Preablation Atrial Fibrillation Burden
Aims
Data on the success rate of ablation in atrial fibrillation (AF) are controversial. Our hypothesis is that the efficacy must be evaluated considering the ...AF burden (AFB) before the procedure. Moreover, the clinical significance of early recurrence (ERAT) of AF or atrial tachyarrhythmias (AT) is debatable. The aim is to describe the outcome of pulmonary vein isolation in paroxysmal AF through a subcutaneous cardiac monitor (ICM) implanted before the procedure.
Methods
Using CARTO 3, circumferential lesions around the pulmonary veins were placed. The study endpoint was the first documented recurrence of AF/AT by ICM after the blanking period (3 months). AFB (percentage of time in AF/AT) was collected every month before and after the procedure during the 12‐month follow‐up.
Results
The ICM was implanted 94 ± 23 days before the procedure in 35 patients with paroxysmal AF (54 ± 11 years, refractory to 1.8 ± 0.6 antiarrhythmic drugs). Cumulative AFB before the procedure and after the blanking period was 2.5% (1–5%) versus 0% (0–0.25%), P < 0.001. Twenty patients (57.1%) were free of documented AF/AT recurrence, 5 patients (14.2%) reduced the AFB 90%, 6 patients (17.1%) continued the same, and 4 patients (11.4%) increased the AFB 90% for AT. The success rate with second procedure was 71.4%. All 13 patients with ERAT had recurrence after the blanking period.
Conclusions
The outcome of pulmonary vein isolation in patients with paroxysmal AF is well documented by an ICM. The success rate is dependent of the previous AFB that can be randomly variable and lower than expected. ERATs predict late recurrence.
The constellation of His-bundle pacing Arce León, Álvaro; Moraleda Salas, María Teresa; Fernández Gómez, Juan Manuel ...
European heart journal : case reports,
08/2020, Letnik:
4, Številka:
4
Journal Article
Introduction
In patients with uncontrolled atrial fibrillation, atrioventricular (AV) node ablation after permanent His bundle pacing (p‐HBP) could be a therapeutic option for heart rate (HR) ...control. We aimed to demonstrate the advantages of AV node ablation with p‐HBP, and to describe its effectiveness and safety.
Methods
This descriptive observational study included patients with uncontrolled permanent atrial arrhythmias who were candidates for HR control (January 2019 to July 2020) and underwent p‐HBP and AV node ablation.
Results
A total of 39 patients were included. The median left ventricular ejection fraction (LVEF) was 55% (45–60); 46.1% in NYHA class II and 43.6% in NYHA class III. p‐HBP was achieved in 92.3% (n = 36), and AV node ablation was successfully performed in all patients. The LVEF improved in patients with reduced LVEF (baseline, 35% 23.8–45.3%; follow‐up, 40% 35–56.5%, p < 0.05); the NYHA class also showed improvement (baseline, 71.4% patients in class III and 7.1% in class II, and at follow‐up, 78.6% patients in class II and 14.3% in class I). In patients with previously normal LVEF, LVEF remained stable; nevertheless, a significant NYHA class improvement was observed (baseline, 63.6% class II and 31.8% class III patients; follow‐up, 54.5% class I and 45.5% class II patients). The His thresholds and lead parameter values did not significantly change during the follow‐up and remained stable.
Conclusions
In patients with uncontrolled atrial arrhythmias who underwent AV node ablation after p‐HBP, the NYHA class improved and the LVEF increased in those with reduced baseline LVEF. The values of pacing parameters were acceptable and remained stable during the follow‐up.
Background
The impact of contact force (CF) monitoring in pulmonary vein (PV) isolation after a circumferential anatomic ablation (CAA) is unknown. We analyze the usefulness of CF monitoring in acute ...PV isolation and procedure parameters using a CAA.
