Definition and management of arrhythmia-induced cardiomyopathy: findings from the European Heart Rhythm Association survey.

AIMS: Arrhythmia-induced cardiomyopathy (AiCM) represents a subtype of acute heart failure (HF) in the context of sustained arrhythmia. Clear definitions and management recommendations for AiCM are lacking. The European Heart Rhythm Association Scientific Initiatives Committee (EHRA SIC) conducted a survey to explore the current definitions and management of patients with AiCM among European and non-European electrophysiologists. METHODS AND RESULTS: A 25-item online questionnaire was developed and distributed among EP specialists on the EHRA SIC website and on social media between 4 September and 5 October 2023. Of the 206 respondents, 16% were female and 61% were between 30 and 49 years old. Most of the respondents were EP specialists (81%) working at university hospitals (47%). While most participants (67%) agreed that AiCM should be defined as a left ventricular ejection fraction (LVEF) impairment after new onset of an arrhythmia, only 35% identified a specific LVEF drop to diagnose AiCM with a wide range of values (5-20% LVEF drop). Most respondents considered all available therapies: catheter ablation (93%), electrical cardioversion (83%), antiarrhythmic drugs (76%), and adjuvant HF treatment (76%). A total of 83% of respondents indicated that adjuvant HF treatment should be started at first HF diagnosis prior to antiarrhythmic treatment, and 84% agreed it should be stopped within six months after LVEF normalization. Responses for the optimal time point for the first LVEF reassessment during follow-up varied markedly (1 day-6 months after antiarrhythmic treatment). CONCLUSION: This EHRA Survey reveals varying practices regarding AiCM among physicians, highlighting a lack of consensus and heterogenous care of these patients.

Electrical storm treatment by percutaneous stellate ganglion block: the STAR study.

BACKGROUND AND AIMS: An electrical storm (ES) is a clinical emergency with a paucity of established treatment options. Despite initial encouraging reports about the safety and effectiveness of percutaneous stellate ganglion block (PSGB), many questions remained unsettled and evidence from a prospective multicentre study was still lacking. For these purposes, the STAR study was designed. METHODS: This is a multicentre observational study enrolling patients suffering from an ES refractory to standard treatment from 1 July 2017 to 30 June 2023. The primary outcome was the reduction of treated arrhythmic events by at least 50% comparing the 12 h following PSGB with the 12 h before the procedure. STAR operators were specifically trained to both the anterior anatomical and the lateral ultrasound-guided approach. RESULTS: A total of 131 patients from 19 centres were enrolled and underwent 184 PSGBs. Patients were mainly male (83.2%) with a median age of 68 (63.8-69.2) years and a depressed left ventricular ejection fraction (25.0 ± 12.3%). The primary outcome was reached in 92% of patients, and the median reduction of arrhythmic episodes between 12 h before and after PSGB was 100% (interquartile range -100% to -92.3%). Arrhythmic episodes requiring treatment were significantly reduced comparing 12 h before the first PSGB with 12 h after the last procedure [six (3-15.8) vs. 0 (0-1), P < .0001] and comparing 1 h before with 1 h after each procedure [2 (0-6) vs. 0 (0-0), P < .001]. One major complication occurred (0.5%). CONCLUSIONS: The findings of this large, prospective, multicentre study provide evidence in favour of the effectiveness and safety of PSGB for the treatment of refractory ES.

Zero fluoroscopy catheter ablation of premature ventricular contractions: a multicenter experience.

BACKGROUND: Catheter ablation has become an established treatment option for premature ventricular complexes (PVCs). The use of fluoroscopy exposes patients and medical staff to potentially harmful stochastic and deterministic effects of ionizing radiations. We sought to analyze procedural outcomes in terms of safety and efficacy using a "zero fluoroscopy" approach for catheter ablation of PVCs. METHODS: The present retrospective, multicenter, observational study included 131 patients having undergone catheter ablation of PVCs using "zero fluoroscopy" between 2019 and 2020 in four centers compared with another group who underwent the procedure with fluoroscopy. RESULTS: Median age was 51.0 ± 15.9 years old; males were 77 (58.8%). Among the study population, 26 (19.8%) had a cardiomyopathy. The most frequent PVC origin was right ventricular outflow tract (55%) followed by the left ventricle (16%), LVOT and cusps (13.7%), and aortomitral continuity (5.3%). Acute suppression of PVC was achieved in 127 patients (96.9%). At 12 months, a complete success was documented in 109 patients (83.2%), a reduction in PVC burden in 18 patients (13.7%), and a failure was recorded in four patients (3.1%). Only two minor complications occurred (femoral hematoma and arteriovenous fistula conservatively treated). CONCLUSIONS: The PVC ablation with a "zero" fluoroscopy approach appears to be a safe procedure with no major complications and good rates of success and recurrence in our multicenter experience.

