Bipolar ablation involving coronary venous system for refractory left ventricular summit arrhythmias.

Background: Catheter ablation of premature ventricular complexes (PVCs) and ventricular tachycardia (VT) from the left ventricular summit (LVS) may require advanced ablation techniques. Bipolar ablation from the coronary veins and adjacent endocardial structures can be effective for refractory LVS arrhythmias. Objective: The aim of this study was to investigate the outcomes of bipolar ablation performed between the coronary venous system and adjacent endocardial left ventricular outflow tract (LVOT) or right ventricular outflow tract (RVOT). Methods: This multicenter study included consecutive patients with LVS PVC/VT who underwent bipolar ablation between the anterior interventricular vein (AIV) or great cardiac vein (GCV) and the endocardial LVOT/RVOT after failed unipolar ablation. Ablation was started with powers of 10-20 W and uptitrated to achieve an impedance drop of at least 10%. Angiography was performed in all cases to confirm a safe distance (>5 mm) of the catheter from the major coronary arteries. Results: Between 2013 and 2023, bipolar radiofrequency ablation between the AIV/GCV and the adjacent LVOT/RVOT was attempted in 20 patients (4 female; age 57 ± 16 years). Unipolar ablation from sites of early activation (AIV/GCV, LVOT, aortic cusps, RVOT) failed to effectively suppress the PVC/VT in all subjects. Bipolar ablation was delivered with a maximum power of 30 ± 8 W and total duration of 238 ± 217 s and led to acute PVC/VT elimination in all patients. No procedural-related complications occurred. Over a follow-up period of 30 ± 24 months, the freedom from arrhythmia recurrence was 85% (1 recurrence in the VT group and 2 in the PVC group). PVC burden was reduced from 22% ± 10% to 4% ± 8% (P <.001). Conclusion: In cases of LVS PVC/VT refractory to unipolar ablation, bipolar ablation between the coronary venous system and adjacent endocardial LVOT/RVOT is safe and effective if careful titration of power and intraprocedural angiography are performed to ensure a safe distance from the coronary arteries.

Autothreshold algorithm feasibility and safety in left bundle branch pacing.

AIMS: Autothreshold algorithms enable remote monitoring of patients with conventional pacing, but there is limited information on their performance in left bundle branch pacing (LBBP). Our objective was to analyse the behaviour of the autothreshold algorithm in LBBP and compare it with conventional pacing and manual thresholds during initial device programming (acute phase), after 1-7 days (subacute), and 1-3 months later (chronic). METHODS AND RESULTS: A prospective, non-randomized, single-centre comparative study was conducted. Consecutive patients with indication for cardiac pacing were enrolled. Implants were performed in the left bundle branch area or the right ventricle endocardium at the discretion of the operator. Left bundle branch pacing was determined according to published criteria. Autothreshold algorithm was activated in both groups whenever allowed by the device. Seventy-five patients were included, with 50 undergoing LBBP and 25 receiving conventional pacing. Activation of the autothreshold algorithm was more feasible in later phases, showing a favourable trend towards bipolar pacing. Failures in algorithm activation were primarily due to insufficient safety margins (82.8% in LBBP and 90% in conventional pacing). The remainder was attributed to atrial tachyarrhythmias (10.3% and 10%, respectively) and electrical noise (the remaining 6.9% in the LBBP group). In the LBBP group, there were not statistically significant differences between manual and automatic thresholds, and both remained stable during follow-up (mean increase of 0.50 V). CONCLUSION: The autothreshold algorithm is feasible in LBBP, with a favourable trend towards bipolar pacing. Automatic thresholds are similar to manual in patients with LBBP, and they remain stable during follow-up.

Septal fascicle involvement during a Purkinje-related ventricular tachycardia: Electroanatomic correlation using omnipolar technology.

Idiopathic verapamil-sensitive fascicular ventricular tachycardia (VT) is the most common form of Purkinje-related ventricular tachycardia (PRVT). Left septal fascicle (LSF) involvement and its connections with the other fascicles, have been recently reported as a pathophysiologic mechanism for this form of PRVT. We describe a case of idiopathic PRVT with LSF involvement using omnipolar technology (OT) mapping in relation to a false tendon. Ablation in the area with concealed fusion entrainment did not terminate the tachycardia. However, radiofrequency application in the area of LSF with manifest fusion entrainment, resulted in immediate tachycardia termination. Six months follow-up showed no tachycardia recurrence.