Methods
Fifty patients with paroxysmal atrial fibrillation were randomized into CF‐on (CF >10 grams; n = 25) or CF‐off (CF blinded; n = 25) groups. We performed a first round of CAA with a ThermoCool® SmartTouch® catheter blinded to the LASSO® catheter (Biosense Webster, Diamond Bar, CA, USA), with radiofrequency (RF) lesions tagged with the VisiTag™ Module. After the CAA, each PV was reviewed with the LASSO® catheter recording the segments with gaps.
Results
All the PVs were isolated with a CAA in 20 patients of the CF‐on versus eight of the CF‐off (P = 0.001). Of the 45 segments with gaps in the left PVs, 38 were from the CF‐off (P = 0.0001). Of the eight segments with gaps in the right PVs, seven were from the CF‐off (P = 0.06). The CF in the left PVs was higher in the CF‐on (16.3 ± 3.2 grams vs 10.5 ± 4.3 grams; P = 0.0001) and similar in the right PVs (17.6 ± 3.6 grams vs 15.2 ± 5.3 grams; P = 0.08). All of the gaps were closed with additional RF LASSO®‐guided touch‐up. Procedure and fluoroscopy times were shorter in the CF‐on (139 ± 24 minutes vs 157 ± 32 minutes and 20 ± 6 minutes vs 24 ± 7 minutes; both P = 0.039). At 12 months the AF recurrence was 84% CF‐on versus 75% CF‐off (log‐rank P = 0.4).
Conclusions
In paroxysmal atrial fibrillation, a CAA guided by CF reduces PV gaps and shortens the procedure parameters at the expense of the left PVs.
Introduction
Permanent His bundle pacing (p‐HBP) could be an alternative for traditional cardiac resynchronization therapy (CRT), but an important limitation is that p‐HBP cannot always correct the ...left bundle branch block (LBBB). The purpose of this article is to assess electrocardiographic patterns of LBBB that can predict electrocardiographic response (QRS narrowing) to His bundle pacing.
Methods
We designed a prospective descriptive study of patients with LBBB and CRT indication proposed for CRT by p‐HBP. We analyzed the correlation between the different electrocardiographic patterns and the correction of conduction disturbance (LBBB).
Results
We included 70 patients. Pacing at the location where His bundle electrogram was recorded narrowed the QRS in 81.4% (n = 57). Basically, we identified two electrocardiographic patterns in lead V1: QS or rS. The QS pattern was a sensitivity of 56%, a specificity of 84.6%, and a positive predictive value (PPV) of 94.1% to predict the correction of the LBBB (area under the curve AUC = .70). In patients with rS pattern, a ratio between the descending and the ascending S wave component duration ≥0.64 was a very good predictor of the correction of the LBBB (AUC = .968); with a value ≥0.64, the sensitivity, specificity, and PPV was 92%, 100%, and 100%, respectively.
Conclusions
In patients with LBBB and CRT indication, the QS pattern in lead V1 predicts the correction of the QRS with HBP. In the case of rS pattern in lead V1, the ratio descending/ascending S wave component duration has a strong correlation with the LBBB correction.
Background
Pulmonary vein isolation (PVI) causes a reduction in left atrium size that is attributable to reverse atrial remodeling (RAR). The objective of this study was to identify predictors of RAR ...and determine its association with other parameters of improvement in cardiac function.
Methods
It is a prospective study with 74 patients (52 ± 9 years old, 81% male), and 51% of patients had paroxysmal atrial fibrillation. Patients were serially assessed with transthoracic echocardiography; plasma N‐terminal B‐type natriuretic peptide (NT‐proBNP); and high‐sensitivity C‐reactive protein levels at baseline and 3, 6, and 12 months following the PVI. RAR was defined as a reduction in the left atrial volume index (LAV‐index) >10% from baseline at the end of follow‐up. A multivariate analysis was conducted to identify predictors of RAR.