Prevention of venous thromboembolism in right heart-sided electrophysiological procedures: results of an European Heart Rhythm Association survey.

Limited data are available regarding venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), following right-sided ablations and electrophysiological (EP) studies. Compared to left-sided procedures, no guidelines on antithrombotic management strategies for the prevention of DVT and PE are available. The main purpose of the present European Heart Rhythm Association (EHRA) survey is to report the current management of right-sided EP procedures, focusing on anticoagulation and prevention of VTE. An online survey was conducted using the EHRA infrastructure. A total of 244 participants answered a 19-items questionnaire on the periprocedural management of EP studies and right-sided catheter ablations. The right femoral vein is the most common access for EP studies and right-sided procedures. An ultrasound-guided approach is employed by more than 2/3 of respondents. Intravenous heparin is not commonly given by the majority of participants. About 1/3 of participants (34%) routinely prescribe VTE prophylaxis during (mostly aspirin and low molecular weight heparin) and 1/4 of respondents (25%) commonly prescribe VTE prophylaxis after discharge (mostly aspirin). Of note, respectively 13% and 9% of participants observed at least one DVT and one PE related to right-sided ablation or EP study within the last year in their center. The present survey shows that only a minority of operators routinely gives intraprocedural intravenous heparin and prescribes VTE prophylaxis after right-sided EP procedures. Compared to left-sided procedures like atrial fibrillation (AF) ablation, there are no consistent systematic antithrombotic management strategies.

Feasibility and safety of reprocessing of intracardiac echocardiography catheters for electrophysiology procedures - a large single center experience.

PURPOSE: Intra-cardiac echocardiography (ICE) has become an important tool for catheter ablation. Adoption of ICE imaging is still limited because of its prohibitively high cost. Our aim was to study the safety and feasibility of ICE catheters reprocessing and its environmental and financial impact. METHODS: This was a single center retrospective analysis of all consecutive electrophysiology procedures in which ICE catheters were used from 2015 to 2022. In total, 1128 patients were studied (70.6% male, mean age was 57.9 ± 13.2 years). The majority of procedures were related to atrial fibrillation ablation (84.6%). RESULTS: For the whole cohort, 57 new ICE catheters were used. Consequently one catheter could be used for 19.8 procedures. New catheters were only used when the image obtained by reused probes was not satisfactory. There were no cases of ICE probe steering mechanism malfunction, no procedure related infections and no allergic reactions that could be attributed to the resterilization process. In total, there was 8.6% of complications not related to ICE imaging. Financially, ICE probe reprocessing resulted with 90% cost reduction (> 2 millions of Euros savings for the studied period) and 95% waste reduction (639.5 kg less, mostly non degradable waste was produced). CONCLUSION: Our data suggests that ICE catheter reprocessing is feasible and safe. It seems that risk of infection is not increased. Significant economic and environmental savings could be achieved by ICE catheters reprocessing. Furthermore, ICE reprocessing could allow more extensive ICE usage resulting in safer procedures with a potential reduction of serious complications.

Cryoballoon ablation for atrial fibrillation in octogenarians: a propensity score-based analysis with a younger cohort.

BACKGROUND: In terms of safety and efficacy, cryoballoon ablation (CB-A) has become a valid option for achieving pulmonary vein isolation (PVI) in patients affected by symptomatic atrial fibrillation. However, CB-A data in octogenarians are still scarce and limited to single-centre experiences. The present multicentre study aimed to compare the outcomes and complications of index CB-A in patients older than 80 years with a cohort of younger patients. METHODS AND RESULTS: We retrospectively enrolled 97 consecutive patients aged ≥80 years who underwent PVI using the second-generation CB-A. This group was compared with a younger cohort of patients using a 1:1 propensity score matching. After the matching, 70 patients from the elderly group were analysed and compared with 70 younger patients (control group). The mean age was 81.4 ±â€Š1.9 years among octogenarians and 65.2 ±â€Š10.2 years in the younger cohort. The global success rate after a median follow-up of 23 [18-32.5] months was 60.0% in the elderly group and 71.4% in the control group (P = 0.17). Phrenic nerve palsy was the most common complication occurring in a total of 11 patients (7.9%): in 6 (8.6%) patients in the elderly group and in 5 patients (7.1%) in the younger group (P = 0.51). Only two (1.4%) major complications occurred: one (1.4%) femoral artery pseudoaneurysm in the control group, which resolved with a tight groin bandage, and one (1.4%) case of urosepsis in the elderly group. Arrhythmia recurrence during the blanking period and the need for electrical cardioversion to restore sinus rhythm after PVI were found to be the only independent predictors of late arrhythmia relapses. CONCLUSIONS: The present study showed that CB-A PVI is as feasible, safe and effective among appropriately selected octogenarians as it is in younger patients.

