First-Line Catheter Ablation of Monomorphic Ventricular Tachycardia in Cardiomyopathy Concurrent With Defibrillator Implantation: The PAUSE-SCD Randomized Trial.

BACKGROUND: Catheter ablation as first-line therapy for ventricular tachycardia (VT) at the time of implantable cardioverter defibrillator (ICD) implantation has not been adopted into clinical guidelines. Also, there is an unmet clinical need to prospectively examine the role of VT ablation in patients with nonischemic cardiomyopathy, an increasingly prevalent population that is referred for advanced therapies globally. METHODS: We conducted an international, multicenter, randomized controlled trial enrolling 180 patients with cardiomyopathy and monomorphic VT with an indication for ICD implantation to assess the role of early, first-line ablation therapy. A total of 121 patients were randomly assigned (1:1) to ablation plus an ICD versus conventional medical therapy plus an ICD. Patients who refused ICD (n=47) were followed in a prospective registry after stand-alone ablation treatment. The primary outcome was a composite end point of VT recurrence, cardiovascular hospitalization, or death. RESULTS: Randomly assigned patients had a mean age of 55 years (interquartile range, 46-64) and left ventricular ejection fraction of 40% (interquartile range, 30%-49%); 81% were male. The underlying heart disease was ischemic cardiomyopathy in 35%, nonischemic cardiomyopathy in 30%, and arrhythmogenic cardiomyopathy in 35%. Ablation was performed a median of 2 days before ICD implantation (interquartile range, 5 days before to 14 days after). At 31 months, the primary outcome occurred in 49.3% of the ablation group and 65.5% in the control group (hazard ratio, 0.58 [95% CI, 0.35-0.96]; P=0.04). The observed difference was driven by a reduction in VT recurrence in the ablation arm (hazard ratio, 0.51 [95%CI, 0.29-0.90]; P=0.02). A statistically significant reduction in both ICD shocks (10.0% versus 24.6%; P=0.03) and antitachycardia pacing (16.2% versus 32.8%; P=0.04) was observed in patients who underwent ablation compared with control. No differences in cardiovascular hospitalization (32.0% versus. 33.7%; hazard ratio, 0.82 [95% CI, 0.43-1.56]; P=0.55) or mortality (8.9% versus 8.8%; hazard ratio, 1.40 [95% CI, 0.38-5.22]; P=0.62]) were observed. Ablation-related complications occurred in 8.3% of patients. CONCLUSIONS: Among patients with cardiomyopathy of varied causes, early catheter ablation performed at the time of ICD implantation significantly reduced the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death. These findings were driven by a reduction in ICD therapies. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02848781.

Evaluation of the Efficacy of Sacubitril/Valsartan on Radiofrequency Ablation in Patients with Hypertension and Persistent Atrial Fibrillation.

OBJECTIVE: To evaluate whether the effect of radiofrequency ablation can be improved by using sacubitril/valsartan (S/V) to control blood pressure in hypertensive patients with persistent atrial fibrillation. METHODS: A total of 63 and 67 hypertension patients with persistent atrial fibrillation were enrolled in an S/V group and ACEI/ARB group, respectively. All patients underwent radiofrequency catheter ablation (RFCA). The blood pressure of the two groups was controlled within the range of 100-140 mmHg (high pressure) and 60-90 mmHg (low pressure). The clinical outcomes of the two groups were observed after 12 months of follow-up. RESULTS: No significant differences in blood pressure were observed between the S/V and ACEI/ARB groups. In addition, the recurrence rate of atrial fibrillation between the two groups was not different. The left atrial diameter was an independent predictor of recurrence (HR = 1.063, P = 0.008). However, in the heart failure subgroup, the recurrence rate of S/V was significantly lower than that of the ACEI/ARB group (P = 0.005), and Cox regression analysis showed that the recurrence risk of atrial fibrillation of the S/V group was 0.302 lower than that of the ACEI/ARB group. NT-proBNP, LVEF, and LAD were significantly improved in hypertension patients with heart failure when comparing cases before and at the end of follow-up. CONCLUSIONS: S/V is better than ACEI/ARB in reducing the recurrence of persistent atrial fibrillation in patients with hypertension and heart failure after RFCA.

Predictive value of nutritional indices for left atrial thrombus in patients with valvular atrial fibrillation.

