搜索结果：The Journal of innovations in cardiac rhythm management

Micra™ retrieval techniques involve snaring the proximal knob; however, device orientation can hinder knob access. Unorthodox retrieval methods included a two-snare approach and a "snare-in-snare" technique. We describe a single-tine-based snaring approach of a Micra™ leadless pacemaker (Medtronic, Minneapolis, MN, USA) 4 days after implantation due to loss of capture. An 89-year-old man with a history of chronic kidney disease, hypertension, and transcatheter aortic valve replacement complicated by complete heart block underwent Micra™ implantation. Four days later, he presented with syncope. Interrogation showed an elevated capture threshold with intermittent loss of capture. Chest radiography confirmed an upside-down orientation in the right ventricular outflow tract. A 27-Fr outer-diameter Aveir™ Introducer Sheath (Abbott, Chicago, IL, USA) was advanced via the right femoral vein. The Aveir™ leadless pacemaker (Abbott) was implanted in a lower septal position. Multiple attempts to snare the Micra™ device's retrieval knob using the Aveir™ Retrieval Catheter (Abbott) and a Goose Neck Snare (20-mm loop diameter, 102 cm; Covidien [Medtronic], Dublin, Ireland) through a steerable sheath failed. A figure-of-eight stitch was placed around the introducer sheath and left untied. The snare engaged a partially free tine. Gentle traction confirmed secure engagement, and controlled traction disengaged the remaining tines. The device was withdrawn into the inferior vena cava but could not be pulled into the sheath due to angulation. The entire system was removed, and the groin stitch was tied. However, the Micra™ dislodged into the groin subcutaneous tissue. Iliofemoral angiography via internal jugular vein access confirmed no extravasation, and the device was explanted through a small groin incision using forceps. Percutaneous retrieval of a Micra™ leadless pacemaker, with short dwell time, is feasible using a one-tine-based snaring technique when snaring of the proximal retrieval knob fails. The tine is durable; however, caution should be exercised.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Although its pathogenesis remains incompletely elucidated, accumulating evidence implicates oxidative stress (OS) as a key contributor to the development of the arrhythmogenic substrate. OS may facilitate atrial remodeling through modulation of calcium-handling proteins and ion channel function, potentially promoting the initiation and maintenance of AF. This article summarizes the role of OS biomarkers such as 8-hydroxydeoxyguanosine (8-OHdG), glutathione peroxidase (GPx), advanced glycation end-products (AGEs), superoxide dismutase (SOD), malondialdehyde (MDA), isoprostanes (IsoPs), derivatives of reactive oxidative metabolites that oxidize reduced glutathione (Eh GSH) and cysteine, and advanced oxidation protein products (AOPPs) in the pathogenesis of AF. Plasma 8-OHdG levels progressively increase with advancing low-voltage area stages, indicating a strong association between oxidative DNA damage and the severity of atrial fibrosis. Also, the reduction in GPx activity appears to contribute to arrhythmogenic electrochemical disturbances and oxidative lipid damage, independent of dyslipidemia. The receptor for the AGE axis plays a part in arrhythmogenic structural atrial remodeling. Patients who develop post-surgical AF demonstrate paradoxically elevated SOD activity, possibly reflecting a compensatory antioxidant response to heightened OS. As serum MDA levels were not linked to the development of postoperative AF (POAF), it is possible that lipid peroxidation is not the primary cause of POAF pathogenesis. Even when AF patients are receiving anticoagulant medication, elevated 8-isoprostane levels are linked to thromboembolic events, in part because of changes in the fibrin clot structure. Each 10% increase in Eh GSH was associated with a 40% increase in the risk of incident AF. Future research is required on AOPPs in AF pathogenesis. Future investigations should aim to identify and characterize novel OS markers and evaluate their potential therapeutic relevance in the prevention and management of AF.

