Sex Differences in Left Bundle Branch Area Pacing Versus Biventricular Pacing for Cardiac Resynchronization Therapy.

BACKGROUND: Women respond more favorably to biventricular pacing (BIVP) than men. Sex differences in atrioventricular and interventricular conduction have been described in BIVP studies. Left bundle branch area pacing (LBBAP) offers advantages due to direct capture of the conduction system. We hypothesized that men could respond better to LBBAP than BIVP. OBJECTIVES: This study aims to describe the sex differences in response to LBBAP vs BIVP as the initial cardiac resynchronization therapy (CRT). METHODS: In this multicenter prospective registry, we included patients with left ventricular ejection fraction ≤35% and left bundle branch block or a left ventricular ejection fraction ≤40% with an expected right ventricular pacing exceeding 40% undergoing initial CRT with LBBAP or BIVP. The composite primary outcome was heart failure-related hospitalization and all-cause mortality. The primary safety outcome included all procedure-related complications. RESULTS: There was no significant difference in the primary outcome when comparing men and women receiving LBBAP (P = 0.46), whereas the primary outcome was less frequent in women in the BIVP group than men treated with BIVP (P = 0.03). The primary outcome occurred less frequently in men undergoing LBBAP (29.9%) compared to those treated with BIVP (46.5%) (P = 0.004). In women, the incidence of the primary endpoint was 24.14% in the LBBAP group and 36.2% in the BIVP group; however, this difference was not statistically significant (P = 0.23). Complication rates remained consistent across all groups. CONCLUSIONS: Men and women undergoing LBBAP for CRT had similar clinical outcomes. Men undergoing LBBAP showed a lower risk of heart failure-related hospitalizations and all-cause mortality compared to men undergoing BIVP, whereas there was no difference between LBBAP and BIVP in women.

Left Bundle Branch Pacing vs Left Ventricular Septal Pacing vs Biventricular Pacing for Cardiac Resynchronization Therapy.

BACKGROUND: Left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) are considered to be acceptable as LBBAP strategies. Differences in clinical outcomes between LBBP and LVSP are yet to be determined. OBJECTIVES: The purpose of this study was to compare the outcomes of LBBP vs LVSP vs BIVP for CRT. METHODS: In this prospective multicenter observational study, LBBP was compared with LVSP and BIVP in patients undergoing CRT. The primary composite outcome was freedom from heart failure (HF)-related hospitalization and all-cause mortality. Secondary outcomes included individual components of the primary outcome, postprocedural NYHA functional class, and electrocardiographic and echocardiographic parameters. RESULTS: A total of 415 patients were included (LBBP: n = 141; LVSP: n = 31; BIVP: n = 243), with a median follow-up of 399 days (Q1-Q3: 249.5-554.8 days). Freedom from the primary composite outcomes was 76.6% in the LBBP group and 48.4% in the LVSP group (HR: 1.37; 95% CI: 1.143-1.649; P = 0.001), driven by a 31.4% absolute increase in freedom from HF-related hospitalizations (83% vs 51.6%; HR: 3.55; 95% CI: 1.856-6.791; P < 0.001) without differences in all-cause mortality. LBBP was also associated with a higher freedom from the primary composite outcome compared with BIVP (HR: 1.43; 95% CI: 1.175-1.730; P < 0.001), with no difference between LVSP and BIVP. CONCLUSIONS: In patients undergoing CRT, LBBP was associated with improved outcomes compared with LVSP and BIVP, while outcomes between BIVP and LVSP are similar.

50-W vs 40-W During High-Power Short-Duration Ablation for Paroxysmal Atrial Fibrillation: A Multicenter Prospective Study.

