Impact of intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion procedures: A meta-analysis.

BACKGROUND: Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. METHODS: All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. RESULTS: Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I2 = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I2 = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04). CONCLUSION: ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.

Anatomical considerations and clinical interpretation of the 12-lead ECG in the prone position: a prospective multicentre study.

AIMS: The aim of this study is to provide guidance for the clinical interpretation of electrocardiograms (ECGs) in prone position and to establish the electroanatomic explanations for the possible differences to supine position ECGs that may be observed. Additionally, to determine if prone back ECG can be used as an alternative to standard ECG in patients who may benefit from prone position. METHODS AND RESULTS: The ECG in supine (standard ECG), prone back (precordial leads placed on the patient's back), and prone anterior position (precordial leads placed in the standard position with the subjects in prone position) were prospectively examined on 85 subjects. Comparisons of ECG parameters between these positions were performed. Computed tomography (CT) scans were performed in both positions to determine possible electroanatomic aetiologies for prone-associated ECG changes. There were significant differences in QRS amplitude in Leads V1-V5 between supine and prone positions. Q waves were more frequently observed in prone back position vs. supine position (V1: 74.1 vs. 10.6%, P < 0.0001; V2: 23.5 vs. 0%, P < 0.0001, respectively). Flat and inverted T waves were more common in prone back leads (V1: 98 vs. 66%, P < 0.0001; V2: 96 vs. 8%, P < 0.0001; V3: 45 vs. 7%, P < 0.0001). The 3D-CT reconstructions measurements corroborated the significant inverse correlation between QRS amplitude and the distance from the centre of the heart to the estimated lead positions. CONCLUSION: In prone back position ECG, low QRS amplitude should not be misinterpreted as low voltage conditions, neither should Q waves and abnormal T waves are considered anteroseptal myocardial infarction. These changes can be explained by an increased impedance (due to interposing lung tissue) and by the increased distance between the electrodes to the centre of the heart.

Extracardiac Prothrombotic Effects of COVID-19.

COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.

Improved survival in patients with atrial fibrillation and heart failure undergoing catheter ablation compared to medical treatment: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. METHODS AND RESULTS: A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% confidence interval [CI] 0.51-0.83, p = .0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of all-atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40-0.76, p = .0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6-8.8, p < .00001). CONCLUSION: CA for AF in patients with HF decreases all-cause mortality, improves all-atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated.

Design methodology for sewage water treatment system comprised of Imhoff 's tank and a subsurface horizontal flow constructed wetland: a case study Dakhla Oasis, Egypt.

In this study, in order to reuse the treated wastewater in irrigation in rural areas, a new sewage water treatment system comprised of primary treatment Imhoff's tank, Hama drying basins, inlet well, a subsurface horizontal flow constructed wetland (HSFW), water control device, and a groundwater tank is proposed and designed in Dakhla Oasis western desert of Egypt. The proposed system serves a population of 5000 capita with a designed discharge of 750 m3 d-1. The kinetic parameters involved macrophyte organisms, media forms, water level, hydraulic retention time (HRT), and hydraulic loading rate (hl) for the system were selected to achieve an efficient wastewater treatment system design. Imhoff's tank is sized as the primary sedimentation efficiency is 30%, and HSFW is sized based on the first-order kinetics (k-C∗) model, and total hydraulic design theory. The air temperatures were 29.7 °C and 13.8 °C in summer and winter respectively, influent pollutant concentrations after primary sedimentation for BOD, fecal coliforms (FC), total nitrogen (TN), and total phosphorus (TP) were 210 mg L-1, 108 CFU100 mL-1, 30 and 7 mg L-1, respectively. The expected designed effluent BOD and FC were 30 mg L-1 and 1000 CFU100 mL-1 respectively. The results show that FC removal controls the area of the HSFW (2.87 ha), 6 units of reed (Phragmites Australis and Papyrus) plants each one is 66 ×72.6 m with hl of 2.6 cm d-1 and HRT of 6.91 d. The expected overall removal efficiencies for BOD and FC were 85.7%, and 99.9% respectively.