Despite advancements in medical therapy, managing symptomatic inappropriate sinus tachycardia (IST) remains challenging. The role of catheter ablation in addressing this condition remains ambiguous according to multiple cardiac society guidelines. In this case study, we illustrate the efficacy of a hybrid approach involving sinus node modification and ablation in a patient with refractory symptoms, while also addressing the associated challenges and safety considerations of this procedure. A 58-year-old female patient was troubled with recurrent palpitations secondary to IST. Due to the proximity of the target ablation site to the phrenic nerve, this area was not amenable to complete ablation endocardially. To alleviate symptoms, an ablation procedure was planned, aiming for epicardial sinus node modification and displacement of the phrenic nerve from the target site. The procedure was completed under general anesthesia. The conventional subxiphoid technique was deemed challenging even with a surgical approach due to the patient's body habitus and significantly increased body mass index; hence, she underwent a 5-cm right anterior thoracotomy to establish access to the pericardium. The sinoatrial (SA) node was ablated surgically by direct application under vision of the right atrium around the area of the SA node to avoid the phrenic nerve. Modification and ablation of the sinus node in patients exhibiting features of IST may be considered to help alleviate patients' symptoms. Further follow-up and assessments with large cohorts and powered randomized controlled studies are needed. Our case represents an example where a hybrid invasive approach resulted in a safe procedure with immediate symptomatic benefit.

Anti-arrhythmic drugs (AADs) have been a mainstay of dysrhythmia control for over a century. Even in the current era of evolving ablation use and technology, AADs remain therapeutically important. Nonetheless, the effectiveness of AADs may be incomplete and/or adverse effects may limit their use despite efficacy. Ideally, to maximize the clinical profile of AADs, clinicians should be aware of the full array of their complexities and selection options. However, commonly, some of them seem to be frequently underappreciated. Among others, these include dosing intricacies, targeting therapy to the arrhythmia trigger, avoiding habitual choices of AAD selection, consideration of AAD combinations, and more. These factors are discussed in this paper as a means of improving AAD use by clinicians and tolerance by patients. Notably, it is only these issues that are the focus of this paper, which is not meant as a review of the pharmacologic profile of each of our AADs.

Class IC anti-arrhythmic drugs are primarily preferred for the rhythm control of atrial fibrillation (AF). In cases where ablation fails, the appropriate rhythm-control strategy is still unclear. In our study, we aimed to evaluate the efficacy of flecainide, propafenone, and radiofrequency ablation (RFA) as rhythm-control strategies in paroxysmal AF patients with failed cryoballoon ablation (CBA). In this cross-sectional study, 1120 patients who underwent CBA for paroxysmal AF between 2017 and 2024 were screened. Within this patient group, 230 patients with recurrent AF (&#x2265;3 months) after CBA were identified. A total of 120 patients (40 cases per treatment) who underwent rhythm control and received flecainide, propafenone, or RFA were finally included in the study. Study participants were then divided into three groups, receiving flecainide (group I), propafenone (group II), or RFA (group III). All patients were followed up for at least 1 year for AF recurrence, which was confirmed in 52 (43.2%) patients. The AF recurrence rates in groups I, II, and III were 35%, 75%, and 20%, respectively. Although the frequency of AF recurrence in groups I and III was statistically similar (P > .05), it was significantly lower in these groups than that in group II (P < .05). Group I patients were significantly more likely to use &#x3b2;-blockers than group II or III patients (P < .05). Patients with AF recurrence had a larger left atrial (LA) diameter and greater propafenone use. The number of patients who used flecainide and underwent RFA was lower in the AF recurrence group. In logistic regression analysis, LA diameter was found to be an independent predictor of AF recurrence (P = .002). In conclusion, based on the findings of our study, flecainide therapy can be used with an acceptable success rate in patients with recurrent AF after CBA.

Sick sinus syndrome (SSS) is a cardiac conduction disorder that often necessitates pacemaker implantation, especially in older adults. Emerging evidence suggests a potential association between coronavirus disease 2019 (COVID-19) infection and SSS, but the impact on SSS trends and permanent pacemaker (PPM) implantation rates remains unclear. This study compares the pre- and post-COVID-19 trends in SSS incidence and PPM implantation rates. Using the TriNetX Research Network, we analyzed the monthly incidence rate (IR) of SSS and the rate of PPM implantation in the overall population from January 2018 to December 2023. Additionally, we conducted a subgroup analysis focusing on patients >50 years of age to examine trends in IR and PPM implantations during the same period. To evaluate changes before and after COVID-19, we used interrupted time series analysis, with March 1, 2020, as the cutoff. In the overall SSS population, the IR increased significantly post-COVID-19 (IR, 1.80 cases/100,000 person-years [PY] per month; P < .001), which was accompanied by a significant rise in PPM implantation rates (119.16 cases/100,000 PY per month; P < .001). Among patients <50 years of age, the IR increased post-COVID-19 (IR, 0.355 cases/100,000 PY per month; P < .001), but PPM implantation rates in this subgroup remained unchanged (P = .897). Our findings suggest an increase in SSS incidence across all age groups post-COVID-19. However, the lack of increased PPM implantation in younger patients may reflect either a more transient disease course or a higher threshold for device implantation in this age group. Further research is needed to determine the prognosis of SSS in the recent era.

