Arrhythmia detection using an implantable loop recorder after a negative electrophysiology study in Brugada syndrome: Observations from a multicenter international registry.

BACKGROUND: Risk stratification in Brugada syndrome (BrS) remains controversial. In this respect, the role of the electrophysiology study (EPS) has been a subject of debate. In some centers, it is common practice to use an implantable loop recorder (ILR) after a negative EPS to help in risk stratification. However, the diagnostic value of this approach has never been specifically addressed. OBJECTIVE: The aim of this study was to describe the baseline characteristics and the main findings of a diagnostic workup strategy with an ILR after a negative EPS in BrS. METHODS: We conducted a retrospective international registry including patients with BrS and negative EPS (ie, noninducible ventricular tachycardia or ventricular fibrillation) before ILR monitoring. RESULTS: The study included 65 patients from 8 referral hospitals in The Netherlands, Spain, and the United Kingdom (mean age, 39 ± 16 years; 72% male). The main indication for ILR monitoring was unexplained syncope/presyncope (66.2%). During a median follow-up of 39.0 months (Q1 25.0-Q3 47.6 months), 18 patients (27.7%) experienced 21 arrhythmic events (AEs). None of the patients died during follow-up. Bradyarrhythmias were the most common finding (47.6%), followed by atrial tachyarrhythmias (38.1%). Only 3 patients presented with ventricular arrhythmias. AEs were considered incidental in 12 patients (66.7%). In 11 patients (61.1%), AEs led to specific changes in treatment. CONCLUSION: The use of ILR after a negative EPS in BrS is a safe strategy that reflected the high negative predictive value of EPS for ventricular arrhythmia in this syndrome. In addition, it allowed the detection of AEs in a significant proportion of patients, with therapeutic implications in most of them.

Feasibility and safety of left bundle branch area pacing in cardiac amyloidosis. A single center experience.

BACKGROUND: Conventional right ventricle (RV) pacemaker stimulation has been associated with worse clinical outcomes in patients with cardiac amyloidosis (CA). Left bundle branch area pacing (LABPP) has been suggested as a promising alternative. We sought to assess the safety, feasibility, and outcomes of LABPP in patients with CA. METHODS: We retrospectively analyzed echocardiography and pacing parameters and clinical outcomes in 23 consecutive patients with CA and LBBAP implanted from June 2020 to October 2022. RESULTS: LBBAP was successfully performed in 22 over 23 patients (19 male, 78.6 ± 11.7 years, 20 ATTR, mean LVEF 45.5 ± 16.2%). After the procedure, 9 patients showed Qr pattern and 11 a qR pattern in V1 on ECG. Average procedure time was 67 ± 28 min. After 7.7 ± 5.2 months follow-up, no procedure-related complications had occurred. Although, a significant reduction in QRS width (p = .001) was achieved, we did not observe significant changes in LVEF and Nt ProBNP at 6 months of follow-up. Pacing parameters were stable during follow-up: LBB capture threshold and R wave amplitude were 1.0 ±  0.5 V and 10.6 ± 6.0 mV versus 0.8 ±  0.1 V, p = .21 and 10.6 ± 5.1 mV (p = .985) at follow up. CONCLUSION: LBBAP is safe and feasible pacing technique for patients with CA. LBBAP is associated with significant narrowing of QRSd without worsening in LVEF and Nt-proBNP.

Symptom burden guiding invasive electrophysiological study in paroxysmal supraventricular tachycardia: The believe SVT registry.