BACKGROUND: High-power short-duration (HPSD) radiofrequency ablation of atrial fibrillation (AF) increases first-pass pulmonary vein isolation (PVI) and freedom from atrial arrhythmias while decreasing procedural time. However, the optimal power setting in terms of safety and efficacy has not been determined. OBJECTIVES: This study compared the procedural characteristics and clinical outcomes of 50-W vs 40-W during HPSD ablation of paroxysmal AF. METHODS: Patients from the REAL-AF prospective multicenter registry (Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation) undergoing HPSD ablation of paroxysmal AF, either using 50-W or 40-W, were included. The primary efficacy outcome was freedom from all-atrial arrhythmias. The primary safety outcome was the occurrence of any procedural complication at 12 months. Secondary outcomes included procedural characteristics, AF-related symptoms, and the occurrence of transient ischemic attack or stroke at 12 months. RESULTS: A total of 383 patients were included. Freedom from all-atrial arrhythmias at 12 months was 80.7% in the 50-W group and 77.3% in the 40-W group (Log-rank P = 0.387). The primary safety outcome occurred in 3.7% of patients in the 50-W group vs 2.8% in the 40-W group (P = 0.646). The 50-W group had a higher rate of first-pass PVI (82.3% vs 76.2%; P = 0.040) as well as shorter procedural (67 minutes [IQR: 54-87.5 minutes] vs 93 minutes [IQR: 80.5-111 minutes]; P < 0.001) and radiofrequency ablation times (15 minutes [IQR: 11.4-20 minutes] vs 27 minutes [IQR: 21.5-34.6 minutes]; P < 0.001) than the 40-W group. CONCLUSIONS: There was no significant difference in freedom from all-atrial arrhythmias or procedural safety outcomes between 50-W and 40-W during HPSD ablation of paroxysmal AF. The use of 50-W was associated with a higher rate of first-pass PVI as well as shorter procedural times.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic.

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic.

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic.

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Left Bundle Branch Area Pacing Versus Biventricular Pacing as Initial Strategy for Cardiac Resynchronization.

BACKGROUND: Left bundle branch area pacing (LBBAP) for cardiac resynchronization therapy (CRT) is an alternative to biventricular pacing (BiVp). OBJECTIVES: The purpose of this study was to compare the outcomes between LBBAP and BiVp as an initial implant strategy for CRT. METHODS: In this prospective multicenter, observational, nonrandomized study, first-time CRT implant recipients with LBBAP or BiVp were included. The primary efficacy outcome was a composite of heart failure (HF)-related hospitalization and all-cause mortality. The primary safety outcomes were acute and long-term complications. Secondary outcomes included postprocedural New York Heart Association functional class and electrocardiographic and echocardiographic parameters. RESULTS: A total of 371 patients (median follow-up of 340 days [IQR: 206-477 days]) were included. The primary efficacy outcome occurred in 24.2% in the LBBAP vs 42.4% in the BiVp (HR: 0.621 [95% CI: 0.415-0.93]; P = 0.021) group, driven by a reduction in HF-related hospitalizations (22.6% vs 39.5%; HR: 0.607 [95% CI: 0.397-0.927]; P = 0.021) without significant difference in all-cause mortality (5.5% vs 11.9%; P = 0.19) or differences in long-term complications (LBBAP: 9.4% vs BiVp: 15.2%; P = 0.146). LBBAP resulted in shorter procedural (95 minutes [IQR: 65-120 minutes] vs 129 minutes [IQR: 103-162 minutes]; P < 0.001) and fluoroscopy times (12 minutes [IQR: 7.4-21.1 minutes] vs 21.7 minutes [IQR: 14.3-30 minutes]; P < 0.001), shorter QRS duration (123.7 ± 18 milliseconds vs 149.3 ± 29.1 milliseconds; P < 0.001), and higher postprocedural left ventricular ejection fraction (34.1% ± 12.5% vs 31.4% ± 10.8%; P = 0.041). CONCLUSIONS: LBBAP as an initial CRT strategy resulted in a lower risk of HF-related hospitalizations compared to BiVp. A reduction in procedural and fluoroscopy times, shorter paced QRS duration, and improvements in left ventricular ejection fraction compared with BiVp were observed.