Comparison of automated subcutaneous defibrillator screening between different pacing sites in cardiac pacing device carriers.

AIMS: The compatibility of cardiac pacing with the presence of a subcutaneous implantable cardioverter-defibrillator (S-ICD) has been investigated, but S-ICD screening test results have not been compared among different pacing sites. The objective was to compare S-ICD screening results among different cardiac pacing sites and to assess the electrocardiographic predictors of success. METHODS AND RESULTS: This prospective single-centre study conducted automated S-ICD screening in 102 carriers of cardiac pacing devices in conduction system (CSP), biventricular (BVP), right ventricular outflow tract (RVOT), or right ventricular apex (RVA) pacing sites. The study included 102 patients: 40 with CSP (20 left bundle pacing and 20 His bundle pacing), 21 with BVP, and 20 and 21 with RVOT and RVA pacing, respectively. The percentage of positive screenings was significantly higher for CSP (97.5%) than for the other patient groups (BVP 71.4%, RVOT 70%, and RVA 19%). In multivariate analysis, positive screening was associated with a narrower QRS (OR 0.95 [0.92-0.98] P = 0.001) and higher R/T ratio in precordial leads (1.76 [1.18-2.61]). CONCLUSION: A higher S-ICD eligibility rate of cardiac pacing device carriers was obtained in CSP than in conventional pacing (RVA or RVOT) or BVP. The presence of narrower paced QRS width and paced corrected QT interval and of higher R/T ratio in precordial and limb leads are electrocardiographic predictors of a positive response to screening.

Efecto de la cardioversión eléctrica programada de fibrilación auricular sobre la función renal / Effect of programmed electrical cardioversion of atrial fibrillation on renal function

Resumen Introducción: Estudios previos han relacionado la presencia de fibrilación auricular (FA) con una tasa de filtrado glomerular estimada (TFGe) reducida. Objetivo: comparar la evolución de la TFGe en pacientes con FA persistente tras cardioversión eléctrica (CVE) programada en función de la existencia o no de recurrencias, así como la evolución de varios biomarcadores. Materiales y métodos: Cohorte prospectiva de pacientes con FA persistente remitidos a nuestro centro para CVE programada con seguimiento de un año. La TFGe se obtuvo mediante la fórmula CKD-EPI en el momento basal y a los 3 y 12 meses. Se midieron biomarcadores antes de la CVE y a los 12 meses. Resultados: Se incluyeron 92 pacientes con FA persistente, edad media de 64 ± 11 años. Al año de seguimiento y en el total de pacientes, la TFGe se redujo de 86,5 [74,6-97,6 a 84,5 [71,7-95,1 ml/min/1,73 m2 (p = 0,002) y la creatinina aumentó de 0,80 [0,72-0,94] mg/dl a 0,83 [0,74-0,97] mg/dl (p = 0,005). La TFGe se redujo al final del seguimiento, sin diferencia estadísticamente significativa entre los pacientes que presentaron recurrencia a los 12 meses y los que no. Las cifras de BNP y corina mejoraron a los 12 meses, mientras que las de galectina-3 no cambiaron, sin relación con la TFGe. Conclusiones: En los pacientes con FA persistente tratados con CVE programada se observó un empeoramiento de la TFGe al año de seguimiento. Los niveles de BNP y corina mejoraron al año de seguimiento. No hubo diferencias en los niveles de galectina-3.

Abstract Introduction: Previous studies have linked the presence of atrial fibrillation (AF) with a reduced estimated glomerular filtration rate (eGFR). Objective: to compare the evolution of eGFR in patients with persistent AF after elective electrical cardioversion (ECV) based on the existence or not of recurrences, as well as the evolution of various biomarkers. Materials and methods: Prospective cohort of patients with persistent AF referred to our center for elective EVC with a 1-year follow-up. The eGFR was obtained using the CKD-EPI formula at baseline and at 3 and 12 months. Biomarkers were measured before ECV and at 12 months. Results: 92 patients with persistent AF were included, mean age 64 ± 11 years. At one year of follow-up and in all patients, the eGFR decreased from 86.5 [74.6-97.6 to 84.5 [71.7-95.1 ml/min/1.73 m2 (p = 0.002) and creatinine increased from 0.80 [0.72-0.94] mg/dl to 0.83 [0.74-0.97] mg/dl (p = 0.005). The eGFR was reduced at the end of the follow-up, with no statistically significant difference between the patients who had recurrence at 12 months and those who did not. BNP and corin levels improved at 12 months, while galectin-3 did not change, unrelated to eGFR. Conclusions: In patients with persistent AF treated with elective ECV, a worsening of eGFR was observed at one year of follow-up. BNP and corin levels improve at one year of follow-up, there were no differences in galectin-3 levels.

