Catheter ablation for supraventricular tachycardia and health resource utilization and expenditures: A propensity-matched cohort study.

BACKGROUND: Few data are available regarding temporal patterns of health resource utilization (HRU) and expenditures among patients undergoing catheter ablation for paroxysmal supraventricular tachycardia (PSVT). This study aimed to describe expenditures and HRU in patients with PSVT who underwent catheter ablation compared to a matched cohort of patients on medical therapy alone. METHODS: Using a large US administrative database, we identified adult patients (age 18 to 65 years) with a new PSVT diagnosis between 2008 and 2016. Propensity-score matching was used to assemble a PSVT cohort treated with ablation or medical therapy alone (N = 2556). Longitudinal trends in HRU and expenditures in the 3-years preceding and following PSVT diagnosis were compared. RESULTS: There were no significant differences in expenditures between groups except within the first year after PSVT diagnosis: $48,004 ablation vs. $17,560 medical therapy (p < 0.001). This difference was driven by procedural expenditures, where the mean cost of catheter ablation was $32,057 ± SD 26,737. In Years 2 and 3 post-ablation, HRU and expenditures decreased to the levels associated with the medical therapy group, although fewer ablation patients required any prescription for beta-blockers, calcium channel blockers, or anti-arrhythmic drugs (32% ablation vs. 42% medical therapy group, p < 0.001). CONCLUSION: Catheter ablation reduces medication burden in PSVT, yet health resource use and expenditures were similar beyond 2 years post-ablation when compared to PSVT patients on medical therapy alone. Additional studies are required to better understand drivers of these sustained health expenditures, and barriers to achieving cost-savings for a potentially curative procedure.

Plain language summary of the safety and effectiveness of etripamil for atrioventricular-nodal-dependent supraventricular tachycardia: the RAPID study.

WHAT IS THIS SUMMARY ABOUT?: This is a plain language summary of a clinical research study called RAPID. The study looked at the potential for how safe and effective etripamil was at stopping an episode of rapid heartbeats in people with atrioventricularnodal-dependent supraventricular tachycardia (AV-node-dependent SVT). An episode is used to describe the period of time when a person experiences an abnormally very fast heartbeat. This was done by comparing an investigational drug called etripamil with a placebo, each administered via a rapidly acting nasal spray. AV-node-dependent SVT affects the rhythm of the heart, causing it to suddenly beat rapidly. The condition often requires medical treatment to help return the heart to its normal, healthy heartbeat pattern and speed, called 'sinus rhythm'. Researchers are looking at ways of improving the management of supraventricular tachycardias (SVT) by reducing the need for patients to attend an urgent care clinic, emergency ward or hospital for treatment. In the RAPID study, participants used a nasal spray containing either 70 mg etripamil or a placebo solution when they experienced an episode of SVT. The researchers wanted to know how long it took for each participant's rapid heartbeat to return to sinus rhythm after administering the etripamil or placebo nasal spray. Participants in the study were considered successfully treated if their heartbeats returned to sinus rhythm for at least 30 seconds within 30 minutes of using the nasal spray. Although 30 seconds may seem brief, it's medically important because it shows that a person's heartbeat has been temporarily stabilized and returned to normal functioning. WHAT WERE THE RESULTS?: Out of 99 people who used etripamil during an SVT episode, 63 participants (64%) experienced a return to sinus rhythm for at least 30 seconds within 30 minutes after using the nasal spray. In contrast, 26 out of 85 participants (31%) who used the placebo nasal spray experienced a return to sinus rhythm for at least 30 seconds within 30 minutes after use. Furthermore, the average time taken for the return to sinus rhythm was 17 minutes for the etripamil group which was 3-times faster than the placebo group at 53 minutes. Also, in the study no serious side effects occurred that were related to etripamil. WHAT DO THE RESULTS OF THE STUDY MEAN?: The RAPID study supports the potential that etripamil may be safe and well tolerated by participants as a treatment for episodes of rapid heartbeat in people with AV-node-dependent SVT. The results also showed a significant improvement in symptoms following treatment with etripamil.

[Esophageal-ECG in the emergency department]. / ABC om Esofagus-EKG.