Current practice in transvenous lead extraction in Latin America: Latin American Heart Rhythm Association survey.

BACKGROUND: Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead-related complications. Currently, objective data on TLE in Latin America is lacking. OBJECTIVE: To describe the current practice standards in Latin American centers performing TLE. METHODS: An online survey was sent through the mailing list of the Latin American Heart Rhythm Society. Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for 1 month, after which no more answers were accepted. RESULTS: A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27.1% from Brazil), with most respondents (82%) being electrophysiologists. Twenty-nine institutions (66%) performed <10 lead extractions/year, with 7 (16%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (66%) and only 13% reported the use of laser sheaths. Management of infected leads was performed according to current guidelines. CONCLUSION: This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.

Focal impulse and rotor modulation guided ablation versus pulmonary vein isolation for atrial fibrillation: A meta-analysis of head-to-head comparative studies.

INTRODUCTION: Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)-guided ablation is currently used as an adjunct to PVI, evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM-guided ablation with or without PVI is associated with a decrease in all-atrial arrhythmia recurrence as compared to PVI alone. METHODS: A systematic review of PubMed, Cochrane, and Embase was performed for head-to-head study designs comparing outcomes of patients who underwent FIRM-guided ablation with or without PVI to those who underwent PVI alone. The primary efficacy endpoint was all-atrial arrhythmia recurrence. The secondary endpoints were complications rates and procedural characteristics. RESULTS: Overall, six studies comprising 674 patients undergoing either FIRM-guided ablation ± PVI versus PVI were included (mean age 63.4 ± 9.2, male 74%, 9% paroxysmal AF, 91% nonparoxysmal AF). After a mean follow-up of 18.8 months, FIRM-guided ablation with or without PVI was not associated with improvement in all-atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs. 45.9%, risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.77-1.47; p = .70). No statistically significant difference was noted in complication rates between the two groups (RR: 1.66; 95% CI: 0.08-34.54; p = .74). CONCLUSION: In this meta-analysis of head-to-head comparison studies, FIRM-guided ablation with or without PVI did not provide any benefit in improving all-atrial arrhythmia recurrence at follow-up when compared to PVI alone.

Efficacy and safety of left atrial appendage electrical isolation during catheter ablation of atrial fibrillation: an updated meta-analysis.

AIMS: Left atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation. METHODS AND RESULTS: A systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42-0.69; P < 0.0001]. A 46% relative risk reduction and 22.9% absolute risk reduction in atrial-arrhythmia recurrence was noted with LAAEI. Rates of cerebral thromboembolism were not significantly different between the two groups (LAAEI 3% vs. standard ablation 1.6%, respectively; RR 1.76; 95% CI 0.61-5.04; P = 0.29). Furthermore, there was no significant difference in the acute procedural complication rates between the two groups (LAAEI 4% vs. standard ablation 3%, respectively; RR 1.29; 95% CI 0.83-2.02; P = 0.26). CONCLUSION: At long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events.

Schindleria parva, a new species of Schindler's fish (Teleostei: Schindleriidae: Schindleria) from Jeddah, Saudi Arabia, Red Sea.

Schindleria parva, a new species of the family Schindleriidae, is described from two specimens collected from the central Red Sea of Saudi Arabia. The new species is characterized by lack of pigmentation on the body, possession of an inconspicuous gas bladder and the presence of small teeth on the premaxillae. The holotype is a female of 11 mm standard length (SL) (11.9 mm total length) and the paratype is a male of 9 mm SL. Dorsal fin rays 10 (9) anal fin rays 9 (7). The body depth at pectoral-fin origin 5% (4%) of SL, depth at anal-fin origin 8% (7%) SL, predorsal length 63% (65%) SL, preanal length 72% (72%) SL, the first anal-fin ray situated below the fourth dorsal-fin ray), a total of 23 + 16 myomeres. The female contained a series of 30 rectangular eggs in a single row, whereas the male is characterized by a short rod-like urogenital papilla. Species of the genus Schindleria are likely the smallest marine vertebrates on the planet and S. parva is likely the smallest Schindleria species in the Red Sea. The global diversity of Schindleria is likely underestimated due to the paedomorphic features of this genus. Its fast generation times make it a species-rich genus of high turnover rates, thus potentially highly important for the trophic food webs of coral reefs. Thus, this finding advances knowledge on the biodiversity of the Red Sea, highlights its conservation significance, and contributes towards the understanding of the complexity of the coral-reef fish community.

