Stable Sinus Rhythm Research Articles

State of the Art: Mapping Strategies to Guide Ablation in Ischemic Heart Disease.

Catheter ablation to prevent ventricular tachycardia (VT) that emerges late after a myocardial infarction aims to interrupt the re-entry substrate. Interruption of potential channels and regions of slow conduction that can be identified during stable sinus or paced rhythm is often effective and a number of substrate markers for guiding this approach have been described. While there is substantial agreement with different markers in some patients, the different markers select different regions for ablation in others. Mapping during VT to identify critical re-entry circuit isthmuses is likely more specific, and most useful when VT is incessant or frequent during the procedure or when sinus rhythm substrate ablation fails. Both approaches are often combined. These methods for identifying and characterizing post-infarct-related arrhythmia substrate and the re-entry circuits are reviewed.

Catheter ablation for atrial fibrillation: indications and future perspective.

Recent advances in techniques, technologies and proven superiority over anti-arrhythmic drugs have made catheter ablation the cornerstone of management for atrial fibrillation (AF), which has shown a steady increase in prevalence in the ageing population worldwide. The aim of therapeutic interventions is to achieve stable sinus rhythm that would improve the quality of life and reduce the risk of AF-associated complications. Pulmonary veins (PVs) were first described as the source of initiation of ectopic triggers driving AF, which led to the establishment of PV isolation (PVI) as the most widely practiced procedure to treat AF. Antral PVI is still recognized as the stand-alone ablation strategy for newly diagnosed paroxysmal AF (PAF). However, in non-PAF patients, PVI seems to be inadequate and several adjunctive strategies, including ablation of left atrial posterior wall and non-PV triggers, AF mapping and ablation of rotors and drivers, ethanol infusion of vein of Marshall and renal denervation, etc. have been reported with mixed results. Recent trials have also documented the benefits of early rhythm control in preventing cardiovascular events in addition to slowing the progression of PAF to more persistent forms. Similarly, very late relapse of the arrhythmia after successful PVI has drawn attention to the critical role of non-PV triggers and highlighted their relevance as potential ablation targets during repeat procedures. Ablation technology is also under constant evolution with the introduction of non-thermal energy sources and new tools to create durable lesions. This review summarizes the indications, advancements, and future perspective of AF ablation.

Tissue Oedema Following Pulsed Field Ablation Recognized during a Concomitant Left Atrial Appendage Closure Procedure. A Case Report

Abstract Background In patients with non-valvular atrial fibrillation (AF), at high stroke risk and who are ineligible for long-term oral anticoagulation the left atrial appendage closure (LAAC) could be an alternative to anticoagulation. Pulsed field ablation (PFA) is a new nonthermal method for cardiac ablation modality based on high-voltage electrical energy for irreversible electroporation. We first report a case of a concomitant PFA pulmonary vein isolation and LAAC. Case Summary A 74-year-old female patient was referred to our department for pulmonary vein isolation (PVI) for persistent AF (CHA2DS2-VASc Score 5). A concomitant percutaneous LAAC was proposed because of a history of previous cerebellar transient ischemic attack despite continuous oral anticoagulation therapy. PVI was achieved with a pentaspline PFA catheter, LAAC performed with a WATCHMAN FLXTM device (Boston Scientific, Plymouth, MN, USA). After PVI, a swelling of the left atrial ridge was observed, yet a 27 mm LAAC device was successfully implanted. The follow-up transesophageal echo (TEE) after 6 weeks showed complete resolution of the oedema, no device related thrombus but a slight proximal tilting of the LAAC device without leakage could be observed. The 6-month follow-up demonstrated a stable sinus rhythm, no stroke or bleeding events were recorded. Discussion In this case of synchronous PFA-PVI procedure in AF and Watchman FLXTM device implantation, the electroporation created an acute oedema at the ridge level which at the TEE follow-up after 6 weeks was resolved. This resulted in a slightly tilted Watchman device position which was nevertheless stable and showed no leakage.

Treatmen of atrial fibrillation with cryoballoon pulmonary vein isolation - results of a 5-year follow-up