BACKGROUND: The prognostic nutritional index (PNI) and geriatric nutritional risk index (GNRI) are well known indicators for adverse outcomes in various diseases, but there is no evidence on their association with the risk of left atrial thrombus (LAT) in patients with valvular atrial fibrillation (VAF). METHODS: A comparative cross-sectional analytical study was conducted on 433 VAF patients. Demographics, clinical characteristics and echocardiographic data were collected and analyzed. Patients were grouped by the presence of LAT detected by transesophageal echocardiography. RESULTS: LAT were identified in 142 patients (32.79%). The restricted cubic splines showed an L-shaped relationship between PNI and LAT. The dose-response curve flattened out near the horizontal line with OR = 1 at the level of 49.63, indicating the risk of LAT did not decrease if PNI was greater than 49.63. GNRI was negative with the risk of LAT and tended to be protective when greater than 106.78. The best cut-off values of PNI and GNRI calculated by receiver operating characteristics curve to predict LAT were 46.4 (area under these curve [AUC]: 0.600, 95% confidence interval [CI]:0.541-0.658, P = 0.001) and 105.7 (AUC: 0.629, 95% CI:0.574-0.684, P<0.001), respectively. Multivariable logistic regression analysis showed that PNI ≤ 46.4 (odds ratio: 2.457, 95% CI:1.333-4.526, P = 0.004) and GNRI ≤ 105.7 (odds ratio: 2.113, 95% CI:1.076-4.149, P = 0.030) were independent predictors of LAT, respectively. CONCLUSIONS: Lower nutritional indices (GNRI and PNI) were associated with increased risk for LAT in patients with VAF.

Effect of COVID-19 Pandemic on Acute Coronary Syndrome Clinical Practice Patterns: Findings from a Multicenter Clinician Survey in China.

Background: The coronavirus disease 2019 (COVID-19) pandemic has severely affected healthcare systems around the world. This study aimed to investigate the perceptions of cardiologists regarding how the COVID-19 pandemic has affected the clinical practice patterns for acute coronary syndrome (ACS). Methods: A multicenter clinician survey was sent to 300 cardiologists working in 22 provinces in China. The survey collected demographic information and inquired about their perceptions of how the COVID-19 pandemic has affected ACS clinical practice patterns. Results: The survey was completed by 211 (70.3%) cardiologists, 82.5% of whom were employed in tertiary hospitals, and 52.1% reported more than 10 years of clinical cardiology practice. Most respondents observed a reduction in ACS inpatients and outpatients in their hospitals during the pandemic. Only 29.9% of the respondents had access to a dedicated catheter room for the treatment of COVID-19-positive ACS patients. Most respondents stated that the COVID-19 pandemic had varying degrees of effect on the treatment of acute ST-segment elevation myocardial infarction (STEMI), acute non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina. Compared with the assumed non-pandemic period, in the designed clinical questions, the selection of coronary interventional therapy for STEMI, NSTEMI, and unstable angina during the COVID-19 pandemic was significantly decreased (all p < 0.05), and the selection of pharmacotherapy was increased (all p < 0.05). The selection of fibrinolytic therapy for STEMI during the pandemic was higher than in the assumed non-pandemic period (p < 0.05). Conclusions: The COVID-19 pandemic has profoundly affected ACS clinical practice patterns. The use of invasive therapies significantly decreased during the pandemic period, whereas pharmacotherapy was more often prescribed by the cardiologists.

Catheter ablation of arrhythmogenic right ventricular cardiomyopathy ventricular tachycardia: 18-year experience in 284 patients.