Outcomes of chlorhexidine lavage without capsulectomy versus complete capsulectomy after lead extraction for the treatment of cardiac implantable electronic device infection.

INTRODUCTION: Capsulectomy is recommended in patients with cardiac implantable electronic device (CIED) infection after transvenous lead extraction (TLE) but is time-consuming and requires extensive tissue debridement. In this study, we describe the outcomes of chlorhexidine gluconate (CHG) lavage in lieu of capsulectomy for the treatment of CIED infections. METHODS: This retrospective study included patients who underwent TLE for CIED-related infections in two institutions in Colombia. In the capsulectomy group, complete capsulectomy was performed after hardware removal. In the CHG group, exhaustive lavage of the generator pocket with 20 cc of CHG at 2% followed by irrigation with approximately 500 cc of normal saline (0.9% sodium chloride) was performed. The primary outcomes included reinfection and hematoma formation in the generator pocket. Secondary outcomes included the occurrence of any adverse reaction to chlorhexidine, the need for reintervention, infection-related mortality, and total procedural time. RESULTS: A total of 102 patients (mean age 67.2 ± 13 years, 32.4% female) underwent CIED extraction with either total capsulectomy (n = 54) or CHG (n = 48) lavage. Hematoma formation was significantly higher in the capsulectomy group versus the CHG group (13% vs. 0%, p = .014), with no significant differences in the reinfection rate. Capsulectomy was associated with longer procedural time (133.7 ± 78.5 vs. 89.9 ± 51.8 min, p = .002). No adverse reactions to CHG were found. Four patients (4.3%) died from worsening sepsis: three in the capsulectomy group and one in the CHG group (p = .346). CONCLUSIONS: In patients with CIED infections, the use of CHG without capsulectomy resulted in a lower risk of hematoma formation and shorter procedural times without an increased risk of reinfection or adverse events associated with CHG use.

Critical appraisal of technologies to assess electrical activity during atrial fibrillation: a position paper from the European heart rhythm association and European society of cardiology working group on ecardiology in collaboration with the heart rhythm society, Asia pacific heart rhythm society, Latin American Heart rhythm society and computing in cardiology

Abstract We aim to provide a critical appraisal of basic concepts underlying signal recording and processing technologies applied for (I) atrial fibrillation (AF) mapping to unravel AF mechanisms and/or identifying target sites for AF therapy and (ii) AF detection, to optimize usage of technologies, stimulate research aimed at closing knowledge gaps, and developing ideal AF recording and processing technologies. Recording and processing techniques for assessment of electrical activity during AF essential for diagnosis and guiding ablative therapy including body surface electrocardiograms (ECG) and endo- or epicardial electrograms (EGM) are evaluated. Discussion of (I) differences in uni-, bi-, and multi-polar (omnipolar/Laplacian) recording modes, (ii) impact of recording technologies on EGM morphology, (iii) global or local mapping using various types of EGM involving signal processing techniques including isochronal-, voltage- fractionation-, dipole density-, and rotor mapping, enabling derivation of parameters like atrial rate, entropy, conduction velocity/direction, (iv) value of epicardial and optical mapping, (v) AF detection by cardiac implantable electronic devices containing various detection algorithms applicable to stored EGMs, (vi) contribution of machine learning (ML) to further improvement of signals processing technologies. Recording and processing of EGM (or ECG) are the cornerstones of (body surface) mapping of AF. Currently available AF recording and processing technologies are mainly restricted to specific applications or have technological limitations. Improvements in AF mapping by obtaining highest fidelity source signals (e. g. catheter­electrode combinations) for signal processing (e. g. filtering, digitization, and noise elimination) is of utmost importance. Novel acquisition instruments (multi-polar catheters combined with improved physical modelling and ML techniques) will enable enhanced and automated interpretation of EGM recordings in the near future.