Atrial fibrillation (AF), the most common arrhythmia worldwide, affects approximately 59 million people globally. It poses a significant health burden by increasing morbidity and mortality. Artificial intelligence (AI) is emerging as a potentially transformative technology across the AF care continuum. This review synthesizes current evidence and critically evaluates AI applications in AF management, including innovations in detection and screening using electrocardiography and wearables; advanced mapping techniques using signal processing and computational modeling to guide catheter ablation; machine learning-based prediction of treatment outcomes; and personalization of long-term therapy, such as anticoagulation. Key studies and trials illustrating AI's capabilities in improving diagnostic yield, refining ablation targets, and enhancing prognostic accuracy are analyzed. The potential for AI to facilitate integrated care pathways, such as the "AF Better Care" approach, is considered, balancing innovation against clinical practicality, rigorous validation, and workflow integration. While AI shows considerable potential to augment precision in AF management, significant challenges concerning data generalizability, model interpretability, clinical utility validation, and equitable implementation remain. Optimal integration requires careful alignment with clinical expertise and a focus on patient-centric outcomes. Addressing these challenges through collaborative efforts among clinicians, researchers, and technology developers will be essential to fully realize AI's promise in improving AF care. Future research should prioritize robust validation, transparent methodologies, and practical implementation strategies to ensure that AI effectively enhances patient outcomes.

Catheter ablation has emerged as a first-line therapy for many arrhythmias. However, data on the safety and outcomes of catheter ablation in the elderly population remain limited. Here, we aimed to study the outcomes of catheter ablation in octogenarians. The data used in this study were obtained from the National Inpatient Sample database through years 2016-2019. We identified patients &#x2265;80 years old who were diagnosed with atrial fibrillation (AF), atrial flutter (AFL), supraventricular tachycardia (SVT), or ventricular tachycardia (VT) as primary diagnoses. The patients' characteristics and common procedure complications were extracted. We investigated the predictors of mortality and in-hospital complications using multivariable logistic regression. A total of 18,595 patients were included in our analysis. The most common procedure performed was ablation for AF (46%), followed by AFL ablation (23%), VT ablation (18%), and SVT ablation (12%). Higher rates of tamponade (1.6%) were seen in patients undergoing VT ablation. A Charlson's comorbidity index (CCI) score of &#x2265;3 points was used as an independent predictor for complications (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.4-3.3, P = .001). Mortality was higher in VT ablation (4.2%) compared to AFL (1.3%), AF (0.9%), and SVT (0.3%). After logistic regression analysis, a CCI score of &#x2265;3 points (OR, 14.7; 95% CI, 1.88-114.9; P = .01) and tamponade (OR, 4.9; 95% CI, 1.65-14.8; P = .004) were independent predictors of mortality. We found a low incidence of procedural complication rates across all ablation groups in octogenarians. Those undergoing VT ablation were more likely to have complications and a higher mortality rate. Baseline comorbidities can be used to risk-stratify patients when deciding on the best treatment strategy.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as an alternative to conventional ICD systems. Although not considered mandatory, short-time fluoroscopy is used in clinical practice, both preprocedurally and intraoperatively. The aim of this study was to compare totally fluoroless versus limited fluoroscopy-assisted S-ICD implantation in terms of clinical and technical efficacy and safety. In this non-randomized, single-center study, 49 patients (24.5% women; mean age, 43.2 &#xb1; 18.4 years) at high risk for arrhythmic cardiac death underwent S-ICD implantation in the context of either primary or secondary prevention between May 2016 and June 2024 with at least 6 months of follow-up thereafter. Patients were allocated to group A (n = 25), where a totally fluoroless implantation strategy was followed (January 2023-June 2024), or group B, where a limited fluoroscopy-guided S-ICD implantation process (first 24 cases) was followed. Following implantation, a pre-discharge chest X-ray confirmed an anatomically acceptable lead position in all cases. Further, our data revealed similar acute and long-term clinical efficacy with both approaches: the success rate of defibrillation testing at 60 J was 100%, the appropriate shock rate was low (8.2%) with defibrillation therapy successful in all cases, the mean PRAETORIAN score remained in the low-risk category, and no arrhythmic deaths were recorded. The rate of inappropriate shocks was similar between groups (8% vs. 8.3%; P = .97 for groups A and B, respectively). Finally, no major periprocedural complications were recorded with either approach. Compared to the limited fluoroscopy-guided technique, totally fluoroless S-ICD implantation showed comparable efficacy, reliability, and safety in the present study.