AIMS: The study aims to describe the long-term outcome of radiofrequency catheter ablation for ventricular tachycardia (VT) in a large cohort arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. METHODS AND RESULTS: Radiofrequency catheter ablation was performed in 284 ARVC patients due to VT between July 2000 and January 2019. An endocardial approach was used initially, with epicardial ablation procedures reserved for those patients who failed an endocardial ablation. Activation, entrainment, pace and substrate mapping strategies were used with regional ablation applied. A total of 393 ablation procedures were performed including endocardial approach only (n = 377) and endo and epicardial combined (n = 16). Right ventricular basal free wall was accounted as the primary substrate of VT in 258 (65.6%) patients. There were 81 patients underwent redo ablation procedure (second time = 81; ≥3 times = 28). New targets were observed in 68.8% of redo procedures. There were 171 VT recurrences and 19 deaths occurred during the follow-up. Ventricular tachycardia-free survival rate of the first, second, and last ablation procedure was 56.7%, 73.2%, and 78.1%, respectively. Multivariate analysis showed ≥3 induced VTs in the procedure was correlated with rehospitalized VT recurrence [hazard ratio (HR) 1.467, 95% confidence interval (CI) 1.052-2.046; P = 0.024]. For all-cause mortality, rehospitalized VT and ≥3 induced VTs were the independent risk factors (HR 2.954, 95% CI 1.8068.038; P = 0.034; HR 3.189, 95% CI 1.073-9.482; P = 0.037). CONCLUSION: Endocardial ablation is effective to ARVC VT though it may require repeated procedures. Induced multiple VTs was correlated with worse outcomes.

ECG patterns of successful permanent left bundle branch area pacing in bradycardia patients with typical bundle branch block.

AIM: To assess the electrocardiogram patterns of paced QRS narrowing after successful left bundle branch area pacing (LBBAP) and echocardiographic measurements in patients with bradycardia and bundle branch block (BBB). METHODS: We prospectively enrolled 55 consecutive bradycardia patients with BBB and left ventricular ejection fraction ≥40% who had attempted LBBAP. Successful LBBAP was defined as paced QRS morphology of a right BBB (RBBB) pattern in lead V1 and a recording of abruptly shortened and then constant stimulus to peak left ventricular activation time with high and low output. Pacing characteristics and echocardiographic measurements were evaluated perioperatively and at 6-month follow-up. RESULTS: The success rate of LBBAP was 83.6% in patients with BBB, and median cumulative X-ray dose-area product was 100.5 µGym2 (60.0, 179.3). LBBAP was successful in 19 of 26 patients with left BBB (LBBB) (73.1%) and in 27 of 29 patients with RBBB (93.1%). The QRS duration (QRSd) was significantly shortened in patients with LBBB (QRSd 169.4 ± 22.6 to 119.6 ± 9.5 ms), and five forms of QRSd narrowing were observed in patients with RBBB with the mean QRSd shortened from 143.1 ± 16.6 ms to 119.5 ± 11.7 ms. The thresholds for narrowing of QRSd were higher in RBBB than LBBB (1.74 ± 0.36 V/0.4 ms vs 0.79 ± 0.17 V/0.4 ms, P < .001). During the 6-month follow-up, both left and right ventricular synchronies were improved, and narrow QRSd persisted in patients with BBB. CONCLUSION: In most bradycardia patients, RBBB could be completely or partially narrowed by LBBAP at different pacing models in addition to the correction of LBBB with LBBAP.

Atrial involvement in arrhythmogenic right ventricular cardiomyopathy patients referred for ventricular arrhythmias ablation.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable myocardium disorder that predominantly affects the ventricle. Little is known about atrial involvement. This study aimed to assess atrial involvement, especially the role of genotype on atrium in ARVC. METHODS: The incidence, characterization and predictors of atrial involvement were investigated. Nine known ARVC-causing genes were screened and the correlation between genotype and atrial involvement was assessed. RESULTS: Right atrium (RA) dilation, left atrium (LA) dilation, and sustained atrial tachyarrhythmias (ATa) were found in 45, 16 and 3 patients, respectively. Gene mutations were identified in 64 (64.0%) patients. Mutation carriers showed more RA dilation than noncarriers (54.7% vs. 27.8%, P = 0.009), and no difference in LA dilation and ATa. Multivariate analysis showed tricuspid regurgitation (OR: 18.867; 95% CI: 1.466-250.000; P = 0.024) increased the risk of RA dilation and decreased left ventricular ejection fraction (LVEF) (OR: 1.134; 95% CI: 1.002-1.272; P = 0.031) correlated with LA dilation, whereas genotype showed no significant effect. At a median follow-up time of 91 months, 7 patients died and 1 patient accepted heart transplantation. New-onset RA dilation, LA dilation, and sustained ATa were found in 8, 7, and 6 patients, respectively. Atrial involvement was not associated with the long-term survival. Despite mutation carriers showing more RA dilation, Kaplan-Meier analysis showed genotype was not associated with atrial involvement. CONCLUSION: Atrial involvement was common in ARVC. Tricuspid regurgitation and decreased LVEF increased the risk for atrial dilation. Genotype was not associated with atrial involvement.

