Comparing Left Atrial Low Voltage Areas in Sinus Rhythm and Atrial Fibrillation Using Novel Automated Voltage Analysis: A Pilot Study.

Background: Low voltage areas (LVAs) have been proposed as surrogate markers for left atrial (LA) scar. Correlation between voltages in sinus rhythm (SR) and atrial fibrillation (AF) have previously been measured via point-by-point analysis. We sought to compare LA voltage composition measured in SR to AF, utilizing a high-density automated voltage histogram analysis (VHA) tool in those undergoing pulmonary vein isolation (PVI) for persistent AF (PeAF). Methods: We retrospectively analyzed patients with PeAF undergoing de novo PVI. Maps required ≥ 1,000 voltage points in each rhythm and had a standardized procedure (mapped in AF then remapped in SR post-PVI). We created six anatomical segments (AS) from each map: anterior, posterior, roof, floor, septal and lateral AS. These were analyzed by VHA, categorizing atrial LVAs into 10 voltage aliquots 0 - 0.5 mV. Data were analyzed using SPSS v.26. Results: We acquired 58,342 voltage points (n = 10 patients, mean age: 67 ± 13 years, three females). LVA burdens of ≤ 0.2 mV, designated as "severe LVAs", were comparable between most AS (except on the posterior wall) with good correlation. Mapped voltages between the ranges of 0.21 and 0.5 mV were labeled as "diseased LA tissue", and these were found significantly more in AF than SR. Significant differences were seen on the roof, anterior, posterior, and lateral AS. Conclusions: Diseased LA tissue (0.21 - 0.5 mV) burden is significantly higher in AF than SR, mainly in the anterior, roof, lateral, and posterior wall. LA "severe LVA" (≤ 0.2 mV) burden is comparable in both rhythms, except with respect to the posterior wall. Our findings suggest that mapping rhythm has less effect on the LA with voltages < 0.2 mV than 0.2 - 0.5 mV across all anatomical regions, excluding the posterior wall.

The impact of steerable sheath visualization during catheter ablation for atrial fibrillation.

AIMS: Incorporating a steerable sheath that can be visualized using an electroanatomical mapping (EAM) system may allow for more efficient mapping and catheter placement, while reducing radiation exposure, during ablation procedures for atrial fibrillation (AF). This study evaluated fluoroscopy usage and procedure times when a visualizable steerable sheath was used compared with a non-visualizable steerable sheath for catheter ablation for AF. METHODS AND RESULTS: In this retrospective, observational, single-centre study, patients underwent catheter ablation for AF using a steerable sheath that is visualizable using the CARTO EAM (VIZIGO; n = 57) or a non-visualizable steerable sheath (n = 34). The acute procedural success rate was 100%, with no acute complications in either group. Use of the visualizable sheath vs. the non-visualizable sheath was associated with a significantly shorter fluoroscopy time [median (first quartile, third quartile), 3.4 (2.1, 5.4) vs. 5.8 (3.8, 8.6) min; P = 0.003], significantly lower fluoroscopy dose [10.0 (5.0, 20.0) vs. 18.5 (12.3, 34.0) mGy; P = 0.015], and significantly lower dose area product [93.0 (48.0, 197.9) vs. 182.2 (124.5, 355.0) µGy·m2; P = 0.017] but with a significantly longer mapping time [12.0 (9.0, 15.0) vs. 9.0 (7.0, 11.0) min; P = 0.004]. There was no significant difference between the visualizable and non-visualizable sheaths in skin-to-skin time [72.0 (60.0, 82.0) vs. 72.0 (55.5, 80.8) min; P = 0.623]. CONCLUSION: In this retrospective study, use of a visualizable steerable sheath for catheter ablation of AF significantly reduced radiation exposure vs. a non-visualizable steerable sheath. Although mapping time was longer with the visualizable sheath, the overall procedure time was not increased.

Ablation Index Outcome in Redo Persistent Atrial Fibrillation Ablation: Results of a Short-Term Study.