Implantable cardioverter-defibrillators (ICDs) are life-saving devices used to prevent sudden cardiac death. Two newer types of ICDs-the extravascular ICD (EV-ICD) and the subcutaneous ICD (S-ICD)-offer alternatives to traditional transvenous ICDs. Additionally, efforts are being made to introduce defibrillation and pacing interventions through a single device called the modular cardiac rhythm management system (mCRM). This review compares the EV-ICD and S-ICD based on currently available clinical data, focusing on their safety and performance. Additionally, we review modular ICD systems, which integrate leadless pacing with defibrillation. We conducted a comprehensive literature search of PubMed and ScienceDirect, focusing on articles demonstrating the clinical outcomes of EV-ICDs and S-ICDs as well as modular systems. However, we found that sufficient studies are not available to determine the clinical efficacy and safety outcomes of EV-ICDs and the mCRM. Additionally, comparative studies between EV-ICDs and S-ICDs are still required to determine their relative roles in the field of electrophysiology, with the goal of empowering clinicians to understand these emerging technologies to support better patient care decision-making.

The safety and efficacy of pulsed field ablation (PFA) for cardiac ablation have been demonstrated in pulmonary vein (PV) isolation (PVI), but its relevance to target additional extra-PV substrate is still under investigation. We conducted a pilot, prospective, single-center, nonrandomized study in 25 patients with atrial fibrillation despite previous catheter ablation (52% men; 74 &#xb1; 9 years of age). Patients underwent catheter ablation using PFA with the goal of ablating artificial intelligence (AI)-guided spatiotemporal dispersion. Biatrial mapping of spatiotemporal dispersion was obtained using the Volta AF-Xplorer&#x2122; (Volta Medical, Providence, RI, USA). Re-conducting PVs and extra-PV regions of interest exhibiting dispersion were ablated using the Farawave&#x2122; catheter (Boston Scientific, Marlborough, MA, USA). This catheter was used either in the basket or flower configuration sequentially centered at an estimated geometric center of AI-detected dispersion regions. The mean procedure and biatrial mapping times were 75 &#xb1; 12 and 14 &#xb1; 7 min, respectively, and no fluoroscopy was used. No complications occurred, and sinus rhythm conversion by ablation was obtained in 23 patients (92%). The rate of freedom from any atrial arrhythmia at 6 months was 88%. In conclusion, we observed that PFA for personalized, AI-guided extra-PV dispersion repeat ablation appears safe and procedurally efficient.

Cardiovascular laser application (CVLA) is an innovative approach in the field of cardiology aimed at treating various cardiovascular diseases, including cardiac arrhythmias, cardiomyopathies, systemic and pulmonary resistant hypertension, and varicose leg veins, by using a key technology, the laser. Tissue-selective photon absorption of the 1064-nm wavelength induces tissue-selective irreversible lesions of arrhythmogenic myocardium, modulation of retrocardiac ganglion plexi, and renal and pulmonary perivascular innervation. This review summarizes the development and the experimental and clinical results of the CVLA, highlighting its potential advantages over other catheter ablation methods. Based on its unique characteristics, laser treatment has the potential to become an all-pervasive, safe, and effective procedure for the benefit of countless patients.