The management of tachycardias depends on their underlying pathophysiology. The key to uncovering this pathophysiology is in finding the temporal relationship between atrial and ventricular activation. The P-waves resulting from atrial activation can however be hard to detect on a traditional EKG in the setting of a tachycardia. Esophageal-EKG can help reveal the P-waves. The patient swallows an electrode, whose position in the esophagus is then adjusted to maximize the signal coming from the left atrium, clearly revealing atrial activity. This article describes the indications and contraindications for esophageal-EKG, as well as how it is performed and interpreted. Esophageal-EKG is of particular diagnostic value in the setting of a regular tachycardia with wide QRS complexes and no obvious signs of atrio-ventricular dissociation. In this setting, the esophageal-EKG can distinguish between ventricular tachycardia and a supraventricular tachycardia with aberrant conduction.

Comparing the effects of pulsed and radiofrequency catheter ablation on quality of life, anxiety, and depression of patients with paroxysmal supraventricular tachycardia: a single-center, randomized, single-blind, standard-controlled trial.

BACKGROUND: Radiofrequency catheter ablation (RFCA) may lead to decreased quality of life (QOL) and increased anxiety and depression in patients with paroxysmal supraventricular tachycardia (PSVT), possibly due to the lack of selectivity of the ablation tissue and the long ablation time. In recent years, pulsed field ablation (PFA) has been used for the first time in China to treat PSVT patients because of its ability to ablate abnormal tissue sites in a precise and transient manner. This study was conducted to compare the effects of PFA and RFCA on QOL and psychological symptoms of PSVT patients. METHODS: We have designed a single-center, randomized, single-blind, standard-controlled trial. A total of 50 participants who met the eligibility criteria would be randomly allocated into the PFA group or RFCA group in a 1:1 ratio. All participants were assessed using the 36-Item Short-Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS) at pre-procedure (T0), post-procedure (T1), and 3 months post-procedure (T2). The SPSS 21.0 software was used to analyze the data through Wilcoxon and Fisher's exact tests and repeated measures ANOVA. RESULTS: Twenty-five in the PFA group and 24 in the RFCA group completed the trial. SF-36: (1) Between-group comparison: At T1, PFA group had significantly higher SF-36 scores on physiological function (PF) and general health (GH) than RFCA group, with a treatment difference of 5.61 points and 18.51 points(P < 0.05). (2) Within-group comparison: We found that in the PFA and RFCA groups, T2 showed significant improvement in the remaining 6 subscales of the SF-36 scale compared to T1 and T0 (P < 0.05), except for body pain (BP) and social function (SF) scores. HADS: (1) Between-group comparison: no significant difference (P > 0.05). (2) Within-group comparison: The HADS scores of the PFA and RFCA groups were statistically significant at T2 compared to T0 and T1 (P < 0.05). CONCLUSIONS: Our study provided new and meaningful evidence that PFA was effective in significantly improving QOL and decreasing anxiety and depression in PFA patients. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2200060272.

Incidental Arrhythmias During Atrial Fibrillation Screening With Repeat 7-Day Holter ECGs in a Hospital-Based Patient Population.

BACKGROUND: Screening for atrial fibrillation (AF) may reveal incidental arrhythmias of relevance. The aim of this study was to describe incidental arrhythmias detected during screening for AF in the STAR-FIB (Predicting SilenT AtRial FIBrillation in Patients at High Thrombembolic Risk) cohort study. METHODS AND RESULTS: In the STAR-FIB cohort study, we screened hospitalized patients for AF with 3 repeat 7-day Holter ECGs. We analyzed all Holter ECGs for the presence of the following incidental arrhythmias: (1) sinus node dysfunction, defined as sinus pause of ≥3 seconds' duration; (2) second-degree (including Wenckebach) or higher-degree atrioventricular block (AVB); (3) sustained supraventricular tachycardia of ≥30 seconds' duration; and (4) sustained ventricular tachycardia of ≥30 seconds' duration. We furthermore report treatment decisions because of incidental arrhythmias. A total of 2077 Holter ECGs were performed in 794 patients (mean age, 74.7 years; 49% women), resulting in a mean cumulative duration of analyzable ECG signal of 414±136 hours/patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were sinus node dysfunction in 14 patients (1.8%), AVB in 41 (5.2%), supraventricular tachycardia in 42 (5.3%), and ventricular tachycardia in 2 (0.3%). Second-degree AVB was found in 23 patients (2.9%), 2:1 AVB in 10 (1.3%), and complete AVB in 8 (1%). Subsequently, 8 patients underwent pacemaker implantation, 1 for sinus node dysfunction (post-AF conversion pause of 9 seconds) and 7 for advanced AVB. One patient had an implantable cardioverter-defibrillator implanted for syncopal ventricular tachycardia. CONCLUSIONS: Incidental arrhythmias were frequently detected during screening for AF in the STAR-FIB study and resulted in device therapy in 1.1% of our cohort patients.