Background: Ablation index (AI) is a novel catheter-based parameter that has improved the outcome and safety of radiofrequency (RF) ablation of pulmonary vein isolations (PVIs). This index incorporates contact force (CF) (g), time (s), and power (W) parameters. The role of AI in redo ablations for persistent atrial fibrillation (peAF) has not been fully investigated. Hence, the impact of AI on the success of the redo PVI during the short-term follow-up period is the aim of this study. Methods: A retrospective analysis of 39 consecutive patients who underwent redo PVI ablations for peAF was carried out between January 2016 and December 2018. Target values for AI were 500 - 550 for anterior and roof and 400 - 380 for posterior and inferior regions. We compared outcomes between AI-guided and catheter CF ablations (i.e., forced time integral (FTI) of more than 400 g/s) during a follow-up of 24 months. Results: Pulmonary vein reconnections at redo procedure were similar in both groups (P = 0.1). AF free burden period was non-significant (mean 15.53 ± 2.4 months in AI group vs. 15.22 ± 1.9 months in CF group, P = 0.79) at 24 months. The AI group demonstrated greater numbers of patients for whom anti-arrhythmic therapy could be de-escalated over 1 year (n = 11 (65%) in AI vs. n = 6 (27%) in CF, P = 0.02). Fewer patients underwent escalation of their anti-arrhythmic therapy (n = 2 (12%) in AI vs. n = 7 (32%) in CF, P = 0.15). The AI group trended towards a shorter procedure time (111.6 ± 27 min) compared to the CF group (133 ± 40 min) (P = 0.06). Other procedural details were comparable. Conclusion: Redo PVI interventions using AI lead to a significant de-escalation in medication during follow-up. Procedure time and radiation dose using AI tends to be shorter. Both techniques are safe with minimal complications.

Use of a radiofrequency guidewire to simplify workflow for left atrium access: a case series.

PURPOSE: Transseptal puncture (TSP) is widely used in catheter-based cardiac procedures to gain left atrial access, but its workflow has remained largely unchanged in the last 50 years. This study evaluated the safety and efficacy of a novel, simplified technique for TSP with a radiofrequency (RF)-powered guidewire that eliminates multiple exchanges required with standard needles. METHODS: TSP was performed in 84 patients undergoing left-sided procedures (72 atrial fibrillation ablations [32 RF, 40 cryoballoon], 4 atrial tachycardia ablations, 2 ventricular arrhythmia ablations, 6 left atrial appendage closure) utilizing a stiff, exchange length RF guidewire. Under fluoroscopic and echocardiographic guidance, the RF guidewire was used to facilitate septal puncture with RF energy and provide a rail for advancing catheters to the left atrium without exchange. All procedures were performed under general anesthesia or sedation. RESULTS: TSP was achieved in all patients with no complications. The RF guidewire allowed catheters to be tracked back up to the superior vena cava without exchange in cases where another dropdown was desired to locate a preferred puncture site. The stiffness of the wire provided adequate support to advance all sheaths to the left side regardless of outer diameter. CONCLUSION: TSP was performed safely and successfully for various left heart procedures with a RF guidewire that served as an RF transseptal device and a stiff guidewire. This allowed for a more efficient and potentially safer technique without the need for re-wiring or an over the wire sheath exchange. This provides substantial savings in both time and materials.

Comparison between radiofrequency with contact force-sensing and second-generation cryoballoon for paroxysmal atrial fibrillation catheter ablation: a multicentre European evaluation.

AIMS: Whether pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using contact force (CF)-guided radiofrequency (RF) or second-generation cryoballoon (CB) present similar efficacy and safety remains uncertain. METHODS AND RESULTS: We performed a multicentre study comparing procedural safety and arrhythmia recurrence after standardized PVI catheter ablation for PAF using CF-guided RF ablation (Thermocool(®) SmartTouch™, Biosense Webster; or Tacticath™, St Jude Medical) (CF group) with second-generation CB ablation (Arctic Front Advance™, Medtronic) (CB group). Overall, 376 patients (mean age 59.8 ± 10.4 years, 280 males) were enrolled in 4 centres: 198 in CF group and 178 in CB group. Procedure was shorter for CB group than for CF group (109.6 ± 40 vs. 122.5 ± 40.7 min, P = 0.003), but fluoroscopy duration and X-ray exposure were not statistically different (P = 0.1 and P = 0.22, respectively). Overall complication rate was similar in both groups: 14 (7.1%) in the CF group vs. 13 (7.3%) in the CB group (P = 0.93). However, transient right phrenic nerve palsy occurred only in CB group (10 patients, 5.6%; P = 0.001 vs. CF group) and severe non-lethal complications (embolic event, tamponade, or oesophageal injury) occurred only in CF group (5 patients, 2.5%; P = 0.03 vs. CB group). No periprocedural death occurred in either group. Single-procedure freedom from any atrial arrhythmias at 18 months post-ablation was comparable in CF group and CB group (76 vs. 73.3%, respectively, log rank P = 0.63). CONCLUSION: Pulmonary vein isolation using CF-guided RF and second-generation CB leads to comparable single-procedure arrhythmia-free survival at up to 18 months with similar overall complication rate.