Critical appraisal of technologies to assess electrical activity during atrial fibrillation: a position paper from the European Heart Rhythm Association and European Society of Cardiology Working Group on eCardiology in collaboration with the Heart Rhythm Society, Asia Pacific Heart Rhythm Society, Latin American Heart Rhythm Society and Computing in Cardiology.

We aim to provide a critical appraisal of basic concepts underlying signal recording and processing technologies applied for (i) atrial fibrillation (AF) mapping to unravel AF mechanisms and/or identifying target sites for AF therapy and (ii) AF detection, to optimize usage of technologies, stimulate research aimed at closing knowledge gaps, and developing ideal AF recording and processing technologies. Recording and processing techniques for assessment of electrical activity during AF essential for diagnosis and guiding ablative therapy including body surface electrocardiograms (ECG) and endo- or epicardial electrograms (EGM) are evaluated. Discussion of (i) differences in uni-, bi-, and multi-polar (omnipolar/Laplacian) recording modes, (ii) impact of recording technologies on EGM morphology, (iii) global or local mapping using various types of EGM involving signal processing techniques including isochronal-, voltage- fractionation-, dipole density-, and rotor mapping, enabling derivation of parameters like atrial rate, entropy, conduction velocity/direction, (iv) value of epicardial and optical mapping, (v) AF detection by cardiac implantable electronic devices containing various detection algorithms applicable to stored EGMs, (vi) contribution of machine learning (ML) to further improvement of signals processing technologies. Recording and processing of EGM (or ECG) are the cornerstones of (body surface) mapping of AF. Currently available AF recording and processing technologies are mainly restricted to specific applications or have technological limitations. Improvements in AF mapping by obtaining highest fidelity source signals (e.g. catheter-electrode combinations) for signal processing (e.g. filtering, digitization, and noise elimination) is of utmost importance. Novel acquisition instruments (multi-polar catheters combined with improved physical modelling and ML techniques) will enable enhanced and automated interpretation of EGM recordings in the near future.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS).

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Imaging Integration to Localize and Protect the Left Coronary Artery in Patients Undergoing LAAEI.

OBJECTIVES: This study sought to determine the distance between the anterior wall of the left atrial appendage (LAA) ostium to the left main coronary artery (LMCA) and the left circumflex artery (LCx) in patients undergoing left atrial appendage electrical isolation (LAAEI). BACKGROUND: LAAEI improves outcomes in nonparoxysmal atrial fibrillation ablation. There is a potential risk of damaging the LMCA and the LCx during LAAEI. METHODS: Patients undergoing LAAEI during the period between January 1, 2017 and October 31, 2018, were included in this study. Patients underwent cardiac computed tomography prior to ablation. The position of the LAA was analyzed. The closest distances between the LMCA, its bifurcation, LCx, and the anterior wall of the LAA ostium were measured. Additionally, imaging integration was performed to localize these vessels and catheter ablation was performed at least 5 mm away. RESULTS: A total of 74 patients (mean age: 68 ± 9.5 years; male 54%) who underwent LAAEI were included. The mean distance from the anterior wall of the LAA ostium to the LMCA was 7.88 ± 2.8 mm, to the LMCA bifurcation was 9.24 ± 4.40 mm, and to the LCx was 10.03 ± 4.56 mm. The LCx artery was found along the LAA ostium in 98% of the cases, whereas the LMCA was found in only 48.6%. No coronary damage or vasospasm was observed after performing LAAEI. CONCLUSIONS: A detailed imaging integration with cardiac computed tomography, electroanatomic mapping, and CARTOSOUND reconstructions to accurately define the anatomical relationship between the LMCA and LCx and the anterior edge of the LAA ostium should be performed prior to delivering radiofrequency energy during LAAEI. When the distance on cardiac computed tomography between the LAA ostium and left coronary arteries is >10 mm, intraprocedural localization of these vessels may be not necessary.