Abstract Background Atrial fibrillation is the most common arrhythmia in the general population and cryoballoon ablation is gradually becoming a first-line treatment. However, data regarding long-term outcomes after this procedure are still lacking. Aim The goal was to show the results of a long-term follow-up following the cryoballoon pulmonary vein isolation in patients with atrial fibrillation (AF). Methods A total of 126 patients were included in the study of which 77.0% had paroxysmal atrial fibrillation (PAF). Successful treatment outcome was defined as AF recurrence-free survival with stabile sinus rhythm during 5 years after the procedure. A treatment failure was defined as symptomatic AF recurrence with ECG verification (12 lead ECG or AF lasting >30s by Holter EKG). The patients on antiarrhythmic therapy and those who underwent a redo pulmonary vein isolation procedure were also included. Results Following cryoballoon pulmonary vein isolation in a 5-year period 52.4% of patients were in stable sinus rhythm without AF recurrence. With redo pulmonary vein procedures a total of 61.9% of patients were without AF recurrence. Together with antiarrhythmic drugs 57.9% of patients were in sinus rhythm without AF recurrence in a 5-year period. With redo pulmonary vein isolation and antiarrhythmic drugs a total of 73.8% of patients were without AF recurrence. There was a statistically significant difference regarding AF recurrence between patients who underwent redo pulmonary vein isolation and those who did not (p=0.006). In patients with PAF, 62.9% remained without AF recurrence, and 79.4% underwent a redo procedure. In patients with persistent atrial fibrillation (PersAF), 41.4% were without AF recurrence, and 55.1% underwent a redo procedure. The difference between PAF and PersAF was statistically significant (p=0.009). Conclusion Data from our center show good long-term results of cryoballoon pulmonary vein isolation in patients with atrial fibrillation. The procedure is especially successful in patients with PAF.1 The use of redo procedures is justified as it increases the long-term success rate.

Impact of catheter ablation on erectile dysfunction in atrial fibrillation patients

Abstract Background Previous studies suggested a consequential link between impaired diastolic function, which could be related to atrial fibrillation (AF), and a heightened susceptibility to erectile dysfunction (ED). No data exists regarding the correlation between restoration of sinus rhythm and ED. Objective This study investigates the influence of cardiac ablation on the need for phosphodiesterase-5 inhibitors (PDEF5i) medications in patients with atrial fibrillation. Methods We retrospectively investigated by chart review 220 consecutive male patients with erectile dysfunction who underwent AF catheter ablation and performed at least one follow-up visit afterward between 2019 and 2022. Exclusion criteria were considered patients older than 85 years old and those assuming non-selective beta-blockers or antidepressant medications. Patients were monitored for arrhythmia at quarterly office visits, ECGs, 7-day Holter monitoring, and event recorders during the first year. The Chi-Square test was utilized to statistically analyze the correlation between the achievement of sinus rhythm post-ablation and the discontinuation of ED medications. Results During follow-up 182 (82.7%) pts remained in sinus rhythm after one year (Group 1). Among these, 141 (77.4%) reported withdrawal of ED medication and a marked improvement in their overall sexual health and satisfaction. Whereas among the 38 (17.3%) who did not maintain stable sinus rhythm during follow-up (Group 2), only 2 (5.2%) reported a reduction in ED medication. A statistically significant difference was observed when comparing the two groups (p<0.001, OR 0,016, 95%, 0,003 - 0,061). Moreover, patients maintaining sinus rhythm for more than six months exhibited a higher tendency to stop ED medications compared to those with shorter periods of sinus rhythm or with recurrent AF episodes. Conclusion Our findings suggest a strong association between the achievement of sinus rhythm through cardiac ablation and a reduction PDEF5i in patients affected by ED medications in AF patients. This highlights the potential dual benefits of cardiac ablation in improving quality of life and in improving sexual health.

CLASS 1C AGENTS ARE EFFECTIVE AND SAFE IN TERMINATING RECENT–ONSET ATRIAL FIBRILLATION IN ELDER PATIENTS TOO

Abstract Background Amiodarone is still widely used in recent–onset atrial fibrillation (AF), mainly in elder people, for its presumed safety. Nevertheless the growing experience with class 1c agents could encourage their use in order to improve the management of AF in elderly too. Aim: To assess whether class 1c agents could be considered effective and safe in elder people, as well in younger, in terminating recent–onset AF. Methods We retrospectively evaluated a three–years experience in over 75 patients treated in the Emergency Department of University Hospital of Verona for recent–onset AF (< 48 h). We excluded patients submitted to electrical cardioversion and those in whom the choice of treatment was forced by clinical conditions or coronary and structural heart disease. Then we compared the results in terms of effectiveness and safety between the two groups of treatment, class 1c agents vs amiodarone. Statistical analysis was performed using Chi–square test, with significance level set at p<0.05. Results We attempted at restoration of sinus rhythm in 264 patients older than 75 years observed for recent–onset AF from January 2018 to December 2020. According to exclusion criteria, the study population was restricted to 147 patients (53 males, 94 females; mean age 80 years, range 75–95) where the treatment depended on the physician‘s choice only. Most of these patients (61.2%) was treated with amiodarone, while in 38.8% class 1c agents were administered. Mean age was not significantly different between the groups (81 vs 78.5). After treatment, stable restoration of sinus rhythm was reported in 43 patients (47.7%) in amiodarone and in 47 (82.4%) in class 1c group (p<0.01). Median time of conversion was 240 minutes (range 30–680) in amiodarone while 60 (range 15–530) in class 1c group (p<0.01), as shown in fig. 1. Surprisingly, even the narrow sample did not allow any significance, the incidence of adverse events was notably superior in amiodarone patients, both in number (5 cases) and seriousness (2 cases). Whereas in class 1c group we reported only one mild adverse event. At the end of observation, 43 patients (75.4%) in class 1c but only 38 (42.2%) in amiodarone group were discharged with stable sinus rhythm (p<0.02). Conclusions Class 1c agents appear to be more effective and as safe as amiodarone in terminating recent–onset AF even in selected elder people. However these preliminary results need to be confirmed in a larger and prospective study.