Clinical outcome of left ventricular multipoint pacing versus conventional biventricular pacing in cardiac resynchronization therapy: a systematic review and meta-analysis.

Cardiac resynchronization therapy (CRT) is an effective treatment for selected patients with systolic heart failure. Unlike conventional biventricular pacing (BIP), the left ventricular multipoint pacing (MPP) can increase the number of left ventricular pacing sites via a quadripolar lead positioned in the coronary sinus. This synthetic study was conducted to integratively and quantitatively evaluate the clinical outcome of MPP in comparison with BIP. We systematically searched the databases of EMBASE, Ovid medline, and Cochrane Library through May 2018 for studies comparing the clinical outcome of MPP with BIP in the patients who accepted CRT. Hospitalization for reason of heart failure, left ventricular eject fraction (LVEF), CRT response, all-cause morbidity, and cardiovascular death rate was collected for meta-analysis. A total of 11 studies with 29,606 participants were included in this meta-analysis. Compared with BIP group, MPP decreased heart failure hospitalization (OR, 0.41; 95% CI, 0.33 to 0.50; P < 0.00001), improved LVEF (mean difference, 4.97; 95% CI, 3.11 to 6.83; P < 0.00001), increased CRT response (OR, 3.64; 95% CI, 1.68 to 7.87; P = 0.001), and decreased all-cause morbidity (OR, 0.41; 95% CI, 0.26-0.66; P = 0.0002) and cardiovascular death rate (OR, 0.21; 95% CI, 0.11-0.40; P < 0.00001). The published literature demonstrates that MPP was more effective than BIP in the heart failure patients who accepted cardiac resynchronization therapy.

Effect of spironolactone on patients with resistant hypertension and obstructive sleep apnea.

OBJECTIVE: To examine whether spironolactone could reduce the severity of obstructive sleep apnea (OSA) and lower blood pressure in patients with resistant hypertension. METHODS: This was a blank-controlled, single-center study. Patients with resistant hypertension and moderate-to-severe OSA (apnea-hypopnea index >15 events/h) were enrolled and randomly assigned to the therapy or control group. Patients in the therapy group were administered spironolactone 20 mg once daily (up to 40 mg once daily for 4 weeks, if required) in addition to original antihypertensive medication. Follow-up was 12 weeks. RESULTS: Thirty patients were enrolled (n = 15 per group). After 12 weeks of follow-up, apnea-hypopnea index (21.8 ± 15.7 vs. 1.8 ± 12.8, p < 0.05), hypopnea index (9.8 ± 11.1 vs. -2.7 ± 16.8, p < 0.05), oxygen desaturation index (20.8 ± 15.0 vs. 0.3 ± 16.1, p < 0.05), clinical blood pressure, ambulatory blood pressure, and plasma aldosterone level (9.8 ± 6.3 vs. 2.9 ± 6.7, p < 0.05) were reduced significantly in the therapy group compared with the control group. No side effects were reported. CONCLUSIONS: Spironolactone reduced the severity of OSA and reduced blood pressure in resistant hypertension patients with moderate-to-severe OSA. These findings may assist in the treatment of OSA in patients with resistant hypertension.

The Impact of COVID-19 Pandemic on the Clinical Practice Patterns in Atrial Fibrillation: A Multicenter Clinician Survey in China.