BACKGROUND AND OBJECTIVE: Patients with palpitations clinically suggestive of paroxysmal supraventricular tachycardia (PSVT) are often managed conservatively until ECG-documentation of the tachycardia, leading to high impact on life quality and healthcare resource utilization. We evaluated results of electrophysiological study (EPS), and ablation when appropriate, among these patients, with special focus on gender differences in management. METHODS: BELIEVE SVT is a European multicenter, retrospective registry in tertiary hospitals performing EPS in patients with palpitations, without ECG-documentation of tachycardia or preexcitation, and considered highly suggestive of PSVT by a cardiologist or cardiac electrophysiologist. We analyzed clinical characteristics, results of EPS and ablation, complications, and clinical outcomes during follow-up. RESULTS: Six-hundred eighty patients from 20 centers were included. EPS showed sustained tachycardia in 60.9% of patients, and substrate potentially enabling AVNRT in 14.7%. No major/permanent complications occurred. Minor/transient complications were reported in 0.84% of patients undergoing diagnostic-only EPS and 1.8% when followed by ablation. During a 3.4-year follow-up, 76.2% of patients remained free of palpitations recurrence. Ablation (OR: 0.34, P < .01) and male gender (OR: 0.58, P = .01) predicted no recurrence. Despite a higher female proportion among patients with recurrence, (77.2% vs 63.5% among those asymptomatic during follow-up, P < .01), 73% of women in this study reported no recurrence of palpitations after EPS. CONCLUSIONS: EPS and ablation are safe and effective in preventing recurrence of nondocumented palpitations clinically suggestive of PSVT. Despite a lower efficacy, this strategy is also highly effective among women and warrants no gender differences in management.

Experience and insights from a prolonged electrocardiographic monitorization with a wearable system after an embolic stroke of unknown source.

BACKGROUND: Embolic cerebrovascular events that remain of unknown etiology after a thorough diagnostic evaluation, are known as Embolic Strokes of Undetermined Source (ESUS). Subclinical atrial fibrillation (AF) represents a significant underlying cause of ESUS. Our aims were to examine the overall diagnostic yield of a prolonged cardiac monitoring wearable system (PCMw) after an ESUS to detect AF and factors associated with it, including the time frame from the ESUS event to PCMw initiation. Additionally, to evaluate the frequency of unexpected arrhythmic events (UAE) and their prognostic implications. METHODS: We retrospectively analyzed 200 ECG recordings (3-leads, 30 days duration) by means of a PCMw in patients with an ESUS to detect AF lasting longer than 30 s, between 2017 and 2021. UAE were defined as arrhythmia events that were not correlated to the main reason of prolonged cardiac monitoring. RESULTS: AF was detected in 21 patients (10.5%). Patients with AF had more left atrial enlargement (OR = 4.22 [1.59-6.85]; p = .01) and atrial arrythmias in the initial 24-h Holter during hospitalization (OR = 5.73 [2.03-16.49]; p = .001). The detection of AF was significatively higher if the PCMw was worn within the first 30 days after the ESUS compared to beyond 30 days (17% vs. 10.3%; p = .002). Fifty three patients (26.5%) had UAE during PCMw. In six of them these findings led to targeted treatment. CONCLUSION: PCMw represents a feasible non-invasive device that could reliably detect subclinical AF episodes after an ESUS. Diagnostic yield was significatively higher when used within the first 30 days after the event, especially in selected patients. UAE were common, but did not impact prognosis.

Efficacy and safety of Proglide use and early discharge after atrial fibrillation ablation compared to standard approach. PROFA trial.

BACKGROUND AND OBJECTIVES: The common practice after atrial fibrillation ablation is to admit patients for an overnight stay. The aim of this study was to compare a strategy of vascular suture mediated closure system utilization and early discharge (strategy A) compared to traditional closure and overnight hospitalization (strategy B) regarding feasibility, safety, quality of life and health care cost effectiveness. METHODS AND RESULTS: Hundred patients were randomized to compare both strategies. No clinical differences were reported except diabetes mellitus. Six patients (6%) had and emergency visit or were admitted in the first 30 days after procedure. Three occurred in strategy A versus three in strategy B (p = 1) (p < .005 for non-inferiority). Forty out of 50 patients (80%) were safely discharged in a time frame of 3 h and 42 patients (84%) were discharged in the same day of the procedure in strategy A. Time to discharge was shorter in strategy A compared to strategy B. (5.89 ± 7.47 h vs. 27.09 ± 2.29 p < .005). No differences were obtained in quality-of-life outcomes. Mean (95% CI) euros cost saving per patient in strategy A was 379.16 ± 93.55 p < .001. Ten acute complications (10% patients CI 95% 4.02%-15.98%) were reported during the trial. Seven (14% CI 95% 4.04%-23.96%) occurred in strategy A patients versus 3 (6% CI 95% 0.8%-12.8%) in strategy B. (p = .182) CONCLUSION: A strategy of vascular suture mediated closure system utilization and early discharge was feasible, reduced time to discharge, saved costs and was not associated with more complications or admissions/emergency visits in a 30-day time frame after procedure compared to a strategy of regular admission and discharge after overnight stay. There were no differences regarding quality-of-life parameters between both strategies.