PERCUTANEOUS LEFT STELLATE GANGLION BLOCK TO INCREASE VENTRICULAR FIBRILLATION THRESHOLD AND DEFIBRILLATION SUCCESS RATE IN ACUTE FULMINANT MYOCARDITIS WITH ELECTRICAL STORM

Abstract Introduction Acute fulminant myocarditis represents a predisposing substrate for life–threatening ventricular arrhythmias (VAs). Percutaneous left stellate ganglion block (PLSGB) usage has been reported for the prevention of recurrent VAs, but clinical data on its acute effect on ongoing ventricular fibrillation (VF) are missing. Case A 57–years–old man suffering gastroenteritis and fever in the past week presented in the ED with typical chest pain. ECG depicted infero–lateral ST–segment elevation, cardiac ultrasound showed a mildly reduced LVEF and coronary angiography ruled out coronary lesions. In the following hours the patient developed frequent premature ventricular complexes with R on T phenomenon triggering short coupled torsade de pointes with rapid degeneration into VF. VAs episodes, initially responsive to single DC shock, kept recurring despite intravenous (iv) amiodarone, iv lidocaine and iv correction of potassium and magnesium. The patient was therefore treated with deep sedation, intubation and ECMO VA placement; still, he reached a status of persistently ongoing VF, refractory even to DC shocks (n=20). Therefore, ultrasound–guided PLSGB using a local bolus of lidocaine 150 mg + ropivacaine 50 mg was performed. After 5 minutes, a single DC shock was delivered, effective in achieving a stable sinus rhythm at 35 bpm with no more recurrences. Despite electrical stabilization, the patient developed a severe cardiogenic shock due to bradycardia and severe biventricular disfunction, treated with vasopressin and dobutamine. In the next 48 hours we observed a significant improvement, resumption of biventricular contractility and absence of VAs recurrences, so the patient was slowly weaned off ECMO and vasopressors. Immunological tests showed Enterovirus IgM positivity, while endomyocardial biopsy was negative for inflammatory infiltrates in the analyzed sections. Cardiac MRI (performed 10 days after onset) showed edema and non–ischemic LGE in the antero–lateral and infero–lateral basal subepicardial regions of the left ventricle, LVEF was 55%. After 15 days from admission, despite ongoing amiodarone and bisoprolol, the patient developed a run of monomorphic VA of 30 beats at 170 bpm, therefore he underwent sICD implantation. Conclusion PLSGB played a key role for the acute management of refractory VF unresponsive to DC shocks, allowing for acute stabilization. More clinical data are needed on acute neuromodulation for electrical storm.

First clinical data on artificial intelligence-guided catheter ablation in long-standing persistent atrial fibrillation.

Despite advanced ablation strategies and major technological improvements, treatment of persistent atrial fibrillation (AF) remains challenging and the underlying pathophysiology is not fully understood. This study analyzed the multiple procedure outcome and safety of catheter ablation of spatiotemporal dispersions (DISPERS) detected by artificial intelligence (AI)-guided software in patients with long-standing persistent AF. The Volta VX1 software was used for 50 consecutive patients undergoing catheter ablation for persistent AF. First, high-density mapping (78% biatrial) with a multipolar mapping catheter was performed. In addition to pulmonary vein isolation (PVI), ablation of DISPERS was performed aiming at homogenizing, dissecting, isolating, or connecting DISPERS areas to nonconducting anatomical structures. Follow-up contained regular visits at our outpatient clinic at 1, 3, 6, and 12 months including 7-day Holter electrocardiograms. Patients were mainly suffering from long-standing persistent AF (mean AF duration 50.30 ± 54.28 months). Following PVI, ablation of left atrial and right atrial DISPERS areas led to AF cycle length prolongation (mean of 162.0 ± 16.6to 202.2 ± 21.6 ms after) and AF termination to atrial tachycardia (AT) or sinus rhythm (SR) in 12 patients (24%). No stroke or pericardial effusion occurred; major groin complications (pseudoaneurysm n = 1, atrioventricularfistula n = 1) were detected in two patients. After a blanking period of 6 weeks, recurrence of any atrial arrhythmia was documented in 26 patients (52%). The majority of patients presented with organized AT (n = 15) while AF was present in n = 9 patients and AT/AF was observed in n = 2 patients. Twenty-twopatients underwent reablation. During a mean follow-up of 363.14 ± 187.42 days and after an average of 1.46 ± 0.68 procedures, 82% of patients remained in stable SR. DISPERS-guided ablation using machine learning software (the Volta VX1 software) in addition to PVI in long-standing persistent AF ablation resulted in high long-term success rates regarding AF and AT elimination. Most arrhythmia recurrences were reentrant AT. After a total of 1.46 ± 0.68 procedures, freedom from AF/AT was 82%. Despite prolonged procedure times complication rates were low. Randomized studies are necessary to evaluate long-term efficacy of dispersion-guided ablation using AI.