The COVID-19 pandemic has severely impacted healthcare systems worldwide. This study investigated cardiologists' opinions on how the COVID-19 pandemic impacted clinical practice patterns in atrial fibrillation (AF). A multicenter clinician survey, including demographic and clinical questions, was administered to 300 cardiologists from 22 provinces in China, in April 2022. The survey solicited information about their treatment recommendations for AF and their perceptions of how the COVID-19 pandemic has impacted their clinical practice patterns for AF. The survey was completed by 213 cardiologists (71.0%) and included employees in tertiary hospitals (82.6%) and specialists with over 10 years of clinical cardiology practice (53.5%). Most respondents stated that there were reductions in the number of inpatients and outpatients with AF in their hospital during the pandemic. A majority of participants stated that the pandemic had impacted the treatment strategies for all types of AF, although to different extents. Compared with that during the assumed non-pandemic period in the hypothetical clinical questions, the selection of invasive interventional therapies (catheter ablation, percutaneous left atrial appendage occlusion) was significantly decreased (all p < 0.05) during the pandemic. There was no significant difference in the selection of non-invasive therapeutic strategies (the management of cardiovascular risk factors and concomitant diseases, pharmacotherapy for stroke prevention, heart rate control, and rhythm control) between the pandemic and non-pandemic periods (all p > 0.05). The COVID-19 pandemic has had a profound impact on the clinical practice patterns of AF. The selection of catheter ablation and percutaneous left atrial appendage occlusion was significantly reduced, whereas pharmacotherapy was often stated as the preferred option by participating cardiologists.

The impacts of the ganglionated plexus ablation sequence on the vagal response, heart rate, and blood pressure during cardioneuroablation.

AIMS: Cardioneuroablation is an emerging and promising therapy to treat vasovagal syncope (VVS). The aim of this study was to assess the characteristics of vagal response (VR), heart rate (HR), and blood pressure (BP) during cardioneuroablation with different sequences of ganglionated plexus (GPs) catheter ablation and clarify the regulatory mechanism of cardiac GPs of the left atrium. METHODS: A total of 28 patients with VVS who underwent cardioneuroablation were prospectively enrolled and randomly assigned to 2 groups according to the ablation order of GPs. Group A: Left superior GP (LSGP) - Left inferior GP (LIGP) - Right inferior GP (RIGP) - Right anterior GP (RAGP); Group B: RAGP - LSGP - LIGP - RIGP. RESULTS: In Group A, the VR in LSGP, LIGP, RIGP, and RAGP during ablation was observed in 11 (78.6%), 5 (35.7%), 4 (28.6%) and 2 (14.3%) cases, respectively. In contrast, in Group B, the VR in RAGP, LSGP, LIGP, and RIGP was observed in 2 (14.3%), 1 (7.1%), 0 (0%) and 0 (0%) cases, respectively. BP reduction during procedure was observed eight times in Group A and once in Group B (P = 0.013). In both groups, the HR increased significantly during ablation of the RAGP (all P < 0.001). CONCLUSION: The sequence of GPs ablation during cardioneuroablation affected the occurrence rate of VR and BP reduction during cardioneuroablation. The RAGP was a critical target to increase HR and inhibit VR and BP reduction during procedure, indicating that it may be a key GP in regulation of the cardiac vagal activity.

Single transseptal puncture technique and contact force catheter: A simplified ablation strategy for paroxysmal atrial fibrillation.

The present study aimed to evaluate the safety and efficacy of an optimized single transseptal puncture technique and contact force sensing atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) strategy within a clinical setting. Fast anatomic mapping and contact force sensing ablation was applied to patients with paroxysmal AF (PAF) ablation between September 2014 and December 2016 using a single trans-septal sheath. Pulmonary vein isolation (PVI) and linear ablation were performed in PAF individually with a 10-20 g contact force with minimal fluoroscopy. Stimulation with 10 mA outputs on the lesions without capture was used as endpoint. A total of 419 consecutive patients who underwent first-time RFCA were enrolled in the current study, and acute PVI was achieved in all patients. The average procedure time was 74.5±9.7 min, with an average ablation time of 27.3±7.8 min. The average fluoroscopy time was 4.7±3.3 min and the average radiation dose was 24.3±25.2 mGy. At a mean follow-up time of 14.5 ± 4.1 months, sinus rhythm was maintained at 85.0%. Cardiac tamponade occurred in one case. The results indicated that this simplified technique was a simple, safe and effective approach for PAF ablation therapy.

The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope.