Estimation of the QTc interval in the presence of right bundle branch block: A comparative study using validated formulae for left bundle branch block.

BACKGROUND: Adequate measurement of the QT interval is of clinical importance in order to identify patients at higher risk for ventricular arrhythmias. Previous studies have described different methods to estimate baseline QT in patients with left bundle branch block (LBBB). However, the evidence regarding the assessment of the QT in patients with right bundle branch block (RBBB) is scarce. AIM: To analyze the feasibility and reliability of the different formulae described for LBBB in the estimation of the baseline QT in the presence of RBBB. METHODS: We performed an observational study including patients who underwent electrophysiology study and/or ablation. Two types of RBBB were considered: 1) pacing-induced and 2) transient true RBBB. QRS, JT and QT intervals were measured during baseline and RBBB. Estimated QTc was calculated using LBBB formulae: Bogossian, Rautaharju, Tabatabaei, Tang-Rabkin, Yankelson, Wang. Linear correlation and intraclass correlation coefficients (ICC) were used to assess the reliability of these formulae for the estimation of baseline QTc. RESULTS: We finally included a total of 100 patients. Correlations between baseline and estimated QTc were strong (R > 0.7) for all the formulae except for Tabatabaei. Yankelson and Wang showed the highest reliability (ICC = 0.775 and 0.727, respectively). Yankelson appeared to be the most accurate formula, with a mean estimated QTc closest to baseline values. CONCLUSION: Previously described formulae for LBBB exhibited marked differences regarding reliability in the estimation of the QTc interval in the presence of RBBB. According to our results, Yankelson showed the most consistent and accurate agreement in this setting.

Trapped p waves causing loss of physiological left bundle branch pacing.

We present the case of a 75-year-old woman with severe aortic stenosis and moderate left ventricular dysfunction, who underwent elective transcatheter aortic valve replacement. After the procedure, the patient developed a left bundle branch block and a long PR interval. For this reason, a dual chamber pacemaker with pacing in the left bundle branch area was implanted. On device interrogation, we confirmed the presence of functional atrial undersensing causing loss of ventricular electric resynchronization. This case highlights the importance of recognizing this problem and, by means of device reprogramming and pharmacological intervention, suggests a stepwise approach to solve it.

Benefits of cardiac pacing in ICD recipients with hypertrophic cardiomyopathy.

PURPOSE: Implantable cardiac defibrillator (ICD) is the only definitive therapy for prevention of sudden cardiac death in hypertrophic cardiomyopathy (HCM). Conventional transvenous ICDs can provide cardiac pacing unlike new subcutaneous ICD, but the usefulness of cardiac pacing in HCM patients is not well defined. We sought to assess the usefulness of ICD pacing in HCM. METHODS: We retrospectively analyzed 93 HCM patients who had undergone ICD implantation at our center. Usefulness of pacing was defined as follows: 1) need of pacing due to bradycardia or AV conduction disturbances, 2) improvement of LV outflow tract obstruction by sequential AV pacing, 3) need for CRT pacing, or 4) successful antitachycardia pacing without a subsequent shock. Independent predictors of useful pacing were investigated by multivariable analysis. RESULTS: During a mean follow-up of 91.3 ± 5.5 months, 43 patients (46.2%) reached the composite endpoint. Independent predictors of pacing usefulness were older age (HR 1.36; 95%CI: 1.088-1.709; p=0.007) and NYHA functional class ≥ II (HR 2.15; 95%CI: 1.083-4.301; p=0.029). Twenty-eight (30.1%) patients had appropriate ICD interventions, triggered by a monomorphic ventricular tachycardia (MVT) in 22 of them (78.5%). In 17 individuals with MVT (77%), antitachycardia pacing successfully treated MVT. CONCLUSIONS: In our HCM series of patients with ICD, 46% of individuals benefitted from cardiac pacing. MVT were documented in nearly 80% of the patients with ventricular arrhythmias and antitachycardia pacing successfully treated them in 77% of cases.