Discontinuation of cardiac implantable electronic device therapy after transvenous lead extraction.

Patients with cardiac implantable electronic devices (CIEDs) may no longer be eligible for continued therapy. The study aimed to assess the circumstances under which CIED reimplantation may not be necessary after transvenous lead extraction (TLE). A retrospective analysis of 3646 TLE procedures was performed with assessment of indications for device reimplantation. Reimplantation was not performed immediately after TLE in 169 (4.6%) and, in long-term follow-up, in 146 (4.0%) of patients. No further need for CIED reimplantation was mostly associated with establishment of stable sinus rhythm (2.4%), conversion of sinus node dysfunction to chronic atrial fibrillation (AF; 1.4%), or improvement in left ventricular ejection fraction (LVEF) (0.9%). Independent prognostic factors were in the pacing groups: LVEF (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05; P <0.001), AF (OR, 3.8; 95% CI, 2.4-15.7; P <0.001), patients' age during first CIED implantation (OR, 0.97; 95% C, 0.96-0.98; P <0.001), and New York Heart Association (NYHA) class (OR, 0.616; 95% CI, 0.43-0.86; P <0.01); in the cardioverter-defibrillator group: LVEF (OR, 1.06; 95% CI, 1.04-1.09; P <001). Non-reimplanted patients had more complex procedures and more frequent complications, but survival after TLE was better in this group of patients. Reassessment of the need for continuation of CIED therapy should be considered in all patients following lead extraction and also before planned device replacement as TLE delay increases implant duration, complexity, and procedural risk. The predictors of non-reimplantation are a younger age during the first CIED implantation, lower NYHA class, presence of AF, and higher LVEF in pacemaker carriers, and, in the defibrillator group, only higher LVEF. A decision not to reimplant does not negatively affect the long-term prognosis.

Left atrial total emptying fraction measured by cardiovascular magnetic resonance imaging predicts low-voltage areas detected during electroanatomical mapping.

Low-voltage areas (LVAs) found during left atrial (LA) electroanatomical mapping are increasingly targeted by radiofrequency catheter ablation (RFCA) on top of pulmonary vein isolation to improve arrhythmia-free survival in patients with atrial fibrillation (AF). However, pre-procedural prediction of LVAs remains challenging. The purpose of the present study was to describe the association between parameters of LA function and dimensions, respectively, derived from pre-procedural cardiovascular magnetic resonance (CMR) imaging, and the presence of LVAs on LA voltage mapping. Patients who underwent first-time RFCA for paroxysmal or persistent AF and who were in stable sinus rhythm during pre-procedural CMR imaging were included in this study. Cardiovascular magnetic resonance-derived parameters of LA function and dimensions were calculated. Low-voltage areas were defined as areas with bipolar voltage amplitudes of ≤0.5 mV on electroanatomical mapping. In total, 259 consecutive patients were included in this analysis. Low-voltage areas were found in 25 of 259 patients (9.7%). Compared with those without LVAs, patients with LVAs were significantly older, were more likely to be female, had a higher CHA2DS2-VASc score, had larger LA volumes, and had a lower LA total emptying fraction (TEF). In multivariate analysis, only LA TEF [odds ratio (OR) 0.885, 95% confidence interval (CI) 0.846-0.926, P < 0.001] and the CHA2DS2-VASc score (OR 1.507, 95% CI 1.115-2.038, P = 0.008) remained independently associated with the presence of LVAs. Left atrial TEF and the CHA2DS2-VASc score were independently associated with the presence of LVAs found during LA electroanatomical mapping. These findings may help to improve pre-procedural prediction of pro-arrhythmogenic LVAs and to improve peri-procedural patient management.

Acute Effect of Atrial Fibrillation on Circulating Natriuretic Peptides: The Influence of Heart Rate, Rhythm Irregularity, and Left Atrial Pressure Overload