Results
The LAV‐index decreased significantly during follow‐up in the entire population (P = 0.0005). RAR (experienced by 63.5% of the patients) was more frequent (76% vs. 42%; P = 0.004) and pronounced (reduction 16.65 ± 14% vs. 8 ± 14%; P = 0.015) in patients with a successful ablation (46 of 74 patients, 62.2%). Only patients with RAR showed significant improvement in NT‐proBNP levels (P = 0.0001), systolic function (P = 0.035), and diastolic function (P = 0.005). Multivariable analysis revealed that a successful ablation (odds ratio OR = 4.6; 95% confidence interval CI 1.46–14.68; P = 0.009), LAV‐index (OR = 1.15; 95% CI 1.03–1.2; P = 0.021), and patient's body mass index (OR = 0.84; 95% CI 0.74–0.96; P = 0.012) were independent predictors of RAR.
Conclusions
Successful PVI ablation is the main predictor of RAR that is associated with other parameters of improvement in cardiac function. The patient's body mass index may have a negative effect on RAR.
Background
Rates of cardiac‐device infections have increased in recent years, but the current incidence and risk factors for infection in patients with implantable cardioverter‐defibrillators (ICDs) ...are not well known.
Hypothesis
The increasing number of ICD infections is related to accumulated pocket manipulations over time.
Methods
This single‐center, prospective study included patients that underwent ICD implantation from 2008 to 2015. The endpoint was time to infection. Multivariate analysis was performed to identify independent risk factors related to infection.
Results
The study included a total of 570 patients, of whom 419 (73.5%) underwent a first implantation. Mean age was 59 ± 14 years, and 80% were male. During a median follow‐up of 36 months (interquartile range, 18–61 months; 1887 patient‐years), infection was identified in 26 patients (4.56%), an incidence of 14.9 × 1000 patient‐years. Median time to infection was 9.7 months (interquartile range, 1.35–23.4 months), and 38.5% were late infections (beyond 12 months of follow‐up). In patients with replacement implants, the incidence was 3‐fold higher than in first implantations (27.7 vs 9.1 × 1000 patient‐years; P = 0.002). Cox regression identified 2 independent predictors of ICD infection: cumulative number of interventions at the generator pocket (hazard ratio: 1.92, 95% confidence interval: 1.42‐2.6, P < 0.001) and pocket hematoma (hazard ratio: 7.0, 95% confidence interval: 2.7‐17.9, P < 0.0001).
Conclusions
The incidence of infection in ICD patients is greater than previously reported, largely due to late infections. Each new cumulative intervention at the same generator pocket nearly doubles the risk of infection.
Background or Purpose
His bundle pacing (HBP) is the most physiological form of ventricular pacing. Few prospective studies have analyzed lead localization using imaging techniques and its ...relationship with electrical parameters and capture patterns. The objective of this study is to examine the correlation between electrical parameters and lead localization using three-dimensional transthoracic echocardiography (3D TTE).
Methods
This single-center, prospective, nonrandomized clinical research study (January 2018 to June 2020) included patients with an indication of permanent pacing, in whom 3D TTE was performed to define lead localization as supravalvular or subvalvular.
Results
A total of 92 patients were included: 56.5% of leads were supravalvular, and 43.5% were subvalvular, which resembles previous anatomic descriptions of autopsied hearts of His bundle localization within the triangle of Koch (ToK). R-wave sensing was higher when the His lead was localized subvalvular instead of supravalvular. His lead localization was not associated with HBP threshold or impedance differences, nor with the two different HBP patterns of capture, or with the ability of HBP to correct baseline BBB. The thresholds remained stable during follow-up visits, regardless of His lead localization. Higher R-wave sensing was observed during follow-up than at baseline, mainly in the subvalvular His leads. However, lead impedances in both positions decreased during follow-up.
Conclusions
Lead localization in relation to the tricuspid valve did not influence the electrical performance of HBPs. Wide anatomical variations of the His bundle within the ToK explain our findings, reinforcing the idea that the technique for HBP should be fundamentally guided by electrophysiological and not anatomical parameters.
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