Evaluación hemodinámica no invasiva a largo plazo de la terapia de resincronización cardíaca endocárdica izquierda / Long-term Non-invasive Hemodynamic Evaluation of Left Endocardial Cardiac Resynchronization Therapy

RESUMEN Introducción: La terapia de resincronización cardíaca presenta una tasa de un 25%-30% de pacientes "no respondedores". La resincronización endocárdica, en la que el catéter del ventrículo izquierdo se implanta en el endocardio, sería una alternativa para estos pacientes, aunque su evolución a largo plazo no ha sido investigada. Objetivos: Evaluación hemodinámica no invasiva a largo plazo de la resincronización endocárdica en respondedores clínicos. Métodos: Se incluyeron pacientes implantados según los criterios para resincronización, usando la técnica Jurdham, con más de 6 meses desde el implante. Todos eran respondedores clínicos. La respuesta hemodinámica se evaluó con un analizador de la función cardíaca, que mide los intervalos sistólicos (períodos preeyectivo y eyectivo) del ventrículo izquierdo y calcula automáticamente un índice de función sistólica y estimar la fracción de eyección (Systocor mod ÍS100). Para determinar la eficacia mecánica de la TRCe se comparó la función cardíaca durante el modo biventricular con el bloqueo completo de la rama izquierda, espontáneo o por estimulación única del ventrículo derecho; los pacientes fueron sus propios controles. Se promediaron al menos 20 latidos en cada modo de estimulación y se consideraron solo los cambios >1% con valor p < 0,01 como clínicamente relevantes y estadísticamente significativos. Resultados: Se incluyeron 17 pacientes, con mediana de seguimiento de 43 meses, rango 9 a 78 meses. La resincronización endocárdica, en comparación con la activación ventricular con BCRI, demostró que todos los pacientes acortaron el período preeyectivo en un promedio de 31 ms (15%), indicativo de disminución de la disincronía interventricular causada por el BCRI. En todos aumentó el índice de función sistólica en 0,3 (23%) y la FE en el 8,3%. En 12/17 (71%) aumentó el período eyectivo en promedio 8,7 mseg (2,9%), lo que sugiere un aumento del volumen sistólico. En todos los cambios el valor de p fue menor de 0,01. Conclusiones: La TRCe ofrece mejoría hemodinámica significativa a largo plazo, detectada por intervalos sistólicos.

ABSTRACT Background: Cardiac resynchronization therapy has 25% to 30% rate of "non-responder" patients. Endocardial cardiac resynchronization therapy (eCRT), in which the left ventricular catheter is implanted in the endocardium, would be an alternative for these patients; however, its long-term outcome has not been investigated. Objectives: The aim of this study was the long-term non-invasive hemodynamic evaluation of eCRT in clinical responders. Methods: Patients implanted according to the criteria for resynchronization, using the Jurdham technique, with more than 6 months after the implant, were included in the study. All were clinical responders. The hemodynamic response was evaluated with a cardiac function analyzer, which measures the left ventricular systolic intervals (preejection and ejection periods) and automatically calculates an index of systolic function and estimates the ejection fraction (Systocor mod ÍS100). To assess the mechanical efficacy of eCRT, the cardiac function during biventricular mode was compared with left bundle branch block (LBBB), either spontaneous or by single stimulation of the right ventricle, with patients as their own controls. At least 20 beats were averaged in each stimulation mode and only changes >1% with p <0.01 were considered as clinically relevant and statistically significant. Results: Seventeen patients were included, with a median follow-up of 43 months, (9 to 78 months). Endocardial resynchronization, compared with LBBB ventricular activation, showed that all patients shortened the preejection period by an average of 31 ms (15%), indicative of decreased interventricular dyssynchrony caused by LBBB. In all patients, systolic function index increased by 0.3 (23%) and the EF by 8.3%. In 12/17 of cases (71%) the ejective period increased on average 8.7 ms (2.9%), suggesting an increase in systolic volume. In all changes p was <0.01. Conclusions: Endocardial resynchronization therapy offers significant long-term hemodynamic improvement, detected by systolic intervals.