Endo-epicardial ablation vs endocardial ablation for the management of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: A systematic review and meta-analysis.

BACKGROUND: The pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt. OBJECTIVE: The aim of this meta-analysis is to assess the outcomes of ARVC patients undergoing combined endo-epicardial VT ablation, as compared to endocardial ablation alone. METHODS: A systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo-epicardial VT ablation vs endocardial-only VT ablation in patients with ARVC. Fixed-Effect model was used if I2 < 25 and the Random-Effects Model was used if I2 ≥ 25%. RESULTS: Nine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow-up of 48.1 ± 21.5 months, endo-epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45-0.75; P < .0001). No significant differences were noted between endo-epicardial and endocardial VT ablation groups in terms of all-cause mortality (RR, 1.19; 95% CI, 0.03-47.08; P = .93) and acute procedural complications (RR, 5.39; 95% CI, 0.60-48.74; P = .13). CONCLUSIONS: Our findings suggest that in patients with ARVC, endo-epicardial VT ablation is associated with a significant reduction in VA recurrence as opposed to endocardial ablation alone, without a significant difference in all-cause mortality or acute procedural complications.

Cavotricuspid isthmus line in patients undergoing catheter ablation of atrial fibrillation with or without history of typical atrial flutter: A meta-analysis.

BACKGROUND: Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for paroxysmal atrial fibrillation (AF). However, for persistent and long-standing persistent AF, there are no established strategies to improve the success rate of CA. Despite studies indicating that prophylactic cavotricuspid isthmus (CTI) ablation provides no or limited incremental benefit in patients with AF, it is still routinely performed worldwide. OBJECTIVE: We sought to examine whether CTI ablation for AF is associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone in patients with and without typical atrial flutter (AFL). METHODS: A systematic review of PubMed, Cochrane, and Embase was performed for clinical studies including AF patients, reporting outcomes of CTI + PVI versus PVI alone. The primary efficacy endpoint was recurrence of all-atrial arrhythmias. RESULTS: Five studies comprising 1400 patients undergoing CTI + PVI versus PVI alone were included; 1110 patients had AF without AFL, and 290 patients had coexistent AF and AFL. After a mean follow-up of 14.4 ± 4.8 months, CTI + PVI was not associated with improvement in recurrence of all-atrial arrhythmias when compared with PVI alone (risk ratio [RR]: 1.29; 95% confidence interval [CI]: 0.93-1.79;p = .13). In the subgroup analysis, there were no differences between both groups in patients with AF without AFL (RR: 1.55; 95% CI: 0.96-2.48; p = .07), and in patients with AF and AFL (RR: 0.91; 95% CI: 0.6-1.39; p = .68). CONCLUSION: In AF patients, irrespective of the presence of typical AFL, additional CTI ablation is not associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone.

Safety of catheter ablation for atrial fibrillation in the octogenarian population.

INTRODUCTION: Catheter ablation (CA) has been shown to be an effective treatment for atrial fibrillation (AF). The complication rates and outcomes among octogenarians remain poorly studied. We aimed to compare trends, morbidity, and mortality associated with CA for AF among octogenarians versus those less than 80 years old. METHODS: Using weighted sampling from the National Inpatient Sample database, we identified patients with a primary diagnosis of AF and a primary procedure of CA (2004-2013). Our primary outcome was mortality. Secondary outcomes included incidence of major and minor complications. RESULTS: Among 86,119 patients who underwent CA for AF, 3,482 were 80 years old or older. Complications were significantly more frequent in octogenarians; [16.2% (564 of 3,482) versus 9.8% (8,092 of 82,637), P < 0.001]. Of note, there was no significant difference for the composite of major complications; [3.6% (124 of 3482) in octogenarians versus 2.8% (2286 of 82637), P = 0.20]. The total mortality rate was not significant in a multivariate regression analysis (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.35-2.64; P = .94). The presence of chronic renal failure (OR, 4.19; 95% CI, 2.75-6.36; P < 0.001), anemia (OR, 1.75; 95% CI, 1.03-2.97; P = .04), and chronic pulmonary disease (OR, 1.75; 95% CI, 1.11-2.62; P = .015) were predictors of major complications in octogenarians. CONCLUSION: Catheter ablation for AF in octogenarians does not confer a higher mortality risk than in those less than 80 years old. The procedure is associated with a higher rate of overall complications but there was no difference in terms of major complications or death. The presence of anemia, CKD or pulmonary disease were predictors of major complications in octogenarians.