BACKGROUND: Increased parasympathetic activity is thought to play important roles in syncope events of patients with vasovagal syncope (VVS). However, direct measurements of the vagal control are difficult. The novel deceleration capacity (DC) of heart rate measure has been used to characterize the vagal modulation. This study aimed to assess vagal control in patients with VVS and evaluate the diagnostic value of the DC in VVS. METHODS: Altogether, 161 consecutive patients with VVS (43±15 years; 62 males) were enrolled. Tilt table test was positive in 101 and negative in 60 patients. Sixty-five healthy subjects were enrolled as controls. DC and heart rate variability in 24-hour ECG, echocardiogram, and biochemical examinations were compared between the syncope and control groups. RESULTS: DC was significantly higher in the syncope group than in the control group (9.6±3.3 versus 6.5±2.0 ms, P<0.001). DC was similarly increased in patients with VVS with a positive and negative tilt table test (9.7±3.5 and 9.4±2.9 ms, P=0.614). In multivariable logistic regression analyses, DC was independently associated with syncope (odds ratio=1.518 [95% CI, 1.301-1.770]; P=0.0001). For the prediction of syncope, the area under curve analysis showed similar values when comparing single DC and combined DC with other risk factors (P=0.1147). From the receiver operator characteristic curves for syncope discrimination, the optimal cutoff value for the DC was 7.12 ms. CONCLUSIONS: DC>7.5 ms may serve as a good tool to monitor cardiac vagal activity and discriminate VVS, particularly in those with negative tilt table test.

Effect of Pregnancy in Arrhythmogenic Right Ventricular Cardiomyopathy.

Less is known about pregnancy in women with arrhythmogenic right ventricular cardiomyopathy (ARVC). From April 1995 to May 2018, 157 women with ARVC were retrospectively enrolled. Data on pregnancy and cardiac outcomes were analyzed. There were 224 pregnancies in 120 patients including 30 (13.4%) spontaneous and 2 (0.9%) medical abortions, 12 cardiac adverse events were recorded including new onset frequent premature ventricular contractions (PVC) in 3 (2.5%) patients, previous PVC numbers increased more than 100% in 5 (4.2%), syncope in 2 (1.7%), sustained ventricular tachycardia and heart failure required hospitalization each in one patient (0.8%). Women with cardiac events showed lower left ventricular ejection fraction (LVEF) (50.3 ± 2.7 vs 60.0 ± 7.3; p = 0.004). No significant change in cardiac structure and function was found at 1 year follow-up postpartum. At a median follow-up of 8 (1 to 32) years, 36 (22.9%) women died. Earlier symptom onset age (hazard ratio 1.046; 95% confidence interval 1.017 to 1.075; p = 0.002) and decreased LVEF (hazard ratio 1.127; 95% confidence interval 1.001 to 1.154; p = 0.041) increased the risk of all-cause mortality, pregnancy had no negative influence on survival. In all the 192 offsprings (mean age 26.3 ± 13.5 years), 2 died of sudden death, no definite ARVC was found. Pregnancy seemed to be acceptable in ARVC, decreased LVEF increased the risk of pregnancy and was associated with poorer long-term survival.

The value of extensive catheter linear ablation on persistent atrial fibrillation (the CLEAR-AF Study).

BACKGROUND: The ablation therapy for persistent atrial fibrillation (PerAF) is still a challenge due to the high recurrence rate. This study was aimed to investigate the value of extensive linear ablation with contact force sensing techniques for PerAF. METHODS: A total of 214 patients with PerAF were enrolled in five centers. The patients were randomly assigned to Group I (PVI + LA roof line+ LA anterior wall line) and Group II (PVI + LA roof line), mitral valve isthmus lines were added in both groups if the atrial fibrillation (AF) could not be terminated after all approaches above. RESULTS: Acute success rate of AF termination during the ablation procedure in Group I was significantly higher than Group II (P = 0.028). Two-years follow-up showed no significant difference in the sinus rhythm maintenance rate between the two groups (63.4% in group I vs. 57.2% in group II, P = 0.218). More patients in Group I recurred as organized atrial tachycardia (AT) and can be precisely mapped during repeat ablation procedures (15 vs. 2, P = 0.001). The Kaplan-Meier estimates of AF/AT-free survival after repeat ablation procedures were 76.2% in Group I and 47.1% in Group II (P = 0.039). CONCLUSIONS: Extensive linear ablation with contact force monitoring did not improve the long-term outcomes for PerAF patients. Repeat ablation procedure showed a possible higher chance of sinus rhythm restoration during follow-up.

Right anterior ganglionated plexus: The primary target of cardioneuroablation?