Comparison of a radiofrequency powered flexible needle with a classic rigid Brockenbrough needle for transseptal punctures in terms of safety and efficacy.

INTRODUCTION: This study aimed to evaluate the safety and efficacy of utilising an innovative radiofrequency (RF) powered flexible needle to achieve transseptal puncture (TSP). METHODS AND RESULTS: A RF powered flexible needle (Toronto catheter, Baylis Medical Company Inc.) associated with a stiffer dilator (Torflex Superstrong, Baylis Medical Company Inc.) was used in 125 consecutive patients referred for left sided ablations (mean age=55.6, male=86.5%) and compared with a standard transseptal set (BRK needle, SL0 sheath and dilator, St Jude Medical, Inc.) used in the previous 100 patients (mean age=56, male 82%). TSP was achieved in 95/100 patients in the Brockenbrough group and in all 125 patients in the Toronto group (p=0.01) despite an equivalent proportion of difficult situations (8 and 9% respectively) and patients with a prior TSP (17% vs 24%). 7/100 needle related events (failure, aborted attempt or pericardial effusion) occurred in the Brockenbrough group and none in the Toronto group (p=0.01). The Toronto needle crossed the septum at the first attempt in 123/125 (98.4%) patients and the Brockenbrough needle in 84/95 (88%) patients (p<0.001). CONCLUSION: Our data suggest that the Toronto RF powered flexible needle is safer and more efficient than a standard Brockenbrough needle and can be used not only in difficult situations but routinely to achieve TSP.

Near elimination of ventricular pacing in SafeR mode compared to DDD modes: a randomized study of 422 patients.

AIMS: SafeR performance versus DDD/automatic mode conversion (DDD/AMC) and DDD with a 250-ms atrioventricular (AV) delay (DDD/LD) modes was assessed toward ventricular pacing (Vp) reduction. METHODS: After a 1-month run-in phase, recipients of dual-chamber pacemakers without persistent AV block and persistent atrial fibrillation (AF) were randomly assigned to SafeR, DDD/AMC, or DDD/LD in a 1:1:1 design. The main endpoint was the percentage of Vp (%Vp) at 2 months and 1 year after randomization, ascertained from device memories. Secondary endpoints include %Vp at 1 year according to pacing indication and 1-year AF incidence based on automatic mode switch device stored episodes. RESULTS: Among 422 randomized patients (73.2±10.6 years, 50% men, sinus node dysfunction 47.4%, paroxysmal AV block 30.3%, bradycardia-tachycardia syndrome 21.8%), 141 were assigned to SafeR versus 146 to DDD/AMC and 135 to DDD/LD modes. Mean %Vp at 2 months was 3.4±12.6% in SafeR versus 33.6±34.7% and 14.0±26.0% in DDD/AMC and DDD/LD modes, respectively (P<0.0001 for both). At 1 year, mean %Vp in SafeR was 4.5±15.3% versus 37.9±34.4% and 16.7±28.0% in DDD/AMC and DDD/LD modes, respectively (P<0.0001 for both). The proportion of patients in whom Vp was completely eliminated was significantly higher in SafeR (69%) versus DDD/AMC (15%) and DDD/LD (45%) modes (P<0.0001 for both), regardless of pacing indication. The absolute risk of developing permanent AF or of remaining in AF for >30% of the time was 5.4% lower in SafeR than in the DDD pacing group (ns). CONCLUSIONS: In this selected patient population, SafeR markedly suppressed unnecessary Vp compared with DDD modes.