Plasma natriuretic peptides (NPs) are increased in patients with atrial fibrillation (AF) compared with the patients with sinus rhythm. This study investigated whether this phenomenon is intrinsic to heart rhythm irregularity and independent of the heart rate and left atrial pressure (LAP) overload. We investigated 46 patients (age: 59 ± 10years, male gender: 77%) with non-valvular paroxysmal AF who were scheduled for catheter ablation and had documented stable sinus rhythm for at least 18hours before the procedure. All patients underwent direct measurement of right atrial pressure and LAP, simultaneously with assessment of plasma B-type NP, N-terminal pro-brain NP, and mid-regional pro-atrial NP. The baseline measurement was followed by induction of AF by rapid atrial pacing in the first 24 patients and by regular pacing from the coronary sinus at 100/min (corresponding to the mean heart rate during induced AF) in the latter 22 patients. Hemodynamic assessment and blood sampling were repeated after 20min of the ongoing AF or fast regular paging. The baseline characteristics and hemodynamic measurements were comparable between study groups; however, patients in the regular atrial pacing group had a higher body mass index and a larger left atrial diameter compared with the induced AF group. Plasma levels of all 3 NPs increased significantly during induced AF but not during fast regular pacing, and the increase of NPs was independent of right atrial pressure and LAP. Baseline concentrations of NPs and heart rhythm irregularity were the only independent predictors of increased NPs.

Dynamics of left and right atrial strain after radiofrequency ablation in patients with paroxysmal and persistent atrial fibrillation

Aim. To assess the dynamics of left (LA) and right atrium (RA) strain after antral pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation.Methods. The study included 57 subjects (31 men and 26 women) aged of 55.4±9.8 years. Patients were divided into 2 groups: group 1 with paroxysmal atrial fibrillation (n=40; 70%) and group 2 with persistent atrial fibrillation (n=17; 30%). All patients were treated (were undergone) with antral isolation of the pulmonary veins. Speckle-tracking echocardiography at sinus rhythm was performed before interventional treatment, after 3 days, 3 months and one year. The reservoir, conduit and contractile LA function and peak longitudinal RA strain were analyzed.Results. In both groups, reservoir (p&lt;0.001), conductive (p&lt;0.001) and contractile LA functions (p&lt;0.001 and p=0.001) decreased significantly in the early postoperative period. LA mechanics recovered after 3 months in all patients and were comparable to the level before and one year after radiofrequency ablation. RA strain was significantly increased in the early postoperative period. RA strain was significantly higher at one year follow-up period compared with baseline.Conclusion. Catheter ablation has a damaging effect on the LA - inhibition of reservoir, conductive and contractile functions in the early postoperative period, while the RA strain is intensified. LA strain is recovered in 3 months after radiofrequency ablation and remains comparable with the baseline level at one year follow-up. Reservoir and conduction function of LA and longitudinal deformation of RA are better in the patients with a stable sinus rhythm for a year after ablation compared with patiens who had a tachyarrhythmia recurrence.

Cardiac Magnetic Resonance in Patients with Suspected Tachycardia-Induced Cardiomyopathy: The Impact of Late Gadolinium Enhancement and Epicardial Fat Tissue.

Tachycardia-induced cardiomyopathy (TIC) is a reversible subtype of dilated cardiomyopathy (DCM) resulting from sustained supraventricular or ventricular tachycardia and diagnosed by the normalization of left ventricular ejection fraction (LVEF) after stable sinus rhythm restoration. The aim of this study was to determine the contribution of cardiac magnetic resonance (CMR) to the differential diagnosis of TIC and DCM with persistent atrial arrythmias in patients hospitalized for the first time with heart failure (HF) with reduced LVEF of nonischemic origin. A total of 29 patients (age: 58.2 ± 16.9 years; males: 65.5%; average EF: 37.0 ± 9.5%) with persistent atrial tachyarrhythmia and first decompensation of HF without known coronary artery diseases were included in this study. The patients successfully underwent cardioversion and were observed for 30 days. The study population was divided into groups of responders (TIC patients; N = 16), which implies achieving FF > 50% or its increase > 10% in 30 days of TIC, and non-responders (N = 13). The increase in left ventricle (LV) volumes measured using CMR was significantly higher in the non-responder group when compared with the responders (114.8 mL ± 25.1 vs. 68.1 mL ± 10.5, respectively, p < 0.05). Non-responders also demonstrated decreased interventricular septum thickness (9.1 ± 0.8 vs.11.5 ± 1.3, respectively, p < 0.05). Late gadolinium enhancement (LGE) was observed in 12 patients (41.4%). The prevalence of LGE was increased in the non-responder group (25.0% vs. 65.1%, respectively, p = 0.046). Notably, a septal mid-wall LGE pattern was found exclusively in the non-responders. Epicardial adipose tissue thickness was decreased in the non-responder group versus the TIC patients. Conclusion: Patients with TIC were found to have smaller atrial and ventricular dimensions in comparison to patients with DCM. In addition, LGE was more common in DCM patients.