Cannon A wave validation as a diagnostic tool in paroxysmal supraventricular tachycardias.

OBJECTIVE: The presence of cannon A waves, the so called "frog sign", has traditionally been considered diagnostic of atrioventricular nodal re-entrant tachycardia (AVNRT). Nevertheless, it has never been systematically evaluated. The aim of this study is to assess the independent diagnostic utility of cannon A waves in the differential diagnosis of supraventricular tachycardias (SVTs). METHODS: We prospectively included 100 patients who underwent an electrophysiology (EP) study for SVT. The right jugular venous pulse was recorded during the study. In 61 patients, invasive central venous pressure (CVP) was registered as well. CVP increase is thought to be related with the timing between atria and ventricle depolarization; two groups were prespecified, the short VA interval tachycardias (including typical AVNRT and atrioventricular reciprocating tachycardia (AVRT) mediated by a septal accessory pathway) and the long VA interval tachycardias (including atypical AVNRT and AVRT mediated by a left free wall accessory pathway). RESULTS: The relationship between cannon A waves and AVNRT did not reach the statistical significance (OR: 3.01; p = .058); On the other hand, it was clearly associated with the final diagnosis of a short VA interval tachycardia (OR: 10.21; p < .001). CVP increase showed an inversely proportional relationship with the VA interval during tachycardia (b = -.020; p < .001). CVP increase was larger in cases of AVNRT (4.0 mmHg vs. 1.2 mmHg; p < .001) and short VA interval tachycardias (3.9 mmHg vs. 1.2 mmHg; p < .001). CONCLUSION: The presence of cannon A waves is associated with the final diagnosis of short VA interval tachycardias.

[Development of catheter ablation of supraventricular tachycardias with special consideration of contributions from German engineers and electrophysiologists]. / Entwicklung der Katheterablation supraventrikulärer Tachykardien unter besonderer Berücksichtigung der Beiträge deutscher Ingenieure und Elektrophysiologen.

The development and clinical implementation of catheter ablation of supraventricular tachycardia is one of the outstanding achievements of modern cardiovascular treatment. Over a period of less than 40 years, a curative and safe treatment strategy for almost all forms of atrial arrhythmias has been developed and implemented. German electrophysiologists and engineers have made a significant contribution to this truly outstanding success story in modern medicine. Their contributions should be appropriately acknowledged because without them, the development of ablation technology and its worldwide dissemination would not have been possible. Both the technological contributions and the medical-electrophysiological contributions were at the absolute forefront of worldwide developments and have made a significant contribution to the fact that today more than 500,000 patients with symptomatic and/or threatening cardiac arrhythmias can be successfully treated every year by use of catheter ablation. We would like to thank them all for their achievements.

Rationale and design of the NODE-303 study: evaluating the safety of symptom-prompted, self-administered etripamil for paroxysmal supraventricular tachycardia episodes in real-world settings.