Prostatic Artery Embolization: A Promising Technique in the Treatment of High-Risk Patients with Benign Prostatic Hyperplasia.

INTRODUCTION: Prostatic artery embolization (PAE) has recently started to be viewed as a promising technology that could be an alternative to different treatment options of benign prostatic hyperplasia (BPH), especially in high-risk patients. The aim of our study was to evaluate the efficacy and safety of PAE in BPH patients who are at high risk for surgery and/or anesthesia. MATERIALS AND METHODS: Between June 2013 and February 2015, BPH patients >50 years with lower urinary tract symptoms (LUTS) refractory to BPH-related medical therapy or had an indwelling urethral catheter due to refractory urine retention were prospectively enrolled in the study. All patients were at high risk for surgery and/or anesthesia. The PAE was performed and the embolising material used was biosphere 300-500 µm particles. Pre- and 1, 3, 9 months post-intervention, all patients were assessed by detailed medical history, physical examination, serum prostate-specific antigen (PSA), uroflowmetry, and abdominal and transrectal ultrasonography. RESULTS: Twenty-two consecutive patients with a mean age of 72.50 years and a mean prostate volume of 77.30 ± 14.89 cm3 were included. The PAE procedure was successful in all patients. Throughout the period of follow-up, there was a significant improvement in the LUTS and urinary flow rate, and reduction in prostate volume and serum PSA (for all p < 0.001). No major complications were reported. CONCLUSION: Our results show that BPH patients with failed medical treatment who are at high risk for surgery and/or anesthesia could be treated safely and effectively through PAE.

Application of ZnO NPs, SiO2 NPs and Date Pollen Extract as Partial Substitutes to Nitrogen, Phosphorus, and Potassium Fertilizers for Sweet Basil Production.

The reduction in mineral fertilizer usage is crucial to the production of medicinal and aromatic products for safety and health purposes. Presently, nanotechnology and the utilization of natural extracts have been extensively studied due to their significant contribution. Ocimum basilicum is commonly employed for various medicinal and aromatic applications. Therefore, randomized complete block design field experiments containing 10 treatments were conducted during the 2021 and 2022 seasons to investigate the effect of nanoparticles (NPs) of ZnO (1.5 and 2.0 g/L) and SiO2 (100 and 150 mg/L) and date palm pollen extract (DPPE) at 10 and 20 g/L either alone or in combination with the ¾ or ½ NPK recommended dose (RD). The NPK RD was served as a control treatment on basil plant production in each season. The effectiveness of ZnO NPs, SiO2 NPs, and DPPE for the decrease in NPK utilization was evaluated. Meanwhile, the most effective treatment for vegetative traits (except for plant height), essential oil %, and yield was ½ NPK RD + 20 g/L DPPE + 2.0 g/L ZnO NPs. Such a treatment increased the branch number/plant, main stem diameter, relevant chlorophyll content, fresh weight/plant, dry weight/plant, essential oil %, and essential oil yield/plant by 21.00 and 9.94%, 58.70 and 40.00%, 20.69 and 15.83%, 68.83 and 58.28%, 48.70 and 56.16%, 45.71 and 35.53%, and 113.22 and 110.32% over the control in the two seasons, respectively. For total phenol and antioxidant activity, the most effective treatments were the ¾ NPK +1.5 g/L ZnO NPs and ½ NPK +2.0 g/L ZnO NPs, respectively. Simultaneously, essential oil composition (with their compound numbers identified (11-29 for control and ¾ NPK RD + 1.5 g/L ZnO NPs)) and the percentage of total compounds, monoterpene hydrocarbons, sesquiterpene hydrocarbons, and oxygenated hydrocarbons were varied among the used applications. The major observed compounds (>8%) estragole, methyl eugenol, linalool, cineole, and caryophyllene were found in different treatments. Thus, the findings of this study indicate the favorable utilization of ZnO NPs, SiO2 NPs, and DPPE in reducing the application of NPK, which may present a novel strategy and beneficial approach.