Results of catheter ablation with zero or near zero fluoroscopy in pediatric patients with supraventricular tachyarrhythmias.

INTRODUCTION AND OBJECTIVES: Ionizing radiation exposure in catheter ablation procedures carries health risks, especially in pediatric patients. Our aim was to compare the safety and efficacy of catheter ablation guided by a nonfluoroscopic intracardiac navigation system (NFINS) with those of an exclusively fluoroscopy-guided approach in pediatric patients. METHODS: We analyzed catheter ablation results in pediatric patients with high-risk accessory pathways or supraventricular tachycardia referred to our center during a 6-year period. We compared fluoroscopy-guided procedures (group A) with NFINS guided procedures (group B). RESULTS: We analyzed 120 catheter ablation procedures in 110 pediatric patients (11±3.2 years, 70% male); there were 62 procedures in group A and 58 in group B. We found no significant differences between the 2 groups in procedure success (95% group A vs 93.5% group B; P=.53), complications (1.7% vs 1.6%; P=.23), or recurrences (7.3% vs 6.9%; P = .61). However, fluoroscopy time (median 1.1minutes vs 12minutes; P <.0005) and ablation time (median 96.5seconds vs 133.5seconds; P=.03) were lower in group B. The presence of structural heart disease was independently associated with recurrence (P=.03). CONCLUSIONS: The use of NFINS to guide catheter ablation procedures in pediatric patients reduces radiation exposure time. Its widespread use in pediatric ablations could decrease the risk of ionizing radiation.

Ablation with zero-fluoroscopy of premature ventricular complexes from aortic sinus cusps: A single-center experience.

BACKGROUND: Catheter ablation of premature ventricular complexes from aortic sinus cusps (ASC-PVC) is a complex procedure that conventionally requires coronary catheterization (CC) to localize coronary artery ostium (CAO). Little published information is available on the mapping and ablation with zero-fluoroscopy (ZF) of ASC-PVC. The aim of the study was to determine the efficacy and safety of ASC-PVC ablation with a ZF approach guided by 3D intracardiac echocardiography integration in the electroanatomical mapping system (ICE 3D-EAM). METHODS: This observational study included one patient cohort treated conventionally and another treated with ICE 3D-EAM-guided ZF ablation. Clinical, efficacy, and safety outcomes were evaluated acutely and at 3 months follow-up. RESULTS: The study included 21 patients with ASC-PVC: 10 in the ZF group (age 49 ± 16 years, 60% males) and 11 in the control group (age 47 ± 15 years, 27% males). Fluoroscopy was not required for any patient in the ZF group. Acute success was obtained in 80% of the ZF group vs 55% of the control group (P = .36). The recurrence rate was 30% in the ZF group vs 27% in the control group (P = 1). One nonsevere complication was observed in the ZF group (P = .48). CONCLUSIONS: ZF catheter ablation of ASC-PVC guided by ICE 3D-EAM is feasible, effective, and safe.

Utility and feasibility of the CartoUnivu™ system for atrial flutter ablation in patients with mechanical prosthetic valves.

Ablation of macroreentrant atrial tachycardia in patients with mechanical prosthetic valves represents a challenge for electrophysiologists, because of the complexity of the procedure and the potential complications. Moreover, the need for fluoroscopy in this type of procedure is greater, due to the risk of interference between the prosthetic valve and the ablation or mapping catheter. We present two cases of patients with mechanical prosthetic valves and atrial flutter who underwent successful ablation with no complications using the CartoUnivu™ tool, which integrates the electroanatomical map and the fluoroscopy image.

Premature ventricular complex site of origin and ablation outcomes in patients with prior myocardial infarction.