Endocardial acceleration (sonR) vs. ultrasound-derived time intervals in recipients of cardiac resynchronization therapy systems.

AIMS: Optimization of cardiac resynchronization therapy (CRT) requires the gathering of cardiac functional information. An accurate timing of the phases of the cardiac cycle is key in the optimization process. METHODS AND RESULTS: We compared Doppler echocardiography to an automated system, based on the recording of sonR (formerly endocardial acceleration), in the detection of mitral and aortic valves closures and measurements of the duration of systole and diastole. We prospectively studied, under various conditions of cardiac stimulation, 75 recipients of CRT systems (69% men), whose mean age was 72 ± 9.2 years, left ventricular ejection fraction 35 ± 11%, baseline QRS duration 154 ± 29 ms, and New York Heart Association functional class 3.0 ± 0.7. We simultaneously recorded (i) sonR, detected by a non-invasive piezoelectric micro-accelerometer sensor clipped onto an electrode located in the parasternal region, (b) electrocardiogram, and (c) Doppler audio signals, using a multichannel data acquisition and analysis system. The correlation between timing of mitral and aortic valve closure by sonR vs. Doppler signals was examined by linear regression analysis. Correlation coefficients and the average absolute error were calculated. A concordance in the timing of the mitral (r = 0.86, error = 9.7 ms) and aortic (r = 0.93, error = 9.7 ms) valves closure was observed between the two methods in 94% of patients. Similarly, sonR and the Doppler-derived measurements of systolic (r = 0.85, error = 13.4 ms) and diastolic (r = 0.99, error = 12 ms) interval durations were concordant in 80% of patients. CONCLUSION: A high concordance was found between sonR and the cardiac ultrasound in the timings of aortic and mitral valve closures and in the estimation of systolic and diastolic intervals durations. These observations suggest that sonR could be used to monitor cardiac function and adaptively optimize CRT systems.

Effects of cardiac resynchronization therapy on echocardiographic indices, functional capacity, and clinical outcomes of patients with a systemic right ventricle.

AIMS: Surgically (SC) or congenitally corrected (CC) transposition of the great arteries (TGA), associated with a systemic right ventricle (RV), is often complicated by heart failure. This retrospective study assessed the functional and mechanical effects of cardiac resynchronization therapy (CRT) in patients presenting with TGA. METHODS AND RESULTS: Seven patients with SC (n = 5) or CC (n = 2) TGA (mean age 24.6 +/- 12 years), a failing systemic RV, and intraventricular dyssynchrony, underwent implantation of a CRT-P. Permanent pacemakers were previously implanted in five patients. The leads were implanted by a combined transvenous and epicardial approach in the five patients with SC TGA. Echocardiography, including tissue Doppler imaging and cardiopulmonary exercise testing were performed before and during CRT. Since, in all patients, ventricular dyssynchrony was due to delayed septal wall contraction, the interventricular septum and RV free wall were stimulated synchronously, with a view to resynchronize a maximum amount of myocardium. After 19.4 +/- 8.1 months of CRT, mean QRS duration decreased from 160 +/- 31 to 120 +/- 28 ms (P = 0.03), intraventricular delay from 104 +/- 27 to 14 +/- 15 ms (P = 0.01), New York Heart Association functional class from 3.0 to 1.57 (P = 0.01), and peak oxygen consumption increased from 13.8 +/- 2.5 to 22.8 +/- 6.7 mL/kg/min (P = 0.03). One patient died suddenly at 23 months of follow-up. CONCLUSIONS: CRT was technically feasible and associated with improvements in cardiac mechanical function and clinical status in patients with TGA, failing systemic RV, and intraventricular dyssynchrony.

Atrial fibrillation in recipients of cardiac resynchronization therapy device: 1-year results of the randomized MASCOT trial.