Myocardial Fibrosis and Left Bundle Branch Block Complicating an Athlete's Heart Syndrome Treated Homeopathically: A Case Report

Abstract Background During 2013, a 59-year-old male patient, a medical practitioner and lifelong sportsperson, complained of being constantly conscious of his heart action, and left sternal heave, as well as retrosternal heaviness at rest. On October 23, 2013, an electrocardiogram (ECG) showed some signs of an athlete's heart syndrome. An ECG on 11 January, 2019, shockingly showed a complete left bundle branch block (LBBB), a broad complex QRS sinus rhythm ECG, without ever experiencing angina pectoris after doing four sets of 20 push-ups. Methods A complication of an athlete's heart may be myocardial fibrosis (MF). MF is the primary pathology to treat, as well as its comorbidities synergistically, when they obstruct progress. Thus, Calcarea fluorata (Calc-f) was prescribed for endocardial fibrosis, Iberis amara (Iber) for endomyocardial fibrosis, Cactus grandiflorus (Cact) for pulmonary arterial hypertension and right ventricular strain, and Crataegus laevigata (Crat) for subendocardial ischaemia. Results After 17 months on Calc-f, the LBBB was unchanged. Iber was again prescribed on February 13, 2022. On February 23, 2022, after 10 days on Iber, a narrow complex QRS sinus rhythm (SR) ECG was recorded with a QRS of 90 milliseconds. This was the first SR ECG after having had a permanent complete LBBB for at least 3 years. Conclusions This case report documents via ECGs the biological effectiveness of Calc-f and Iber for MF. SR returned after the employment of, respectively, Iber and Cact. After employing Crat, the abnormal inverted T waves in most leads became positive. Since October 16, 2022 and beyond, there is a stable SR, but any intense exertion causes an LBBB.

Additional left atrial lesions improve the effect of cryoballoon pulmonary vein isolation in paroxysmal atrial fibrillation patients

Aim. Cryoballoon ablation (CBA) is one of the methods for catheter pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF). Left atrial additional lesion (LAAL) to PVI were proposed to eliminate extrapulmonary AF triggers. Nonetheless whether the additional lesions improve CBA effectiveness is not clear.Methods. Primary CBA procedures performed for paroxysmal AF during 2017-2021 were analyzed. The study group (Algorithm group, n=82) was recruited prospectively in 2019-2021. As the first step CBA PVI were performed in all pts. In those who were on sinus rhythm (SR) after the PVI, AF induction attempts with burst atrial pacing were performed. Pts with induced AF and those who stayed on AF after PVI underwent LAAL at the left ganglionated plexus area. In case of stable SR (non-inducible AF) the procedure finished. If AF was inducible or did not terminate during CBA, the second LAAL set were performed - LA posterior wall lesions. If AF was still inducible or did not terminate, the SR was restored by electrical cardioversion. The control group (Control group, n=94) was formed retrospectively from patients with routinely performed only CBA PVI with achievement of isolation criteria in 2017-2019. If AF continued, sinus rhythm was restored by cardioversion. There were no attempts of induction AF during the procedure.Results. The Algorithm and Control groups were comparable in terms of clinical, demographic and electrophysiological characteristics. At 12 months postoperatively, the effectiveness was higher in the Algorithm group than in the Control group (78.0% vs. 62.8%, p = 0.044). No adverse effects were found.Conclusion. Thus, the stepwise approach with LAAL increases the effectiveness of CBA in the long-term period and does not affect the risk of complications.

Epicardial adipose tissue and its association with atrial fibrillation in middle-aged patients without overt heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Obesity and atrial fibrillation (AF) are emerging health problem, associated with significant morbidity and mortality. There is a significant relation between body mass index (BMI) on one hand and the amount of visceral fat and epicardial adipose tissue (EAT) on the other (1,2). EAT volume is positively related to the incidence, duration, and recurrence of AF (2,3). Aim The aim of the study was to assess echocardiographic variables and their association with BMI and EAT in middle-aged patients with AF. Methods Prospective consecutive patients with AF (n= 936), who had been admitted for sinus rhythm restoration in our hospital for the period January 2016- December 2018, were screened for participation in the study. A total of 70 patients met the inclusion criteria- stable sinus rhythm, age between 40–60 years, without over heart disease. They were separated in two groups: with new onset AF (n=33) and recurrent episode of AF(n=37); 30 healthy subjects were enrolled in the control group. All patients underwent 2DE assessment with speckle tracking analyses. EAT thickness was measured perpendicularly on the free wall of the right ventricle at end-systole when both walls collapse and allow the widest measurement. Results There were significant differences in global longitudinal strain (GLS) of left ventricle (LV) and EAT between AF groups and healthy controls, but not in the other LV parameters. There were significant differences in left atrial (LA) structural and functional indices in AF groups in comparison to healthy controls- picture 1. There were significant correlations between BMI and EAT ( p = 0.001;r=0,710), GLS ( p = 0.001;r=0,557), LA volume index ( p = 0.001;r=0,701), LA reservoir strain ( p = 0.001;r=-0,626), LA stiffness index ( p = 0.001;r=0,557)- picture 2 .There were significant correlations between EAT and GLS ( p = 0.001;r=0,478), LA volume index ( p = 0.001;r=0,539), LA reservoir strain (p = 0.001;r=-0,479),LA stiffness index ( p = 0.001;r=0,487). Conclusion Epicardial adipose tissue, assessed by 2DE, was increased in middle-aged patients with obesity and AF. Obesity is significant risk factor for LA remodelling and AF, but further prospective investigation need to define the causality role of EAT in AF initiation and progression.