Incidencia, tasa de éxito, complicaciones y factores predictores de empleo de la vía femoral en procedimientos percutáneos de extracción de electrodos / Incidence, success rate, complications and predictive factors of the use of the femoral route for the removal of the electrodes after percutaneous procedures

Resumen Introducción: en los procedimientos de extracción de electrodos, la vía femoral se usa cuando la vía superior ha fracasado. Objetivo: describir la incidencia, el éxito, las complicaciones y los predictores de uso de la vía femoral. Métodos: se realizó un análisis de la incidencia del uso de la vía femoral y los factores predictores en pacientes a quienes se les realizó extracción de electrodos entre noviembre de 2011 y noviembre de 2017. Resultados: se incluyeron 85 pacientes, con edad media de 62,36 ± 11,15 años. El 38,9% de los dispositivos eran marcapasos. Se extrajeron 135 electrodos, 59,3% de fijación pasiva. La mediana de tiempo desde el implante fue de 102 (60-174) meses. Se empleó la ruta femoral en el 25,9% de los procedimientos. Se obtuvo éxito clínico en el 92,9% de los pacientes. La extracción no fue exitosa en el 22,7% de los procedimientos cuando se usó la vía femoral, en comparación con el 1,6% cuando se usó la vía superior (p 0,004). La extracción no fue completa en el 36,4% de los procedimientos cuando se empleó la vía femoral en comparación con el 9,5% por vía superior (p 0,007). Los factores que predijeron el empleo de la ruta femoral fueron la presencia de electrodos de fijación pasiva [OR IC 95% 13,69 (3,06-62,5) p 0,001] y el tiempo desde el implante del electrodo [OR IC 95% por cada 10 meses 1,04 (1,00-1,09) p 0,044]. Conclusiones: se empleó la ruta femoral en el 25,9% de los procedimientos. No fue eficaz en el 22,7% de las intervenciones. Los factores que predijeron su utilización fueron la presencia de electrodos de fijación pasiva y el tiempo desde el implante del electrodo.

Abstract Introduction: The femoral route is used in electrode removal procedures when the upper route has failed. Objective: To describe the incidence, success rate, complications and predictive factors for the use of the femoral route. Methods: An analysis was performed on the incidence of use of the femoral route and the predictive factors in patients in whom electrode removal was carried out between November 2011 and November 2017. Results: The study included 85 patients with a mean age of 62.36 ± 11.5 years. Pacemakers made up 38.9% of the devices. A total of 135 electrodes, 59.3% of passive fixation, were removed. The median time since the implant was 102 (60-174) months. The femoral route was used in 25.9% of the procedures. Clinical success was achieved in 92.9% of the patients. The removal was not successful in 22.7% of the procedures when the femoral route was used, compared to 1.6% when the upper route was used (P = .004). The removal was not completed in 36.4% of the procedures when the femoral route was used, compared to 9.5% with the upper route (P = .007). The factors that predicted the use of the femoral route were the presence of passive-fixation electrodes (OR = 13.69: 95% CI; 3.06 - 62.5, P = .001), and the time since the electrodes were implanted (OR = 1.04, 95% CI; 1.00 - 1.09, P = .044, for every 10 months). Conclusions: The femoral route was employed in 25.9% of the procedures. It was not effective in 22.7% of the interventions. The factors that predicted its use were the presence of passive-fixation electrodes and the time since the electrode implant.

The Role of Anxiety in Patients With Persistent Atrial Fibrillation Undergoing Elective Cardioversion: An Observational Study.