Experience with the Aurora extravascular (EV) implantable cardioverter-defibrillator (ICD) (Medtronic, Minneapolis, MN, USA) remains limited among pediatric centers in contrast to its broader implantation in adults. We evaluated our single-center experience with the EV ICD as part of our standard ICD options for treatment of malignant ventricular arrhythmias in pediatric subjects. Following approval for EV ICD implantation at our center, five consecutive adolescent patients underwent implantation over a 7-month period. Patient characteristics, qualification for EV ICD placement, nuances in EV ICD implantation in each patient, and post-implant follow-up were reviewed. A total of six out of eight consecutive ICD candidates were identified as potential EV ICD candidates, with five patients undergoing eventual EV ICD implantation (average age, 16.8 years [range, 14-19 years]; four males). Indications for ICD included genetic arrhythmias (n = 3) and hypertrophic cardiomyopathy (n = 2). All patients underwent successful implantation without intraoperative or early postoperative complications. No lead dislodgement, device migration, infection, or inappropriate shocks were observed. All patients demonstrated appropriate R-wave sensing and stable lead parameters at early (4- to 6-week) and mid-term (>3- to 6-month) follow-up. Post-implant exercise testing in two patients showed no significant P- or T-wave oversensing. EV ICD implantation is feasible and well tolerated in appropriately selected pediatric patients. Most pediatric ICD referrals were candidates for EV ICD implant when integrating the EV ICD in regular practice. Implant indications differ among pediatric versus adult EV ICD recipients. While early outcomes are favorable, long-term performance and applicability in smaller patients require further investigation.

Cardiac imaging is crucial in the electrophysiology field, not only as a diagnostic tool but also to expand and guide interventional cardiac electrophysiology procedures. With this consideration in mind, this article aims to review the critical role of cardiac imaging in stratifying patients' risk profiles and assisting the electrophysiological procedure in various scenarios. This article also highlights the future direction within the cardiac electrophysiology field with digital twins, which incorporate cardiac imaging and clinical data to build physiologically accurate cardiac replicas to assist electrophysiological procedural planning.

Patients with heart failure (HF) may experience depression or anxiety due to various reasons associated with their or caregivers' characteristics. The purpose of this study was to explore patients' and caregivers' characteristics associated with hospitalized HF patients' anxiety and depression. A total of 300 hospitalized HF patients with their caregivers were enrolled in the study. Data were collected using the Hospital Anxiety and Depression Scale, which also included patients' and caregivers' characteristics. The statistical significance level was set at P < .05. A statistically significant association was observed between patients' anxiety and age (P = .044), level of education (P = .015), type of diagnosis (P = .001), New York Heart Association (NYHA) class (P = .001), prior hospitalization within the current year (P = .013), current smoking (P = .001), frequency of physical exercise (P = .001), and their self-reported ability for symptom management after hospital discharge (P = .001). A statistically significant association was observed between patients' depression and age (P = .018), type of diagnosis (P = .001), NYHA class (P = .001), prior hospitalization within the current year (P = .004), current smoking (P = .001), occasional alcohol consumption (P = .026), frequency of physical exercise (P = .001), and their self-reported ability for symptom management after hospital discharge (P = .001). In terms of caregivers' characteristics, a statistically significant association was observed between patients' anxiety/depression and the relationship with caregivers (P = .006 and P = .001, respectively), whether caregivers declared added responsibilities among family members (P = .041 and P = .002, respectively), and whether they felt uncertain about patients' clinical outcome (P = .001 and P = .001, respectively). Finally, a statistically significant association was observed between patients' depression and the occupation of their caregivers (P = .038). Patients' characteristics associated with anxiety/depression were demographic and clinical, while caregivers' characteristics associated with patients' anxiety/depression were their self-reports and demographic characteristics. Knowledge of factors that influence anxiety and depression can enable health care professionals to offer appropriate interventions tailored to their needs.