The significance of high sensitive troponin i and left atrial mechanical dispersion in middle-aged patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is a progressive disease and can initiates and maintains in the absence of left atrial (LA) enlargement¹´². Echocardiographic parameters of LA mechanics had been proposed for best dealing with patients in AF³ . Combining different laboratory biomarkers with echocardiographic parameters can improve prediction, detection and treatment of AF in clinical practice. However, there is limited data about the significance of combination of novel echocardiographic and laboratory biomarkers in prediction of AF in middle-aged patients without LA enlargement. Purpose To investigate middle- aged AF patients with normal standart 2D echocardiography (2DE) to establish novel echocardiographic and laboratory biomarkers as predictors of reccurent AF. Methods Prospective consecutive patients with symptomatic AF (n= 936), were screened for participation in the study. A total of 70 patients met the inclusion criteria- stable sinus rhythm for more than 3 weeks, age between 40–60 years, without over heart disease and normal 2DE. They were separated in two groups: with new-onset AF (n=33) and recurrent episode of AF (n=37); 30 healthy subjects were enrolled in the control group. All patients underwent 2DE with speckle- tracking analyses and biomarker assays were collected, including baseline high sensitive troponin I (hsTnI), galectin-3, uric acid and hsCRP. Results There were significant differences between all groups in echocardiographic parameters of LA mechanics: LA reservoir, conduit and contractile strain and strain rate respectively, LA stiffness index- table 1. There were significant differences in laboratory markers- hsTnI and uric acid between groups. Moreover, pro-fibrotic biomarker Galectin-3 was higher only in patients with reccurent AF as was LA mechanical dispersion from speckle-tracking analysis. There were no differences in hsCRP between groups. Binary regression analysis demonstrated that hsTnI (OR 1,880; p&amp;lt; 0,025; 1,084- 3,260 95,0% CI) and LA mechanical dispersion (OR 1,012; p&amp;lt; 0,034; 1,001- 1,024 95,0% CI) are predictors of reccurent AF- ROC curve image . Conclusion As a progressive disease AF facilitates its own persistence through LA structural and functional remodeling. Left atrial dispersion along with baseline hsTnI may have additive value for prediction of reccurent AF episodes, reflecting this process in middle-aged patients without LA enlargement.

Catheter ablation (CA) for atrial fibrillation and atrial tachycardia in the elderly: Results from a large single center study in 293 patients over 80 years old

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The increasing incidence of atrial arrhythmias in the elderly is mostly adjudicated to the age-dependent development of arhythmic substrate. In recent years, CA has become a standard approach in treating atrial fibrillation (AF) and left and right atrial flutter (AFlut). Data regarding safety and efficacy of CA in patients over 80 years old remains scarce. This study aims to report on our high-volume center experience regarding the safety and efficacy of CA in a large cohort of patients &amp;gt;80 years of age. Methods All patients &amp;gt;80 years undergoing de-novo-CA for AF or AFlut (parox. AF n=85, 29%; pers. AF n=146, 49.8%; left-/right- AFlut n=62, 21.2%) in our institution between 01/2016 and 12/2020 were included (n=293; mean age 82.3 ± 2.27 years). For safety analysis, all complications requiring intervention or causing sequels occurring during or up to 30 days after CA were collected. For efficacy, AF/Aflut-free survival was analysed after a blanking period (3 months) using 7-day Holter ECGs. Results Baseline characteristics are shown in table 1. Most patients suffered from multiple cardiovascular co-morbidities (CHA2DS2-VASc-score 4.45 ± 1.15), &amp;gt;30% were on reduced OAC. Isolation of all pulmonary veins (PV) and/or termination of AFlut with demonstration of bidirectional block across the ablation line was achieved in all patients (procedure success 100%). During a follow-up of 400 ± 446 days, 61.4% of patients remained in stable sinus rhythm after 1.56 ± 0.81 ablations (Figure 1). Single procedure outcome was significantly higher in paroxysmal AF compared to persistent AF (p = 0.03, s. Figure 1b). 32 patients (10.9%) were lost to follow-up. In 17 patients (5.8%) complications occurred: 1 case of pericardial tamponade during PVI and CA of PVCs (LA and CS). 2 patients suffered a stroke within a week after CA of persistent AF and left AFlut, 1 TIA occurred after CA of persistent AF. All patients had been under uninterrupted full-dose OAC. Major groin complications occurred in 13 patients (4.4%). 3 arterial bleeds treated by covered stent implant, 7 pseudoaneurysms needing thrombin injections, 2 infections of the puncture site and 1 patient requiring surgical treatment for a large hematoma. 9 patients underwent pacemaker implantation shortly after CA due to underlying symptomatic sick-sinus-syndrome or higher degree AV-blocks demasked in sinus rhythm, none were procedure-related. Conclusion De novo catheter ablation of AF and AFlut in very old patients is safe and effective. In paroxysmal AF, ablation success rates seem to be similar to those in younger patients and are significantly higher than for persistent AF. After 1.56 ablation procedures, &amp;gt;60% of patients were free of arrhythmia, suggesting that the supposed atrial remodelling does not preclude an interventional treatment approach.