BACKGROUND: Atrial fibrillation (AF) is associated with increased morbidity and mortality in patients suffering from heart failure (HF). Patients in New York Heart Association HF classes III or IV, with systolic dysfunction and a wide QRS, are candidates for cardiac resynchronization therapy (CRT), and might benefit from atrial overdrive pacing (AOP). METHODS: The Management of Atrial fibrillation Suppression in AF-HF COmorbidity Therapy (MASCOT) trial enrolled 409 CRT device recipients (79% men), who were randomly assigned to AOP ON (n = 197), versus AOP OFF (n = 197) and followed up for 1 year. Their mean age was 68 +/- 10 years, left ventricular ejection fraction 25 +/- 6%, QRS duration 163 +/- 29 milliseconds. New York Heart Association class III was present in 86% of patients and 19% had a history of paroxysmal AF. The primary study end point was incidence of permanent AF at 1 year. RESULTS: Atrial overdrive pacing increased the percentage of atrial pacing from 30% to 80% (P < .0001), was well tolerated, and did not interfere with (a) delivery of CRT (95% mean ventricular pacing in both groups), (b) response to CRT (70% responders in the control vs 67% in the treatment group), or (c) cardiac function (left ventricular ejection fraction increased from 24.5% +/- 6.2% to 32.7% +/- 10.9% in the control and from 25.8% +/- 6.8% to 33.1% +/- 12.6% in the treatment group). The incidence of permanent AF was 3.3% in both groups. By logistic regression analysis, a history of AF (P < .001) and absence of antiarrhythmic drugs (P = .002) were associated with permanent AF. CONCLUSIONS: In this first trial of a specific AF prevention algorithm in CRT recipients, AOP was safe and did not worsen HF. The prevention algorithm did not lower the 1-year incidence of AF.

Relationship between cardiac arrhythmias and sleep apnoea in permanently paced patients with type I myotonic dystrophy.

The long-term relationship between cardiac arrhythmias and sleep apnoea in myotonic dystrophy (DM1) is unknown. Pacemakers enabling the long-term monitoring of electrocardiographic and ventilation parameters were implanted in 20 patients with DM1 (mean age = 42+/-11.6 years), followed 40+/-12.3 months. Arrhythmias were recorded by the pacemaker in 17 patients (85%): 14 developed arrhythmic episodes that occurred either in absence or in presence of concomitant sleep apnoea. Conversely, among these 14 patients, the majority of sleep apnoea episodes were not associated with concomitant arrhythmias. In the other three patients who developed arrhythmias, simultaneous sleep apnoea was never observed. Episodes of sleep apnoea were observed in all patients, though only 85% presented with sleep apnoea syndrome. In conclusion, a high incidence of arrhythmias and sleep apnoea was observed. While arrhythmias are generally attributable to an organic substrate, they are sometimes precipitated by functional triggers, as in the case of sleep apnoea.

Use of a new cardiac pacing mode designed to eliminate unnecessary ventricular pacing.

AIMS: To examine the performance of AAIsafeR2, a new pacing mode to minimize the cumulative proportion of ventricular pacing in patients who do not need regular ventricular support. METHODS AND RESULTS: The safety of AAIsafeR2 was examined in 123 recipients (73 +/- 12 years old, 51% men) of dual chamber pacemakers implanted for sinus node dysfunction, paroxysmal AV block or the bradycardia-tachycardia syndrome. Data were collected from pacemaker diagnostics, and the first 43 patients underwent 24-h Holter recordings before being discharged from the hospital with AAIsafeR2 activated. No adverse event related to AAIsafeR2 was observed. All ventricular pauses detected on Holter tapes triggered immediate back-up ventricular pacing. Appropriate switches to DDD occurred in 97 of 123 patients. In 69 of 123 devices (56%) switches to DDD were non-sustained, and the average % ventricular pacing in this group was 0.2+/-0.5%. CONCLUSION: AAIsafeR2 mode seems to be safe and reliable in patients with infrequent slowing or pauses in ventricular activity, while maintaining ventricular pacing below 1%.

Incidence and predictive factors of atrial fibrillation in paced patients.