BACKGROUND: Frequent premature ventricular complexes (PVCs) are common after a myocardial infarction (MI), but data on PVC ablation in this population are limited. OBJECTIVE: The purpose of this study was to analyze data on PVC ablation in post-MI patients. METHODS: Three hundred thirty-two patients with frequent PVCs and left ventricular (LV) dysfunction were prospectively studied. Data from 67 patients (20%; age 63 ± 10 years; 65 men [93%]) with previous MI were compared with the remaining 265 patients. RESULTS: PVCs in post-MI patients originate predominantly from the LV (92% LV vs 6% right ventricle [RV]; P <.001). The most frequent sites of origin (SOO) were MI scar in 23 patients (34%) and left ventricular outflow tract (LVOT) in 22 patients (33%). A papillary muscle origin was more frequent in post-MI patients (16% vs 4%; P = .001), whereas an RV outflow tract origin was less frequent (1% vs 33%; P <.001) compared to patients without MI. In post-MI patients, PVC burden decreased from 29% ± 12% at baseline to 4.6% ± 7% (P <.001); left ventricular ejection fraction (LVEF) improved from 33.6% ± 8% to 42% ± 10% (P <.001); and New York Heart Association functional class improved from 2.1 ± 0.7 to 1.4 ± 0.5 points (P <.001) at 12 months. Compared with the remaining 265 patients, there were no differences in acute ablation success (85% vs 85%; P = .45), complication rate (6% vs 6%; P = .41), or absolute improvement in LVEF (8.8 ± 10 vs 9.9 ± 11 absolute points; P = .38). CONCLUSION: PVC ablation significantly improves cardiac function and functional status in post-MI patients. PVCs predominantly originate from MI scar and LVOT. A papillary muscle SOO was found to be strongly associated with previous MI.

Efecto de la ablación con catéter de venas pulmonares en la función renal de pacientes con fibrilación auricular. Estudio de cohortes prospectivo / Effect of pulmonary vein catheter ablation on kidney function in patients with atrial fibrillation. A prospective cohort study

INTRODUCCIÓN Y OBJETIVOS: Varios estudios han relacionado la presencia de fibrilación auricular (FA) con una tasa de filtrado glomerular estimada (TFGe) reducida. Nuestro objetivo es comparar la evolución de la TFGe en pacientes con FA tras ablación de venas pulmonares (VP) en función del éxito de la técnica, así como estudiar la relación entre TFGe y varios biomarcadores. MÉTODOS: Cohorte prospectiva de pacientes con FA remitidos a nuestro centro para ablación de VP con seguimiento de 1 año. La TFGe se obtuvo mediante la fórmula de la Chronic Kidney Disease Epidemiology Collaboration en el momento basal y a los 3 y 12 meses. Se midieron biomarcadores (péptido natriurético cerebral, corina y galectina-3) antes de la ablación y a los 12 meses. RESULTADOS: Se estudió a 124 pacientes (edad, 55±10 años; el 69,4% varones); 75 presentaban FA paroxística (60,5%). La media de la TFGe basal fue de 90,8 [77,8-100,0] ml/min/1,73 m2. La TFGe se incrementó al final del seguimiento, con diferencia estadísticamente significativa entre los pacientes que habían sufrido recurrencia a los 12 meses y los que no (-1,1 [-6,0 a 8,8] frente a 7,1 [-0,6 a 14,2] ml/min/1,73 m2; p = 0,017). La mejora de la TFGe a los 12 meses fue inversamente proporcional a la TFGe basal. Las cifras de péptido natriurético cerebral y corina mejoraron a los 12 meses, mientras que los de galectina-3 empeoraron, sin relación con la TFGe. CONCLUSIONES: En los pacientes con FA tratados con ablación de VP, se observó una mejora general de la TFGe, más marcada en el subgrupo que no tuvo recurrencias, aunque sin diferencias significativas en el análisis multivariante