Multicenter prospective observational long-term follow-up study of endocardial cardiac resynchronization therapy using the Jurdham procedure.

BACKGROUND: Endocardial cardiac resynchronization therapy (eCRT) avoids the limitations and failures of coronary sinus (CS) resynchronization. However, data regarding long-term outcomes are lacking. OBJECTIVE: The purpose of this study was to report the long-term outcome of eCRT performed using the Jurdham procedure in a real-world setting. METHODS: eCRT was performed in patients who failed a CS implant or failed to respond to cardiac resynchronization therapy (CRT), or in selected patients requiring lifelong oral anticoagulation (OAC). Left ventricular ejection fraction (LVEF), New York Heart Association functional class (NYHA FC), and left ventricular stimulation parameters were assessed during long-term follow-up (FU). RESULTS: From August 2009 to March 2018, the Jurdham procedure was performed in 88 patients at 15 centers in 8 countries, with FU of 32.88 ± 61.52 months (range 0-88 months; 196 patient-years). NYHA FC improved from 2.9 preimplant to 1.3 during FU. LVEF increased <10 percentage points from baseline in 7% of patients, between 10 and 20 percentage points in 11% of patients, and >20 percentage points in 82% of patients. All-cause mortality at 60 months was 30.5%. Three transient ischemic attacks (1.53 per 100 patient-years) and 6 strokes (3.06 per 100 patient-years) occurred. Of the 6 patients with stroke, 4 (66%) had almost complete recovery. CONCLUSION: eCRT using the Jurdham procedure is an effective and safe technique in anticoagulated patients. This approach may be an attractive option for patients with failed CS implants or nonresponders to CS CRT. In addition, it might be a reasonable approach as a first option for treatment of patients requiring lifelong OAC.

2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA).

In 2014, a joint consensus document dealing with the management of antithrombotic therapy in atrial fibrillation (AF) patients presenting with acute coronary syndrome (ACS) and/or undergoing percutaneous coronary or valve interventions was published, which represented an effort of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Since publication of this document, additional data from observational cohorts, randomized controlled trials, and percutaneous interventions as well as new guidelines have been published. Moreover, new drugs and devices/interventions are also available, with an increasing evidence base. The approach to managing AF has also evolved towards a more integrated or holistic approach. In recognizing these advances since the last consensus document, EHRA, WG Thrombosis, EAPCI, and ACCA, with additional contributions from HRS, APHRS, Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA), proposed a focused update, to include the new data, with the remit of comprehensively reviewing the available evidence and publishing a focused update consensus document on the management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing percutaneous coronary or valve interventions, and providing up-to-date consensus recommendations for use in clinical practice.

Cardiac resynchronization therapy: overcoming anatomical challenges / Terapia de ressincronização cardíaca: superando desafios anatômicos

A anatomia venosa coronária pode dificultar ou impossibilitar o implante com sucesso de um dispositivo de terapia de ressincronização cardíaca. O objetivo desta revisão foi o de apresentar uma abordagem interventiva com muitas técnicas e ferramentas que precisam ser aprendidas e conhecidas para melhorar os resultados desta terapia e a saúde dos pacientes

Coronary venous anatomy can make successful implantation of a cardiac resynchronization therapy device difficult or impossible. The aim of this review is introduce an interventional approach with many techniques and tools that are needed to be learned and known in order to improve the results of this therapy and the health of patients

Abordaje de la pared lateral del ventrículo izquierdo a través de una vena posterior para terapia de resincronización cardiaca / Approach to the lateral wall of the left ventricle through a posterior vein for cardiac resynchronization therapy

Resumen Se presenta el caso de una paciente portadora de una miocardiopatía dilatada y marcapasos epicárdico unicameral im plantado por bloqueo atrioventricular completo, quien respondió favorablemente a la terapia de resincronización cardia ca; durante el seguimiento, requirió el implante de un nuevo electrodo del ventrículo izquierdo, el cual fue implantado a través de una vena posterior.