Navik 3D (APN Health, Waukesha, WI, USA) is a navigation software program that uses two-dimensional (2D) fluoroscopy images to provide three-dimensional (3D) information. Left bundle branch area (LBBA) pacing (LBBAP) is a novel physiologic pacing technique where the lead is placed in the right ventricular (RV) basal septum to capture the left bundle branch (LBB). Precise lead placement in this region can be challenging using 2D fluoroscopy. We studied the feasibility of using Navik 3D to identify the location, plane, and depth of the lead in the septum to assist with LBBAP procedures. This observational, prospective single-center study included 14 patients undergoing LBBAP. Navik 3D was used to identify the LBBA, RV septum, RV apex, and lead position in three dimensions using two orthogonal 2D views. The 3D images were overlaid on real-time, gated fluoroscopic images for navigation of the lead. Images of the 3D locations and successful or unsuccessful lead locations were projected onto 2D fluoroscopic images, allowing for repositioning if necessary. All attempted patients had successful LBBA lead implants. An LBB potential was recorded in 61.5% of the patients. Selective LBBAP was achieved in 85% of the patients. The mean QRS duration postimplant was 129.8 &#xb1; 13.1 ms. The mean left ventricular activation time (stimulus R-wave peak in V6) postimplant was 75 &#xb1; 12 ms. No acute complications were recorded. 3D localization of the LBBA using the Navik 3D mapping system was feasible and may assist with more appropriate LBBA lead placement.

A 26-year-old woman at 34 weeks' gestation presented with out-of-hospital cardiac arrest due to ventricular fibrillation. Her electrocardiogram (ECG) showed sinus rhythm with a short P-R interval and an unusually fractionated delta wave. The delta wave was positive in leads I and V2-V6, isoelectric in V1, and negative in inferior leads. An electrophysiology study revealed antegrade accessory pathway conduction with the earliest ventricular activation in the posteroseptal region. Three radiofrequency (RF) ablation procedures, including attempts with pulsed field ablation, were ultimately unsuccessful. Cardiac computed tomography angiography revealed a diverticulum of the middle cardiac vein (MCV). Irrigated RF ablation within the diverticulum successfully eliminated the accessory pathway conduction. We propose that multiple fibers of the coronary sinus or the MCV muscular coat may interface via the diverticulum with the ventricle, leading to multiple wavefronts of ventricular pre-excitation, and that the resultant delta-wave fractionation may allow identification of such an epicardial accessory pathway.

Transcatheter tricuspid valve (TV) interventions (TTVIs), which include transcatheter TV replacement (TTVR) and transcatheter tricuspid edge-to-edge repair (T-TEER), represent a natural evolution in percutaneous valve therapy. However, TTVIs face distinct challenges, chief among them being the frequent presence of transvenous cardiac implantable electronic device (CIED) leads crossing the TV. This review investigates contemporary CIED strategies that eliminate the need for transvenous leads crossing the TV, thereby facilitating safer and more durable integration of device therapy with emerging TTVI technologies.

Prior studies have demonstrated links between systemic inflammation and cardiac arrhythmias. However, evidence on the association between inflammatory biomarkers and resting premature atrial contractions (PACs) or premature ventricular contractions (PVCs) in a national sample of older adults remains limited. Using biomarker data from the Midlife in the United States (MIDUS 3) study (2017-2022), we conducted non-parametric univariate analyses to assess associations between inflammatory markers-specifically, interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor-&#x3b1; (TNF)-&#x3b1;, C-reactive protein (CRP), and fibrinogen-and baseline electrocardiographic (ECG) findings categorized as normal, PVCs, or PACs. We conducted a subsequent multivariate analysis of covariance adjusted for age, waist-hip ratio (WHR), and creatinine, the only confounders showing significant associations. A total of 699 participants were included, 395 (57%) of whom were women, with a mean age of 65.7 years (standard deviation, 9.6 years). The Kruskal-Wallis tests demonstrated significant associations of ECG pattern with IL-6 (median, normal 0.98 vs. PVCs 1.06 vs. PACs 1.40; P = .006) and IL-8 (12.4 vs. 13.99 vs. 13.13; P = .028). No significant associations were found for IL-10, TNF-&#x3b1;, CRP, or fibrinogen (P > .05). After adjustment for age, WHR, and creatinine, the ECG pattern remained significantly associated with IL-6 and IL-8 (P = .034). Elevated IL-6 and IL-8 levels are associated with resting PVCs and PACs in older adults. WHR and renal function also represent significant related factors that warrant consideration in future pathophysiological research.