Feasibility, Efficacy, and Safety of Fluoroless Ablation of VT in Patients With Structural Heart Disease.

BACKGROUND: Catheter ablation of ventricular tachycardia (VT) typically requires radiation exposure with its potential adverse health effects. A completely fluoroless ablation approach is achievable using a combination of electroanatomical mapping and intracardiac echocardiography. Nonetheless, data in patients undergoing VT ablation are limited. OBJECTIVES: This study aimed to determine the feasibility, efficacy, and safety of VT ablation in patients with structural heart disease using a zero-fluoroscopy approach. METHODS: This multicenter study included consecutive patients with ischemic and nonischemic cardiomyopathy undergoing fluoroless VT ablation. Patients requiring epicardial access or coronary angiography were excluded. RESULTS: Between 2017 and 2023 a total of 198 patients (aged 66.4 ± 13.4 years, 76% male, 48% ischemic) were included. Most patients (95.4%) underwent left ventricular (LV) mapping and/or ablation, which was conducted via transseptal route in 54.5% (n = 103), via retrograde aortic route in 43.4% (n = 82), and using a combined approach in 2.1% (n = 4). Two-thirds of patients had a cardiac device, including a biventricular device in 15%; 2 patients had a LV assist device, and 1 patient had a mechanical aortic valve prosthesis. The mean total procedural time was 211 ± 70 minutes, and the total radiofrequency time was 30 ± 22 minutes. During a follow-up period of 22 ± 18 months, the freedom from VT recurrence was 80%, and 7.6% of patients underwent a repeated ablation. Procedural-related complications occurred in 6 patients (3.0%). CONCLUSIONS: Fluoroless ablation of VT in structural heart disease is feasible, effective, and safe when epicardial mapping/ablation is not required.

Improved all-cause mortality with left bundle branch area pacing compared to biventricular pacing in cardiac resynchronization therapy: a meta-analysis.

BACKGROUND: Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative pacing strategy to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). We aimed to assess the impact of LBBAP vs. BIVP on all-cause mortality and heart failure (HF)-related hospitalization in patients undergoing CRT. METHODS: Studies comparing LBBAP and BIVP for CRT in patients with HF with reduced left ventricular ejection fraction (LVEF) were included. The coprimary outcomes were all-cause mortality and HF-related hospitalization. Secondary outcomes included procedural and fluoroscopy time, change in QRS duration, and change in LVEF. RESULTS: Thirteen studies (12 observational and 1 RCT, n = 3239; LBBAP = 1338 and BIVP = 1901) with a mean follow-up duration of 25.8 months were included. Compared to BIVP, LBBAP was associated with a significant absolute risk reduction of 3.2% in all-cause mortality (9.3% vs 12.5%, RR 0.7, 95% CI 0.57-0.86, p < 0.001) and an 8.2% reduction in HF-related hospitalization (11.3% vs 19.5%, RR 0.6, 95% CI 0.5-0.71, p < 0.00001). LBBAP also resulted in reductions in procedural time (mean weighted difference- 23.2 min, 95% CI - 42.9 to - 3.6, p = 0.02) and fluoroscopy time (- 8.6 min, 95% CI - 12.5 to - 4.7, p < 0.001) as well as a significant reduction in QRS duration (mean weighted difference:- 25.3 ms, 95% CI - 30.9 to - 19.8, p < 0.00001) and a greater improvement in LVEF of 5.1% (95% CI 4.4-5.8, p < 0.001) compared to BIVP in the studies that reported these outcomes. CONCLUSION: In this meta-analysis, LBBAP was associated with a significant reduction in all-cause mortality as well as HF-related hospitalization when compared to BIVP. Additional data from large RCTs is warranted to corroborate these promising findings.

