multi-Ethnic Study of Atherosclerosis.

Background Atrial fibrillation (AF) is associated with increased stroke risk and accelerated cognitive decline, but the association of early manifestations of left atrial (LA) impairment with subclinical changes in brain structure is unclear. We investigated whether abnormal LA structure and function, greater supraventricular ectopy, and intermittent AF are associated with small vessel disease on magnetic resonance imaging of the brain. Methods and Results In the Multi-Ethnic Study of Atherosclerosis, 967 participants completed 14-day ambulatory electrocardiographic monitoring, speckle tracking echocardiography and, a median 17 months later, magnetic resonance imaging of the brain. We assessed associations of LA volume index and reservoir strain, supraventricular ectopy, and prevalent AF with brain magnetic resonance imaging measures of small vessel disease and atrophy. The mean age of participants was 72 years; 53% were women. In multivariable models, LA enlargement was associated with lower white matter fractional anisotropy and greater prevalence of microbleeds; reduced LA strain, indicating worse LA function, was associated with more microbleeds. More premature atrial contractions were associated with lower total gray matter volume. Compared with no AF, intermittent AF (prevalent AF with <100% AF during electrocardiographic monitoring) was associated with lower white matter fractional anisotropy (-0.25 SDs [95% CI, -0.44 to -0.07]) and greater prevalence of microbleeds (prevalence ratio: 1.42 [95% CI, 1.12-1.79]). Conclusions In individuals without a history of stroke or transient ischemic attack, alterations of LA structure and function, including enlargement, reduced strain, frequent premature atrial contractions, and intermittent AF, were associated with increased markers of small vessel disease. Detailed assessment of LA structure and function and extended ECG monitoring may enable early identification of individuals at greater risk of small vessel disease.

Left bundle branch pacing: An evolving site for physiological pacing.

For patients with symptomatic bradyarrhythmia, cardiac pacing is the only appropriate treatment option. Electrical and mechanical dyssynchrony caused by traditional right ventricular apical pacing leads to left ventricular dysfunction and atrial arrhythmias. Physiological pacing stimulates natural cardiac conduction, resulting in synchronized ventricular contraction. Even if His bundle pacing (HBP) is an ideal physiological pacing modality, it is technically not always feasible because of high capture thresholds, disease in the distal His bundle, and follow‐up troubleshooting issues. Left bundle branch pacing (LBBP) has been proposed as a viable alternative to HBP since it provides lead stability, a low and stable pacing threshold, and correction of distal conduction system disease.

The Widow Maker: A National Inpatient Sample Study of Health Care Utilization Costs for Cardiovascular Complications Patients Diagnosed with Non-Hodgkin's Lymphoma from 2000-2014

Background:Combination chemotherapy has improved the prognosis of DLBCL but has the potential for cardiovascular toxicity that can contribute to long-term morbidity and mortality. There is limited literature assessing the health care utilization costs for cardiovascular outcomes in patients diagnosed with non Hodgkin Lymphoma (NHL). We conducted this study to evaluate trends in hospital cost, length of stay, complication rates, and in-hospital mortality in adult patients diagnosed with non-Hodgkin lymphomas admitted for cardiovascular complications.Methods:We conducted a population-based study from the Nationwide Inpatient Sample (NIS). All adult admissions with a diagnosis of NHL from 2000-2014 were identified using ICD-9 codes. A priori outcome measures were left heart failure, atrial or ventricular arrhythmias, malignant or accelerated hypertension, hypertensive encephalopathy, and aortic dissection. Total cost was adjusted for inflation using data from the U.S. Bureau of Labor Statistics. Logistic regression was used to compare rates of cardiovascular complications and mortality, cost, and length of stay between patients with NHL the general cardiovascular admissions (GCV), and between teaching and non-teaching hospitals.Results:Data were available for 9711761 hospitalized adults, of which 9711761 comprised the NHL group. The incidence of hospitalization for cardiovascular complications was 2.8 (OR = 2.78, 95% confidence interval [CI] 2.48+/-3.16) times higher in the NHL group than the general cardiovascular admissions (GCV) (58.7% versus 20.9%, P=0.005). Patients with Non Hodgkins lymphoma were 2.8 times more likely to be seen in the ED and admitted with cardiovascular complications than GCV patients (7,112,300 in the NHL group vs. 2,599,450 GCV group p< .005). Cardiovascular death was also twice as common in the NHL group (OR 2.2 95% confidence interval [CI] 1.9-3.6, 28.45% versus 19.54, P= 0.014). Risk factors for death included age ≥ 70 years (OR = 2.1, 95% confidence interval [CI] 1.4-3.0), male sex (OR=2.4, 95%CI 1.6-3.3) Caucasian race (OR=2.3, 95%CI 1.8-3.1), and admission at a teaching hospital (OR=1.67, 95%CI 1.2-2.4), average length of stay (4.8 days versus 2.3 days per 100 patients, p< 0.023) and total hospital cost ($960,554, 4206±45206 versus $479,167 ±19672, p = .002) were significantly higher in NHL patients than GCV patients. The leading cause of mortality was ventricular arrhythmias (88,350 death in the NHL group and 36,530 deaths in the GCV group). Rates for atrial arrhythmias, heart failure, acute myocardial infarction and accelerated hypertension were similar in both groups.Conclusions: There is a high rate of cardiovascular morbidity in NHL patients and survivors, which contributes hospitalization, cost, and increased morbidity and mortality. This large population based study identifies a need for cardiovascular screening and risk reduction strategies after treatment for NHL. DisclosuresNo relevant conflicts of interest to declare.

Spectrum of arrhythmogenic substrate post minimally invasive maze surgery in patients with recurrent.

Advancements in minimally invasive surgical ablation (MISA) have focused on improving pulmonary vein isolation. Additional ablation targets have been developed (such as posterior wall isolation). The mid- and long-term effects of current techniques (including electrophysiologic findings and recurrent arrhythmia mechanisms) have not previously been reported. Twenty eight patients with recurrent atrial arrhythmias after bipolar clamp ablation of the pulmonary vein antrum, ganglionated plexi, posterior wall isolation (roof and floor lines to create a posterior box), and ligament of Marshall ligation/cauterization and left atrial appendage clipping underwent follow up electrophysiology study including left atrial mapping an average of 2.3 years postoperatively. Atrial fibrillation was the most common recurrent arrhythmia (n=18) followed by micro-reentrant atrial tachycardia (n=5), macro-reentry left atrial flutter (n=3), and typical cavo-tricuspid isthmus atrial flutter (n=2). Eighty six of 112 (77%) PVs mapped were electrically isolated, 16 (57%) patients had all four pulmonary veins (PVs) isolated. The posterior wall (PW) was completely isolated in only four (14%) patients, seven (25%) patients had normal PW voltage, while 17 (61%) patients had abnormal delayed or fractionated electrograms in the posterior wall (incomplete isolation). Abnormal PW electrograms were more frequently found in patients with complex recurrent left atrial arrhythmia (micro-reentry or left atrial macro-reentry flutter). With current surgical techniques PV isolation has improved, but PW isolation remains challenging. Incomplete PW isolation may produce arrhythmogenic substrate.