We have designed a prospective observational study to analyze the incidence and predictive factors of atrial fibrillation (AF) during a long follow-up, in a large population. Atrial fibrillation episodes were documented by the fallback mode switch (FMS) provided by implanted pacemakers. We have included 377 patients (61% men). The pacing indications were atrioventricular (AV) block (49%), sinus node disease (SND, 16%), bradycardia-tachycardia syndrome (BTS, 5%), AV block + SND (19%), AV block + BTS (6%), and BTS + SND (5%). The mean age at implant was 75 +/- 12 (range 28-95). Atrial fibrillation before inclusion was documented in 10% of patients. Drug therapy at first follow-up included beta-adrenergic blockers (17% of the patients), amiodarone (13%), and others (16%). The mean follow-up was 30 +/- 24 weeks. At least one AF episode was stored during follow-up in the memory of 169 pacemakers (45%). Among patients without history of AF at implant, 46% had documented FMS during follow-up. Patients with AF received more antiplatelet medications than patients without AF (P = 0.03). In patients with AF, New York Heart Association functional class was slightly higher, amiodarone and sotalol were more often prescribed, and the proportion of hypertension was higher than in patients without AF. However, these trends were not statistically significant. A significant higher incidence of premature atrial beats was observed in patients with AF than patients without AF (P < 0.0002). Patients with AF had a lower atrial percentage of paced events (55%) than patients without AF (63%, P < 0.02). These preliminary results confirm the high incidence of AF in paced patients and suggest a preventive effect of atrial pacing. The effects of other clinical variables may be confirmed with a longer follow-up in a larger population.

Clinical testing of a new pacemaker function to monitor ventricular capture.

Automatic beat-by-beat capture functions are designed to minimize the pacing energy delivered, while maintaining the highest safety by delivering an immediate back-up stimulus in case of loss of capture. The objective of this study was to estimate the lowering of ventricular pacing amplitude allowed by such a function, compared to amplitudes usually set manually in routine practice. An automatic ventricular pacing threshold test is launched every 6 hours to measure the automatic capture threshold (AT). From AT the function calculates: (1) the"capture amplitude"(V(c)) = AT + 0.5 V at a minimum output of 1 V and (2) the"safety amplitude" (V(s)) = twice AT at a minimum output of 2.5 V. The function preferentially uses V(c) and verifies capture after each paced beat. In case of loss of capture, a back-up spike is delivered and V(s) is implemented until the next threshold measurement. We estimated the ventricular amplitude delivered by the pacemaker from data stored in the pacemaker memory. We compared these values with the pacing amplitude typically programmed manually (MPA) by physicians at twice AT and a minimum of 2.5 V. Data from 57 recipients of Talent 3 DR pacemakers were analyzed. Complete data sets were available in 25 patients at 1 day, 28 at 1 month, and 39 between 1 day and 1 month. No loss of capture or ventricular pause was observed on 53 ambulatory electrocardiograms (ECG); and pulse amplitude automatically delivered by the device was significantly lower than the MPA at each of the three time points analyzed. This new beat-by-beat capture function allows a significant lowering of the pacing amplitude compared to manual settings, while preserving a 100% safety.

Intra- and interatrial conduction delay: implications for cardiac pacing.

Atrial conduction disorders are frequent in elderly subjects and/or those with structural heart diseases, mainly mitral valve disease, hyperthrophic cardiomyopathies, and hypertension. The resultant electrophysiological and electromechanical abnormalities are associated with a higher risk of paroxysmal or persistent atrial tachyarrhythmias, either atrial fibrillation, typical or atypical flutter or other forms of atrial tachycardias. Such an association is not fortuitous because intra- and interatrial conduction abnormalities delays disrupt (spatial and temporal dispersion) electrical activation, thus promoting the initiation and perpetuation of reentrant circuits. Preventive therapeutic interventions induce variable, sometimes paradoxical effects as with the proarrhythmic effect of class I antiarrhythmic drugs. Similarly, atrial pacing may promote proarrhythmias or an antiarrhythmic effect according to the pacing site(s) and mode. Multisite atrial pacing was conceived to correct, as much as possible, abnormal activation induced by spontaneous intra- or interatrial conduction disorders or by single site atrial pacing, which are situations responsible for commonly refractory arrhythmias. Atrial electrical resynchronization can also be used to correct mechanical abnormalities like left heart AV dyssynchrony resulting from intraatrial conduction delays.