Early atrial fibrillation detection is associated with higher arrhythmic burden in patients with loop recorder after an embolic stroke of undetermined source.

Background: After an embolic stroke of undetermined source (ESUS), long-term monitoring is recommended to start an anticoagulation therapy in patients with documented atrial fibrillation (AF). Literature is sparse about the AF burden following an ESUS, although this might have significant implications in terms of clinical management and therapeutic strategy. Our primary aim was to evaluate a possible association between early detection of AF (within 90 days from the ILR implantation) and higher AF burden. Methods: This is a retrospective single-center study of 129 consecutive patients who received implantable loop recorders (ILRs) after an ESUS for detection of subclinical AF and their AF burden. Results: Mean age was 70.3 ± 10.4 years old (males: 51.9%). Atrial fibrillation was found in 40.3% of patients. Patients with AF were older, presented a higher CHAD2S2-Vasc Score and greater left atrial volume compared with patients without AF. The median AF burden was 1.2%; 59% of patients had the first AF episode within 90 days from the ILR implant while 41% experienced the first episode later than 90 days. The AF burden was significantly higher in the former group. Of note, the univariate analysis showed that only early AF detection was significantly associated with AF burden >1% (OR 20.0; 95% CI 1.68-238.6, p = 0.01). Conclusions: The early AF detection was found to be significantly associated with a higher burden of AF.

The usefulness of QRS Index for prediction of echocardiographic response in cardiac resynchronization therapy: a multicenter study.

BACKGROUND: The association between QRS narrowing and response to cardiac resynchronization therapy (CRT) has been investigated by several studies, but their findings remain inconclusive. Aim of our study was to explore the relationship between QRS Index and echocardiographic response to CRT. METHODS: This multicenter, retrospective analysis included 326 consecutive patients (mean age was 70.0±10.1 years old; males 76.7%) who underwent CRT-D implantation in primary and secondary prevention between 2018 and 2020. The estimation of QRS shortening after CRT-D implantation was precisely assessed through the QRS Index, calculated as follows: [(QRS duration before implantation - paced QRS duration)/QRS duration before implantation]*100. RESULTS: After a mean follow-up of 12.7±4.5 months, 55.2% (180/326) of the patients showed an echocardiographic response to CRT. The median [25-75th] QRS Index was 3.85% [-14.1% - +13.9%]. The best predictive cut-off value of QRS Index was 1.40% (sensitivity 70.4%, specificity 64.5%, AUC 0.70). In patients with left bundle branch block, the median [25-75th] QRS Index was 9.85% [+3.87% - +16.7%]. In this subgroup, the AUC was 0.737 and the best predictive cut-off of QRS Index was 2.20% (sensitivity 78.3%, specificity 67%). The multivariable model showed that only left ventricular ejection fraction and QRS Index were independently associated with CRT response (respectively OR 0.92, CI 95% 0.86-0.98, P=0.01 and OR 1.057, CI 95% 1.026-1.089, P<0.001). CONCLUSIONS: The QRS Index tightly correlated with CRT response. Only LVEF and QRS Index were independently associated with echocardiographic response to CRT.

Correlation between epicardial adipose tissue and atrial fibrillation burden in coronary artery bypass graft surgery.