BACKGROUND: Paroxysmal supraventricular tachycardia (PSVT) is a common episodic arrhythmia characterized by unpredictable onset and burdensome symptoms including palpitations, dizziness, chest pain, distress, and shortness of breath. Treatment of acute episodes of PSVT in the clinical setting consists of intravenous adenosine, beta-blockers, and calcium channel blockers (CCBs). Etripamil is an intranasally self-administered L-type CCB in development for acute treatment of AV-nodal dependent PSVT in a nonmedical supervised setting. METHODS: This paper summarizes the rationale and study design of NODE-303 that will assess the efficacy and safety of etripamil. In the randomized, double-blinded, placebo-controlled, Phase 3 RAPID trial, etripamil was superior to placebo in the conversion of single PSVT episodes by 30 minutes post initial dose when administered in the nonhealthcare setting; this study required a mandatory and observed test dosing prior to randomization. The primary objective of NODE-303 is to evaluate the safety of symptom-prompted, self-administered etripamil for multiple PSVT episodes in real-world settings, without the need for test dosing prior to first use during PSVT. Secondary endpoints include efficacy and disease burden. Upon perceiving a PSVT episode, the patient applies an electrocardiographic monitor, performs a vagal maneuver, and, if the vagal maneuver is unsuccessful, self-administers etripamil 70 mg, with an optional repeat dose if symptoms do not resolve within 10 minutes after the first dose. A patient may treat up to four PSVT episodes during the study. Adverse events are recorded as treatment-emergent if they occur within 24 hours after the administration of etripamil. RESULTS: Efficacy endpoints include time to conversion to sinus rhythm within 30 and 60 minutes after etripamil administration, and the proportion of patients who convert at 3, 5, 10, 20, 30, and 60 minutes. Patient-reported outcomes are captured by the Brief Illness Perception Questionnaire, the Cardiac Anxiety Questionnaire, the Short Form Health Survey 36, the Treatment Satisfaction Questionnaire for Medication and a PSVT survey. CONCLUSIONS: Overall, these data will support the development of a potentially paradigm-changing long-term management strategy for recurrent PSVT.

Successful high-resolution three-dimensional electroanatomical mapping and radiofrequency catheter ablation of a posteroseptal accessory pathway in a dog using CARTO 3.

A one-year-and-seven-month-old, 28 kg, male castrated crossbreed dog was presented for supraventricular tachycardia causing recurrent episodes of anorexia and lethargy. Sotalol (2.2 mg/kg q12 h) reduced the frequency of symptomatic episodes but did not provide full relief. Three-dimensional electroanatomical mapping was performed at the Ghent University Small Animal Teaching hospital using the CARTO 3. Right atrial activation mapping identified the earliest atrial activation right posteroseptal, near the tricuspid annulus. Fast retrograde ventriculoatrial conduction during tachycardia and extrastimulus testing confirmed the presence of a concealed right posteroseptal accessory pathway. Six radiofrequency catheter ablation applications were delivered, and tachycardia remained uninducible. The dog recovered well from the procedure. Sotalol was stopped three weeks later, and no more clinical signs were noted by the owner. Repeated 24-hour electrocardiography monitoring on day one and at one, three, and 12 months after the procedure showed no recurrence of tachycardia.

The Incidence and Factors Associated with the Recurrence of Supraventricular Tachycardia in Children: 15 Years Experience from Middle-Income Country.

Limited data are available concerning supraventricular tachycardia (SVT) recurrence. Hence, this study aimed to determine the incidence, outcome, and factors associated with SVT recurrence. This retrospective, observational, population-based study was conducted among children with SVT from 2006 to 2020. The primary outcome measure was SVT recurrence. Kaplan Meier analysis was used to estimate SVT-free at 1, 5, and 10 years after diagnosis. Cox regression analysis was used to identify independent factors associated with recurrence. There were 156 patients with SVT with a median age at diagnosis of 1.9 years (Interquartile range [IQR] 11 days to 8.7 years) and follow-up for a median of 3.5 years (IQR 1.7 to 6.1 years). 35 patients (22%) had recurrent SVT at a median age of 7.8 years (IQR 4.4 to 12 years). Infants with Wolff-Parkinson-White Syndrome (WPW) had the highest recurrence (11/16, 68%), with 33% SVT-free at 5 years follow-up. The lowest recurrence rate was observed in neonatal diagnosis (2/54, 3.7%) with 98% SVT-free at 5 years follow-up. The independent factors associated with the recurrence of SVT were the diagnosis of WPW with an adjusted hazard ratio (aHR) of 5.2 (95% CI 2.4-11.2), age of more than 1 year at diagnosis (aHR 3.7 95% CI 1.4-9.7), and combine with or need second-line therapy (aHR 4.0 95% CI 1.5-10.7). One in five children with SVT experienced a recurrence, which is more likely for those with WPW, multiple maintenance therapy, and older age at first presentation. Whereas neonates with non-WPW may benefit from shorter maintenance therapy.

Conduction time around the mitral valve annulus has the potential to rule out postablation perimitral atrial tachycardia.