BACKGROUND: Catheter ablation of ganglionated plexus (GP) as cardioneuroablation in the left atrium (LA) has been used to treat vasovagal syncope (VVS). OBJECTIVE: The purpose of this study was to assess the effects of ablation of GPs on heart rate and to observe the acute, short-term, and long-term effects after cardioneuroablation. METHODS: A total of 115 consecutive patients with VVS who underwent cardioneuroablation were enrolled. GPs of the LA were identified by high-frequency stimulation and/or anatomic landmarks being targeted by radiofrequency catheter ablation. RESULTS: During ablation of right anterior ganglionated plexus (RAGP), heart rate increased from 61.3 ± 12.2 bpm to 82.4 ± 14.7 bpm (P <.001), whereas during ablation of other GPs only vagal responses were observed. During follow-up of 21.4 ± 13.1 months (median 18 months), 106 participants (92.2%) had no recurrence of syncope or presyncope. Holter data showed that minimal heart rate significantly increased at all follow-up time points (all P<.05), and mean heart rate remained higher than baseline 12 months after ablation (P = .001). CONCLUSION: Cardioneuroablation via GP ablation in the LA effectively inhibited the recurrence of VVS. Ablation of RAGP could increase heart rate immediately and for the long term. This unique phenomenon may provide a new potential approach for treatment of neural reflex syncope or bradyarrhythmias.

Bradyarrhythmias in Arrhythmogenic Right Ventricular Cardiomyopathy.

Less is known about bradyarrhythmias in arrhythmogenic right ventricular cardiomyopathy (ARVC). This cross-sectional study aimed to assess the prevalence and clinical significance of bradyarrhythmias in ARVC. From May 1995 to December 2017, bradyarrhythmias including sick sinus syndrome, atrioventricular block, and intraventricular conductional block (ICB) were investigated in 522 ARVC patients. A total of 169 patients (32.4%) presented with bradyarrhythmias including sick sinus syndrome in18 (3.5%), atrioventricular block in 56 (10.7%), and ICB in 118 patients (22.6%). Multivariate analysis showed right atrial dilation increased the risk of bradyarrhythmias (odds ratio [OR] 1.641, 95% confidence interval [CI] 1.081 to 2.492, p= 0.020). Bradyarrhythmias were not associated with death and heart transplantation. In patients with bradyarrhythmias, female gender, left atrial diameter >40 mm, and New York Heart Association Ⅲ/Ⅳ increased the risk of death and heart transplantation (hazards ratio [HR] = 2.790, 95% CI 1.220 to 6.377, p = 0.015; HR = 4.913, 95% CI 2.058 to 11.730, p <0.001; HR = 3.223, 95% CI 1.246 to 8.340, p = 0.016). Among the 23 patients who underwent device implantation, left atrial diameter >40mm was associated with death and heart transplantation (HR = 9.523, 95% CI 1.587 to 57.126, p = 0.014). In conclusion, bradyarrhythmias were commonly seen in ARVC, and ICB was the most common type. Female, left atrial diameter >40 mm, and NYHA class were associated with death and heart transplantation.

Avoidance of Vagal Response During Circumferential Pulmonary Vein Isolation: Effect of Initiating Isolation From Right Anterior Ganglionated Plexi.

BACKGROUND: Circumferential pulmonary vein isolation (CPVI) often cause unavoidable vagal reflexes during procedure due to the coincidental modification of ganglionated plexus which are located on pulmonary vein (PV) antrum. The right anterior ganglionated plexi (RAGP) which located at superoanterior area of right superior PV antrum is an essential station to regulate the cardiac autonomic nerve activities and is easily coincidentally ablated during CPVI. The aim of this study is to assess the effect of RAGP ablation on vagal response (VR) during CPVI. METHODS: A total of 80 patients with paroxysmal atrial fibrillation who underwent the first time CPVI were prospectively enrolled and randomly assigned to 2 groups: group A (n=40), CPVI started with right PVs at RAGP site; group B (n=40): CPVI started with left PVs first, and the last ablation site is RAGP. Electrophysiological parameters include basal cycle length, A-H interval, H-V interval, sinus node recovery time, and atrioventricular node Wenckebach point were recorded before and after CPVI procedure. RESULTS: During CPVI, the positive VR were only observed on 1 patient in group A and 25 patients in group B (P<0.001). A total of 21 patients with positive VR in group B needed for temporary ventricular pacing during procedure, while the only patient with positive VR in group A did not need for temporary ventricular pacing (P<0.001). Compared with baseline, basal cycle length, sinus node recovery time, and atrioventricular node Wenckebach point were decreased significantly after CPVI procedure in both groups (all P<0.05) and without differences between 2 groups. CONCLUSIONS: Circumferential PV isolation initiated from RAGP could effectively inhibit VR occurrence and significantly increase heart rate during procedure.