AIMS: Recent studies suggest an association between epicardial adipose tissue (EAT) and atrial fibrillation. The aim of the study is to evaluate the quantitative and qualitative characteristics of EAT in relation to atrial fibrillation burden after coronary artery bypass graft (CABG). METHODS: This prospective single-centre study included patients undergoing CABG. The patients underwent transthoracic echocardiography and collection of a bioptic sample containing right appendage and EAT during CABG for histological characterization. After surgery, clinical and telemetry data were collected. RESULTS: Fifty-six consecutive patients were enrolled. The mean postsurgical hospitalization was 7.9 ±â€Š3.7 days. Twenty-two patients had at least one episode of atrial fibrillation. In the atrial fibrillation group, there was a bigger atrial volume, a higher degree of diastolic disfunction, a thicker layer of EAT and an older median age in comparison with the group that did not develop it. EAT with a cut-off of 4 mm was a predictor of atrial fibrillation with an odds ratio (OR) of 1.49 (confidence interval (CI) 1.09-2.04), 73% of sensibility and 89% of specificity. From the histological analyses, the patients with atrial fibrillation had a significantly higher percentage of fibrosis. At univariate analysis, atrial volume [OR 1.05, CI 1.01-1.09, P = 0.022], E/A rate (OR 0.04, CI 0.02-0.72 P = 0.29), the percentage of fibrosis (OR 1.12, CI 1.00-1.25, P = 0.045) and age (OR 1.17, CI 1.07-1.28, P = 0.001) were predictors of atrial fibrillation. At multivariate analysis, atrial volume (P = 0.027), fibrosis (P = 0.003) and age (P = 0.039) were independent predictors of atrial fibrillation. CONCLUSION: Postcardiac surgical atrial fibrillation is frequent. EAT thickness, atrial volume, fibrosis and age are predictors of postcardiac surgical atrial fibrillation.

Impact of Systematic Use of Intracardiac Ultrasound during Transseptal Catheterization in the Electrophysiology Laboratory.

AIMS: To explore the impact of the use of intracardiac echocardiography (ICE) in the ablation of supraventricular arrhythmias requiring transseptal catheterization (TSC), whilst analyzing the reduction in periprocedural complications and complications specifically related to TSC. METHODS: A retrospective multicenter study collecting data from consecutive atrial fibrillation (AF) and supraventricular ablation procedures that required TSC was performed in five Italian centers. Based on physician discretion, TSC was performed with or without ICE. Periprocedural complications, separating all complications from complications directly related to TSC, were collected. Independent predictors of periprocedural complications and TSC-related complications were investigated. RESULTS: A total of 2181 TSCs were performed on 1862 patients at five Italian centers from 2006 to 2021, in 76% of cases by AF ablation and in 24% by ablation of other arrhythmias with a circuit in the left atrium. Overall, 1134 (52%) procedures were performed with ICE support and 1047 (48%) without ICE. A total of 67 (3.1%) complications were detected, 19 (1.7%) in the ICE group and 48 (4.6%) in the no ICE group, p < 0.001. A total of 42 (1.5%) complications directly related to TSC: 0.9% in the ICE group and 3.1% in the no ICE group (p < 0.001). The independent predictors of all complications were age (OR 1,02 95% C.I 1.00-1.05; p = 0.036), TSC with the use of ICE (OR 0.27 95% C.I 0.15-0.46; p < 0.001) and AF ablation (OR 2,25 95%C.I 1.05-4.83; p = 0.037). The independent predictors for TSC complications were age (OR 1.03 95% C.I 1.01-1.06; p = 0.013) and TSC with the use of ICE (OR 0.24 95% C.I 0.11-0.49; p < 0.001). CONCLUSIONS: ICE reduced periprocedural and TSC-related complications during electrophysiological procedures for ablation of left atrial arrhythmias.

Wolff-Parkinson-White syndrome and dilated cardiomyopathy: Not only an electrical issue?

The present case describes a dilated cardiomyopathy associated with both antidromic and orthodromic atrio-ventricular reentrant tachycardias supported by multiple right accessory pathways. Both right accessory pathways were successfully eliminated by catheter ablation and the patient progressively recovered during the follow up. The following etiologies might be involved: 1) primitive dilated cardiomyopathy (or post-inflammatory); 2) septal dyssinchrony due to ventricular pre-excitation; 3) tachycardiomyopathy.

Radiation dose reduction in the setting of cryoballoon ablation for atrial fibrillation: the value of optimized fluoroscopy settings and intracardiac echocardiography.