INTRODUCTION: It would be helpful in determining ablation strategy if the occurrence of perimitral atrial tachycardia (PMAT) could be predicted in advance. We investigated whether estimated perimitral conduction time (E-PMCT), namely, twice the time between coronary sinus (CS) pacing and the ensuing wave-front collision at the opposite side of the mitral annulus, correlated with the cycle length of PMAT and could predict future PMAT. METHODS AND RESULTS: We retrospectively (retrospective cohort) and prospectively (validation cohort) investigated atrial fibrillation patients who had received pulmonary vein isolation (PVI) and in whom left atrial maps had been created during CS pacing. We calculated their E-PMCT. PMAT was observed either by provocation or during follow-up in 25, AT other than PMAT was observed in 24 (non-PMAT AT group), and 53 patients never displayed any AT (no-AT group) in the retrospective cohort. In the PMAT group of the retrospective cohort, a strong positive correlation was observed between the PMAT CL and E-PMCT (r = .85, p < 0.001). PMAT was never induced nor observed in patients with E-PMCT less than 176 ms, and the best cut-off value for PMAT was 180 ms by receiver-operating characteristic curve analysis. In the validation cohort of 76 patients, the cut-off value of the E-PMAT less than 180 ms predicted noninducibility of PMAT, with a sensitivity of 78.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 25.0%. CONCLUSION: Short E-PMCT may predict noninducibility of PMAT and guide a less invasive ablation strategy.

A School Nurse's Experience With Supraventricular Tachycardia.

Students visit school health offices with a variety of complaints, and while some may be minor, others may be more pressing. The challenge for the school nurse is being able to differentiate between the two. This article features a case study of a fourth-grade elementary student who presented to the school nurse with a sudden onset of supraventricular tachycardia (SVT), a rapid cardiac arrhythmia that originates above the ventricles in the heart. The student's complaint was a "racing heart," and it was her first time experiencing a cardiac episode. It was also the school nurse's first time encountering this chief complaint. The article will describe the student's presentation to the health office, will discuss the school nurse's assessments along with SVT management techniques, and will conclude with the student's outcome and a sample individualized healthcare plan.

Trans-aortic mitral isthmus ablation after surgical patch closure for an atrial septal defect.

INTRODUCTION: In patients with prior atrial septal defect (ASD) closure and atrial tachyarrhythmias, transseptal puncture can be challenging. METHODS AND RESULTS: This case report discusses a 65-year-old man who had previously undergone pulmonary vein isolation (PVI) and cavo-tricuspid isthmus ablation for atrial fibrillation before ASD closure, respectively. He developed atrial tachycardia (AT) and underwent catheter ablation. AT was diagnosed as peri-mitral flutter and the mitral isthmus (MI) linear ablation via a trans-aortic approach successfully terminated it. CONCLUSION: This case demonstrates the feasibility and safety of transaortic MI linear ablation in patients with ASD closure devices or anatomical challenges when transseptal puncture is difficult.

Timing of critical isthmus from end of P wave and usefulness of activation mapping with window of interest from end to end of P wave in reentrant atrial tachycardia.

In activation mapping of reentrant atrial tachycardia (AT), there was no reference for window of interest (WOI). We examined the timing of a successful termination site from end of the P wave and attempted to determine whether the critical isthmus can be identified using activation mapping when WOI was set as end to end of the P wave. Forty patients with 54 reentrant AT who underwent 3D electroanatomic mapping and radiofrequency catheter ablation were evaluated retrospectively. The critical isthmus was defined as a successful termination site. We evaluate critical isthmus timing from end of the P wave and percentage of critical isthmus timing from end of the P wave to tachycardia cycle length. In 54 reentrant AT, Macro-reentry was identified in 46 (85.2%) and micro-reentry was identified in eight (14.8%). The timing of the critical isthmus site from end of the P wave was - 4.0 ± 31.1 ms (Macro-reentry vs. Micro-reentry; - 8.9 ± 29.4 ms vs. 24.0 ± 26.7 ms; P = 0.005). The percentage of critical isthmus timing from end of the P wave/tachycardia cycle length was - 1.4 ± 10.5% (Macro-reentry vs. Micro-reentry; - 3.1 ± 9.8% vs. 8.3 ± 9.3%, P = 0.004) The critical isthmus of reentrant AT is located within 10% backward and forward from end of the P wave to tachycardia cycle length. Setting the WOI from end to end of the P wave is useful for identification of the critical isthmus through activation mapping.