Abstract Dysautonomia and Chagas disease We present the case of a patient with a congenital dilated myocardiopathy and a single-chamber epicardic pacemaker, implanted by a complete atrioventricular block, who had a favorable response to cardiac resinchronisation therapy; during follow-up, she required a new left ventricle electrode which was implanted through a left posterior vein.

Propagación eléctrica en los mecanismos de torsión y succión en un corazón de tres tiempos / Electrical Propagation in the Mechanisms of Twist and Suction in a Three-phase Heart

Introducción: La hipótesis de Torrent Guasp plantea que los ventrículos están conformados por una banda muscular continua que nace a nivel de la válvula pulmonar y se extiende hasta la raíz aórtica delimitando las dos cavidades ventriculares. Esta anatomía brindaría la interpretación para dos aspectos fundamentales de la dinámica ventricular izquierda: el mecanismo de torsión y el llenado diastólico rápido por efecto de succión. Objetivos: Investigar la activación eléctrica de las bandeletas endocárdica y epicárdica para comprender la torsión ventricular, el mecanismo de succión activa en la fase isovolumétrica diastólica y el significado del volumen residual. Material y métodos: La investigación se realizó mediante un mapeo electroanatómico tridimensional en cinco pacientes. Al ser la bandeleta descendente endocárdica y la ascendente epicárdica, se utilizaron dos vías de abordaje por punción. Resultados: El mapeo tridimensional endoepicárdico demuestra una activación eléctrica de la zona de la lazada apexiana concordante con la contracción sincrónica de las bandeletas descendente y ascendente. La activación simultánea y contrapuesta de la bandeleta ascendente con punto de partida de su activación radial desde la bandeleta descendente, en la zona de entrecruzamiento de ambas, es coherente con la torsión ventricular. La activación tardía de la bandeleta ascendente se compatibiliza con la persistencia de su contracción durante el período inicial de la fase isovolumétrica diastólica (base del mecanismo de succión); se produce sin necesidad de postular activaciones eléctricas posteriores al QRS. Conclusiones: Este trabajo explica el proceso de la torsión ventricular y el mecanismo de succión. Comprueba que la activación de la bandeleta ascendente completa el QRS anulando el concepto tradicional de relajación pasiva en la fase isovolumétrica diastólica.

Background: The hypothesis of Torrent Guasp considers that the ventricular myocardium consists of a continuous muscular band that begins at the level of the pulmonary valve and ends at the level of the aortic root, limiting both ventricular chambers. This anatomy would provide the interpretation for two fundamental aspects of left ventricular dynamics: the mechanism of left ventricular twist and rapid diastolic filling due to the suction effect. Objectives: The aim of this study was to investigate the electrical activation of the endocardial and epicardial bands to understand ventricular twist, the mechanism of active suction during the diastolic isovolumic phase and the significance of the residual volume. Methods: Five patients underwent three-dimensional electroanatomic mapping. As the descending band is endocardial and the ascending band is epicardial, two sites of puncture were used. Results: Three-dimensional endo-epicardial mapping demonstrates an electrical activation sequence in the area of the apex loop in agreement with the synchronic contraction of the descending and ascending band segments. The simultaneous and opposing radial activation of the ascending band segment, starting in the descending band segment, in the area in which both band segments intertwine, is consistent with the mechanism of ventricular twist. The late activation of the ascending band segment is consistent with its persistent contraction during the initial period of the isovolumic diastolic phase (the basis of the suction mechanism), and takes place without need of postulating further electrical activations after the QRS complex. Conclusions: This study explains the process of ventricular twist and the suction mechanism, and demonstrates that the activation of the ascending band segment completes the QRS, ruling out the traditional concept of passive relaxation during the diastolic isovolumic phase.