Cryoballoon (CB) has proven to be very effective in the percutaneous treatment of atrial fibrillation (AF). CB ablation is still hampered by X-ray exposure and the doses applied are consistently higher if compared to radiofrequency ablation. All patients who underwent CB ablation between 2015 and 2020 were analysed. Intracardiac echography was consistently used for transeptal puncture. To demonstrate the differences in radiation exposure 3 groups of 50 consecutive patients were selected. In the first group (G1) 3D rotational angiography (3DRA) was used as an intraprocedural imaging method. In the second group (G2), traditional X-ray imaging was used and frame rates both for fluoro and cine modes of diascopy were lowered. In the third group (G3) only 2-3 frames per second were used, cine mode was abandoned and the grid was removed from the X-ray detector. A total of 150 patients were included (76% males, mean age 57.3 ± 11.5 years). A dramatic reduction of radiation dose was obtained from 9585 ± 5610 µGy/m2 in G1 to 2469 ± 2002 µGy/m2 in G2 and finally 227.1 ± 360 µGy/m2 in G3 (p < 0.0001). There was also a significant decrease of procedural and fluoroscopy times. No difference in major complications and midterm outcomes was found between the groups. By following a few relatively simple steps (omitting the pre-procedural imaging, removing grid from the X-ray detector and using very low frame rates) CB ablation could be performed with ultralow radiation exposure without compromising the safety of efficacy of the procedure.

Electrocardiographic predictors of echocardiographic response in cardiac resynchronization therapy: Update of an old story.

BACKGROUND: A better selection of patients with left bundle branch block (LBBB) might increase the response to cardiac resynchronization therapy (CRT). The aim of the study was to investigate the association between the Strauss criteria, absence of S wave in V5-V6, the Selvester score and response to CRT. METHODS AND RESULTS: The retrospective analysis included all consecutive patients having undergone implantation of biventricular defibrillators in primary prevention between 2018 and 2020. The final analysis included 236 patients (mean age 69.7 ± 9.9; 77.5% of males). The Strauss criteria were significantly associated with CRT response (p < 0.01) with a sensitivity of 71.3% and specificity of 64.1%. The Strauss criteria along with the absence of S wave in V5 and V6 showed a sensitivity of 56.7%, a specificity of 82.6% and a positive predictive value of 90.5%. The Selvester score was significantly and inversely associated with CRT response (OR 0.818, 95% CI 0.75-0.89; p < 0.001). The multivariable model showed that left ventricular ejection fraction (LVEF) and QRS duration (≥140 ms in males and ≥ 130 ms in females) were independently associated with CRT response (respectively OR 0.92, CI 95% 0.86-0.98, p = 0.01 and OR 3.70, CI 95% 1.12-12.21, p = 0.03). CONCLUSIONS: Strauss criteria, especially in association with absence of S wave in V5 and V6, were able to increase specificity and positive predictive value for predicting CRT response. The Selvester score was inversely associated with CRT response. Finally, LVEF and QRS duration were independently associated with echocardiographic response to CRT.

Decline of Admission for Acute Coronary Syndromes and Acute Cardiovascular Conditions during COVID-19 Pandemic in Veneto Region.

Background: The present study aimed to examine longitudinal trends in hospitalizations for acute coronary syndrome (ACS) before and during the COVID-19 pandemic, by reviewing the data from 13 hospitals of the Veneto Region, in the north-east of Italy. Methods: We performed a multicenter, retrospective analysis including all the consecutive patients presenting with ACS and other acute cardiovascular (CV) conditions (defined as heart failure, arrhythmias, cardiac arrest and venous thromboembolism) hospitalized in 13 different hospitals of the Veneto Region covering a population of 2,554,818 inhabitants, during the first (between 15 March 2020 and 30 April 2020) and second (between 15 November 2020 and 30 December 2020) COVID-19 pandemic waves (the 2020 cohort). Data were compared with those obtained at the same time-windows of years 2018 and 2019 (the historical cohorts). Results: Compared to the historical cohorts, a significant decrease in the number of ACS cases was observed in 2020 (−27.3%, p = 0.01 and −32%, p < 0.001, comparing 2018 versus 2020 and 2019 and 2020, respectively). The proportion of patients hospitalized for acute CV conditions decreased during the first and second wave COVID-19 pandemic when compared to the historical cohorts (−36.5%, p < 0.001 and −40.6%, p < 0.001, comparing 2018 versus 2020 and 2019 and 2020, respectively). Pearson's correlation evidenced a significant inverse relationship between the number of COVID-19 cases and both ACS hospital admissions (r = −0.881, p = 0.005) and hospitalizations for acute CV conditions (r = −0.738, p = 0.01), respectively. Conclusions: The decrease in hospitalizations for ACS and other acute CV conditions will strongly affect future patients' management since undiagnosed nonfatal CV events represent a source of increased (and unknown) CV morbidity and mortality.