OBJECTIVE: Anxiety is often present among patients with atrial fibrillation (AF). This condition has been associated with greater symptom severity and worse quality of life in these patients. However, the influence of anxiety on the risk of AF recurrence is not well known. We aimed to define the level of anxiety in patients with persistent AF undergoing elective cardioversion (EC) and determine whether there is an association between anxiety and the risk of early AF recurrence after EC. METHODS: Anxiety was measured before EC using the State-Trait Anxiety Inventory. Early AF recurrence was assessed with a control electrocardiogram at 30-day follow-up. RESULTS: We included 107 patients undergoing effective EC. Early AF recurrence was diagnosed in 40 patients (37.4%). Compared with those who remained in sinus rhythm, individuals with early AF recurrence had significantly higher levels of trait anxiety (23.1 [10.4] versus 17.9 [9.5]; p = .013) and larger left atrial volume index (45.8 [12.3] versus 37.9 [13.3] ml/m; p = .004). Both variables remained independently associated with early AF recurrence after multivariate analysis. A predictive model including trait anxiety score >20 and left atrial volume index >41 ml/m showed acceptable accuracy for the diagnosis of early AF recurrence (area under the curve = 0.733; 95% confidence interval = 0.634-0.832; p < .001). CONCLUSIONS: Our study shows that trait anxiety is an independent risk factor for early AF recurrence after EC. Further studies are warranted to assess the beneficial role of anxiety-reducing strategies on the outcomes of patients with AF.

[Bayes' syndrome in cardiac surgery: prevalence of interatrial block in patients younger than 65 years undergoing cardiac surgery and association with postoperative atrial fibrillation]. / Síndrome de Bayés en cirugía cardiaca: prevalencia de bloqueo interauricular en menores de 65 años sometidos a cirugía cardiaca y su asociación con fibrilación auricular en el postoperatorio.

OBJECTIVE: Interatrial block (IAB) is a well-known entity that is associated with an increased risk of atrial fibrillation (AF). This association is called Bayes' syndrome. The aim of our study was to define the prevalence of IAB among patients younger than 65 years undergoing cardiac surgery and determine whether there is an association between the presence of interatrial conduction delay and postoperative atrial fibrillation (POAF). METHOD: A total of 207 patients were enrolled. Partial IAB was defined as P-wave>120ms. Advanced IAB was defined as P-wave>120ms+biphasic morphology in the inferior leads. Ocurrence of POAF was assessed and a comparative analysis was conducted between patients that did and did not develop AF. RESULTS: IAB prevalence was 78.3% (partial 66.2%, advanced 12.1%). POAF occurred in 28.5% of all patients, and was more frequent among patients with advanced IAB (44%) compared to 27.7% and 24.4% of POAF among patients with partial IAB and without IAB, respectively. Patients who developed POAF were significantly older, had significantly higher NTproBNP, higher prevalence of atrial enlargement and thyroid disease. After multivariate analysis, advanced IAB was found to be independently associated with POAF. CONCLUSIONS: IAB is a frequent finding among patients undergoing cardiac surgery. According to our results, advanced IAB is independently associated with POAF in younger patients (<65 years) undergoing cardiac surgery.

Síndrome de Bayés en cirugía cardiaca: prevalencia de bloqueo interauricular en menores de 65 años sometidos a cirugía cardiaca y su asociación con fibrilación auricular en el postoperatorio / Bayes' syndrome in cardiac surgery: prevalence of interatrial block in patients younger than 65 years undergoing cardiac surgery and association with postoperative atrial fibrillation

Resumen Objetivo: El bloqueo interauricular (BIA) es una entidad asociada con un mayor riesgo de presentar fibrilación auricular (FA), constituyendo el denominado síndrome de Bayés. El objetivo de nuestro estudio fue definir la prevalencia de BIA en pacientes menores de 65 años sometidos a cirugía cardiaca y determinar si existe una asociación entre la presencia de BIA y la aparición de FA postoperatoria. Método: Se incluyeron un total de 207 pacientes. Se definió BIA parcial como onda P > 120 ms. Se definió BIA avanzado como onda P > 120 ms con morfología bifásica en derivaciones inferiores. Se determinó la frecuencia de aparición de FA postoperatoria y se realizó un análisis comparativo entre los pacientes que presentaron y los que no presentaron esta arritmia. Resultados: La prevalencia de BIA fue del 78.3% (parcial, 66.2%; avanzado, 12.1%). La frecuencia de aparición de FA fue del 28.5% de forma global, siendo mayor en los pacientes con BIA avanzado (44%) comparado con pacientes con BIA parcial (27.7%) y sin BIA (24.4%). Los pacientes que presentaron FA fueron significativamente mayores, con niveles más elevados de NTproBNP y presentaron mayor prevalencia de dilatación auricular y de patología tiroidea. El análisis multivariable demostró una asociación independiente entre BIA avanzado y FA postoperatoria. Conclusiones: El BIA es una entidad frecuente en pacientes sometidos a cirugía cardiaca. En nuestro estudio, el BIA avanzado se asocia de forma independiente con una mayor frecuencia de FA postoperatoria en pacientes menores de 65 años sometidos a cirugía cardiaca.