INTRODUCTION AND OBJECTIVES: Several studies have linked the presence of atrial fibrillation (AF) with reduced estimated glomerular filtration rate (eGFR). Our objective was to compare changes in eGFR in patients with AF after pulmonary vein (PV) ablation depending on the success of the technique, as well as to examine the relationship between eGFR and several biomarkers. METHODS: Prospective cohort of patients with AF referred to our center for PV ablation with a 1-year follow-up. We estimated eGFR using the Chronic Kidney Disease Epidemiology Collaboration formula at baseline and at 3 and 12 months. Biomarkers (B-type natriuretic peptide, corin, and galectin-3) were measured before ablation and at 12 months. RESULTS: We studied 124 patients (age 55±10 years, 69.4% men). Seventy-five had paroxysmal AF (60.5%). The mean baseline eGFR was 90.8 [77.8-100.0] mL/min/1.73 m2. The eGFR increased at the end of follow-up, with a statistically significant difference between patients with recurrence at 12 months and those without (−1.1 [-6.0 to 8.8] mL/min/1.73 m2 vs 7.1 [−0.6 to 14.2] mL/min/1.73 m2, P=.017). The improvement in eGFR at 12 months was inversely proportional to baseline eGFR. B-type natriuretic peptide and corin levels improved at 12 months, while galectin-3 levels worsened, which was unrelated to eGFR. CONCLUSIONS: In patients with AF treated with PV ablation, an overall improvement in eGFR was observed, which was more marked in the subgroup without recurrences, although without significant differences on multivariate analysis

Influence of baseline QRS on the left ventricular ejection fraction recovery after frequent premature ventricular complex ablation.

AIMS: Frequent premature ventricular complexes (PVCs) can induce or worsen left ventricular systolic dysfunction. We aimed to investigate the influence of the baseline QRS in the response after PVC ablation in patients with depressed left ventricular ejection fraction (LVEF). METHODS AND RESULTS: Two hundred and fifteen [59 ± 13 years old, 152 (71%) men] consecutive patients with left ventricular (LV) systolic dysfunction and frequent PVCs referred for ablation were included and followed-up for 12 months. Echocardiographic response was defined as an improvement of at least five absolute points in LVEF. Clinical, electrocardiogram, and electrophysiological characteristics were analysed. Mean baseline QRS duration was 110 ms [97-140]. Premature ventricular complex burden significantly decreased after ablation from 23% [16-33] at baseline to 1% [0-8] at 12 months, P < 0.001. Mean PVC burden reduction was 18 [8-30] points. There was a significant improvement of LVEF from 35% [29-40] at baseline to 44% [35-55] at 12 months, P < 0.001. One hundred and thirty (61%) patients were considered as echocardiographic responders. Baseline QRS duration (ms) [odds ratio (OR) 0.98 (0.97-0.99), P = 0.01] was an independent predictor of echocardiographic response. Mean LVEF improvement was 16 [10-21] points when the baseline QRS duration was <90 ms; 12 [4-20] when it was 90-110 ms; 5 [0-15] when it was 110 ± 130 ms; and 0 [0-6] points when it was >130 ms. CONCLUSIONS: In patients with LV systolic dysfunction, intrinsic QRS duration is inversely related to the probability and the degree of echocardiographic response after frequent PVC ablation. Patients with a QRS duration >130 ms at baseline have the poorer response after ablation.

Effect of pulmonary vein catheter ablation on kidney function in patients with atrial fibrillation. A prospective cohort study.

INTRODUCTION AND OBJECTIVES: Several studies have linked the presence of atrial fibrillation (AF) with reduced estimated glomerular filtration rate (eGFR). Our objective was to compare changes in eGFR in patients with AF after pulmonary vein (PV) ablation depending on the success of the technique, as well as to examine the relationship between eGFR and several biomarkers. METHODS: Prospective cohort of patients with AF referred to our center for PV ablation with a 1-year follow-up. We estimated eGFR using the Chronic Kidney Disease Epidemiology Collaboration formula at baseline and at 3 and 12 months. Biomarkers (B-type natriuretic peptide, corin, and galectin-3) were measured before ablation and at 12 months. RESULTS: We studied 124 patients (age 55±10 years, 69.4% men). Seventy-five had paroxysmal AF (60.5%). The mean baseline eGFR was 90.8 [77.8-100.0] mL/min/1.73 m2. The eGFR increased at the end of follow-up, with a statistically significant difference between patients with recurrence at 12 months and those without (-1.1 [-6.0 to 8.8] mL/min/1.73 m2 vs 7.1 [-0.6 to 14.2] mL/min/1.73 m2, P=.017). The improvement in eGFR at 12 months was inversely proportional to baseline eGFR. B-type natriuretic peptide and corin levels improved at 12 months, while galectin-3 levels worsened, which was unrelated to eGFR. CONCLUSIONS: In patients with AF treated with PV ablation, an overall improvement in eGFR was observed, which was more marked in the subgroup without recurrences, although without significant differences on multivariate analysis.