Outcomes of ventricular tachycardia substrate ablation facilitated by preprocedural imaging scar characterization. A prospective multicenter registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation is a recommended therapy for patients with ventricular tachycardia (VT). However, recurrences rate in non-ischemic cardiomyopathy (NICM) patients remains high. Objectives To analyze outcomes of VT substrate ablation facilitated by the integration into the navigator system of the preprocedural image scar characterization in both, patients with ischemic cardiomyopathy (ICM) cand NICM. Methods One hundred and sixty-five consecutive patients with structural heart disease undergoing scar related left-side VT ablation were included in a prospective European multicenter (5 centers) registry. Pixel signal intensity (PSI) maps from the late gadolinium enhancement-CMR (LGE-CMR) and/or the multi-detector cardiac tomography (MDCT) were imported into the navigator system. Ablation approach (e.g. endo vs epicardial; left vs right side) was based in the scar distribution aiming to eliminate the entire arrhythmogenic substrate. Mapping and ablation were focused in the scar areas. In all patients Scar dechanneling was the substrate ablation technique used. Results 165 [153 (93%) men, 66+12 y.o, 117 (71%) with ischemic heart disease] patients were included. Pre-procedure CMR was performed in 65 (39%), MDCT in 12 (7%) and both in 88 (53%) patients. VT induction protocol was negative after substrate ablation in 121 (73%) patients, completing the procedure in stable sinus rhythm. Procedure related complication rate was 5.5%. Arter a mean follow-up of 18+19 months, overall survival was 91% and 44 (27%) patients had VT recurrences. There was no difference in VT-free survival in ischemic vs non-ischemic patients (Log rank:0.9), as Figure 1 shows. Conclusions A strategy of VT substrate ablation facilitated by the integration into the navigator system of the preprocedural image scar characterization with the aim of eliminate the entire arrhythmogenic substrate results in a low recurrence rate. This approach minimizes the gap in VT-free survival after ablation in patients with ICM and NICM.

Radiofrequency ablation for longstanding persistent atrial fibrillation: long-term outcome of a prospective randomized comparison of mapping with multipolar catheter vs. 4-pole ablation catheter

Abstract Funding Acknowledgements Type of funding sources: None. Background In patients with longstanding persistent atrial fibrillation (LSPAF), mapping with multipolar catheter can enhance identification of arrhythmogenic sources during ongoing AF/converted atrial tachycardia (AT), reduce procedure time, and improve outcome of catheter ablation. Purpose To compare procedural characteristics and long-term outcome of radiofrequency catheter ablation (RFA) for LSPAF between two mapping approaches in a prospective randomized bi-centric study. Methods Between 1/2019-9/2021, RFA was performed in in 172 patients with LSPAF. Mapping with multipolar catheter Pentaray (group 1, n=85) vs. mapping with ablation catheter Navistar STSF (group 2, n=87) were compared. Stepwise ablation to the desired AF termination included pulmonary vein isolation (PVI), electrogram guided left atrial (LA) ablation, CS isolation, and right atrial electrogram guided ablation. PVI, mitral isthmus, LA roof, and CTI block were Intermediate endpoints proved at the procedure end. Sinus rhythm (SR) restoration by ablation was the desired procedure endpoint. Follow-up included 7-day ECG monitoring every 3 months during the first year, and every 6 months afterwards. Results In groups 1 vs. 2, AF was terminated (into SR or AT) in 70 (82%) vs. 68 (78%) patients (p=0.81); and SR was restored by ablation in 54 (64%) vs. 46 (53%) patients(p=0.46), respectively. Procedure, fluoroscopy, and RF delivery times (min) were 251±46 vs. 257±45 (p=0.35); 10,4±2,8 vs. 11,0±3,1 (p=0.17), and 70±21 vs. 70±24 (p=0.98), respectively. At the end of 13-45 months follow-up, stable SR was present in 72 (85%) vs. 69 (79%), patients following repeat ablation in 42 (49%) vs. 42 (48%) patients. Only 29 (34%) vs. 26 (30%) patients remained free from any AF/AT recurrence (&amp;gt;30 s) after single ablation (all p=NS). Conclusion Mapping with multipolar catheter vs. standard ablation catheter was associated with nonsignificant differences in procedural characteristics and clinical results of RF catheter ablation for LSPAF.