Abstract Objective: Interatrial block (IAB) is a well-known entity that is associated with an increased risk of atrial fibrillation (AF). This association is called Bayes' syndrome. The aim of our study was to define the prevalence of IAB among patients younger than 65 years undergoing cardiac surgery and determine whether there is an association between the presence of interatrial conduction delay and postoperative atrial fibrillation (POAF). Method: A total of 207 patients were enrolled. Partial IAB was defined as P-wave > 120 ms. Advanced IAB was defined as P-wave > 120 ms + biphasic morphology in the inferior leads. Ocurrence of POAF was assessed and a comparative analysis was conducted between patients that did and did not develop AF. Results: IAB prevalence was 78.3% (partial 66.2%, advanced 12.1%). POAF occurred in 28.5% of all patients, and was more frequent among patients with advanced IAB (44%) compared to 27.7% and 24.4% of POAF among patients with partial IAB and without IAB, respectively. Patients who developed POAF were significantly older, had significantly higher NTproBNP, higher prevalence of atrial enlargement and thyroid disease. After multivariate analysis, advanced IAB was found to be independently associated with POAF. Conclusions: IAB is a frequent finding among patients undergoing cardiac surgery. According to our results, advanced IAB is independently associated with POAF in younger patients (< 65 years) undergoing cardiac surgery.

Two-Dimensional Speckle Tracking Echocardiography in Heart Transplant Patients: Two-Year Follow-Up of Right and Left Ventricular Function.

BACKGROUND: Evolution of left and right ventricular (LV and RV) function after heart transplantation (HT) has not been well described. Our objective was to evaluate the evolution of echocardiographic parameters of both ventricles along the first 2 years after HT. METHODS: We followed 31 HT recipients with serial echocardiograms for up to 2 years. Echocardiograms with AR ≥2R were excluded. We analyzed LV global longitudinal strain (LV GLS) by speckle tracking in 12 segments in four- and two-chamber views and RV global longitudinal strain (RV GLS) in four-chamber view. Control group included 25 healthy volunteers. RESULTS: Even though LVEF was preserved, LV GLS was reduced early post-HT (-17.7 ± 3.0 in HT vs. -20.7 ± 2.8 in controls, P = 0.02), improving progressively until its complete normalization 2 years after HT (-20.0 ± 3.7 vs. -20.7 ± 2.8, P = 0.60). TAPSE was impaired in the early post-HT period and increased progressively (11.9 ± 2.9 mm at baseline vs. 19.0 ± 3.6 mm at 2 years, P < 0.001). RV GLS rose during follow-up as well (-17.4 ± 3.5 at baseline vs. -22.6 ± 3.3 at 2 years, P = 0.001), reaching normal values 1 year after HT. CONCLUSION: In this series of HT recipients with uneventful postoperative course, LV and RV GLS values were significantly reduced early after HT and improved progressively until their complete normalization two and 1 year after HT, respectively. This is the first study to show a full recovery of LV and RV deformation parameters and offers "normal" strain values that, if confirmed in larger studies, could be useful for monitoring the evolution of HT recipients.

Intravascular imaging in Kounis syndrome: role of IVUS and OCT in achieving an etiopathogenic diagnosis.

We report a case of a 60-year-old male patient presenting with anaphylactic response to anchovies associated with an acute coronary syndrome. His history was remarkable for coronary artery disease treated with a drug eluting stent to the right coronary artery six years before and stent fracture documented by coronary angiography four years prior to the event. Coronary angiography on admission revealed a very late stent thrombosis (VLST) in the right coronary artery. Intracoronary imaging techniques (IVUS and OCT) were used and were key to discard main causes of VLST. We described the characteristics of intracoronary images, along with the advantages and disadvantages of these techniques. The findings described in this case could explain a new physiopathological mechanism of stent thrombosis occurring in stent fractures.