Permanent left bundle branch area pacing for atrioventricular block: Feasibility, safety, and acute effect.

BACKGROUND: Left bundle branch area pacing (LBBAP), a new pacing approach, lacks adequate evaluation. OBJECTIVE: To assess the feasibility, safety, and acute effect of permanent LBBAP in patients with atrioventricular block (AVB). METHODS: A total of 33 AVB patients with indications for ventricular pacing were recruited. Electrocardiograms, pacing parameters, echocardiographic measurements, and complications associated with LBBAP were evaluated perioperatively and at 3-month follow-up. Successful LBBAP was defined as a paced QRS morphology of right bundle branch block pattern in lead V1 and QRS duration (QRSd) less than 130 ms. RESULTS: LBBAP was successfully performed in 90.9% (30/33) of patients (mean age: 55.1 ± 18.5 years; 66.7% male). The mean capture threshold was similar during the procedure (0.76 ± 0.26 V at 0.4 ms) and at the 3-month follow-up (0.64 ± 0.20 V at 0.4 ms). The paced QRSd was 112.8 ± 10.9 ms during the procedure and 116.8 ± 10.4 ms at the 3-month follow-up. Baseline left or right bundle branch block was corrected (intrinsic QRSd 153.3 ± 27.8 ms vs paced QRSd 122.2 ± 9.9 ms) with a success rate of 68.7% (11/16). One ventricular septal lead perforation occurred soon after the procedure with characteristics of pacing failure, and lead revision was successful. Cardiac function and left ventricular synchronization by 2-dimensional echocardiographic strain imaging at the 3-month follow-up slightly improved compared with that at baseline. CONCLUSIONS: Permanent LBBAP yielded a stable threshold, a narrow QRSd, and preserved left ventricular synchrony with few complications. Our preliminary results indicate that LBBAP holds promise as an attractive physiological pacing strategy for AVB.

Association between big endothelin-1 and CHADS2/CHA2DS2-VASc scores in non-valvular atrial fibrillation.

BACKGROUND: Endothelial function, as measured by big endothelin-1 (ET-1), has been demonstrated to be useful in predicting adverse long-term events in patients with cardiovascular disease. Nevertheless, there are little data about the association between big ET-1 and thromboembolism risk in atrial fibrillation (AF). We aimed to investigate the relationship between big ET-1 and CHADS2/CHA2DS2-VASc scores used for evaluating thromboembolic risk in patients with non-valvular AF. METHODS: The study population consisted of 238 consecutive AF patients (67.6% with paroxysmal AF and 32.4% with persistent AF). The patients were divided into two groups (high- or low-intermediate risk group) based on CHADS2 and CHA2DS2-VASc scores (score ≥ 2 or < 2, respectively). Clinical, laboratory, and echocardiographic parameters were evaluated, and the CHADS2/CHA2DS2-VASc scores were compared between groups. The association between big ET-1 levels and CHADS2/CHA2DS2-VASc score was assessed. Multivariate logistic regression analysis was performed to identify independent predictors of CHADS2/CHA2DS2-VASc scores. RESULTS: The high CHADS2/CHA2DS2-VASc score group had older age, higher big ET-1 levels, and enlarged left atrial diameter than the low CHADS2/CHA2DS2-VASc score group (P < 0.05). Multiple logistic regression analysis revealed that big ET-1 level was an independent determinant of high CHADS2/CHA2DS2-VASc scores [odds ratio (OR) = 2.545 and OR = 3.816; both P < 0.05]. CONCLUSIONS: Our study indicates that in non-valvular AF, big ET-1 was significantly correlated with CHADS2/CHA2DS2-VASc scores and an independent predictor of high CHADS2/CHA2DS2-VASc scores. Big ET-1 may serve as a useful marker for risk stratification in this setting.