Biomechanics of porcine renal arteries and role of axial stretch.

It is known that arteries experience significant axial stretches in vivo. Several authors have shown that the axial force needed to maintain an artery at its in vivo axial stretch does not change with transient cyclical pressurization over normal ranges. However, the axial force phenomenon of arteries has never been explained with microstructural considerations. In this paper we propose a simple biomechanical model to relate the specific axial force phenomenon of arteries to the predicted load-dependent average collagen fiber orientation. It is shown that (a) the model correctly predicts the authors' experimentally measured biaxial behavior of pig renal arteries and (b) the model predictions are in agreement with additional experimental results reported in the literature. Finally, we discuss the implications of the model for collagen fiber orientation and deposition in arteries.

Catheter Ablation of Left Ventricular Summit Arrhythmias from Adjacent Anatomic Vantage Points.

Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety.

Fluoroless Catheter Ablation of Left Ventricular Summit Arrhythmias: A Step-by-Step Approach.

Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries given the need for heavy protective equipment. CA of ventricular arrhythmias (VAs) arising from the left ventricular (LV) summit is challenging, requiring a vast knowledge of the intricate cardiac anatomy of this area and careful imaging delineation of the different anatomical structures, which is frequently performed using fluoroscopic guidance. Certain techniques, including pericardial mapping and ablation, use of intracoronary wires, and mapping and ablation inside the coronary venous system have been proposed, further prolonging fluoroscopy time. Fluoroless CA procedures are feasible with currently available technology and appear to have similar safety and efficacy outcomes compared with conventional techniques. To successfully perform fluoroless CA of LV summit arrhythmias, it is important to be fully acquainted with intracardiac echocardiography (ICE) imaging and electroanatomic mapping (EAM). We will describe our approach to perform fluoroless CA in LV summit VAs.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: A cost-effectiveness analysis.

BACKGROUND: General anesthesia (GA) is the standard anesthetic approach for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Nonetheless, GA is expensive and can be associated with adverse events. Tumescent local anesthesia (TLA) has been shown to reduce in-room and procedural times and to decrease post-procedural pain, all of which could result in a reduction in procedure-related costs. OBJECTIVE: The purpose of this study is to compare the cost-effectiveness of GA and TLA in patients undergoing S-ICD implantation. METHODS: The present study is a prospective, nonrandomized, controlled study of patients who underwent S-ICD implantation between 2019 and 2022. Patients were allocated to either the TLA or the GA group. We performed a cost analysis for each intervention. As an effectiveness measure, the 0-10 point Numeric Pain Rating Scale at 1, 12, and 24 hours post-implantation was analyzed and compared between the groups. A score of 0 was considered no pain; 1-5, mild pain; 6-7, moderate pain; and 8-10, severe pain. Cost-effectiveness was calculated using incremental cost-effectiveness ratios. RESULTS: Seventy patients underwent successful S-ICD implantation. The total cost of the electrophysiology laboratory was higher in the GA group than in the TLA group (median ± interquartile range US$55,824 ± US$29,411 vs US$37,222 ± US$24,293; P < .001), with a net saving of $20,821 when compared with GA for each S-ICD implantation. There was a significant decrease in post-procedural pain scores in the TLA group when compared with the GA group (repeated measures analysis of variance, P = .009; median ± interquartile range 0 ± 3 vs 0 ± 5 at 1 hour, P = .058; 3 ± 4 vs 6 ± 8 at 12 hours, P = .030; 0 ± 4 vs 2 ± 6 at 24 hours, P = .040). CONCLUSION: TLA is a more cost-effective alternative to GA for S-ICD implantation, with both direct and indirect cost reductions. Importantly, these reduced costs are associated with reduced postprocedural pain.