PolarX vs Arctic Front for Cryoballoon Ablation of Paroxysmal AF: The Randomized COMPARE CRYO Study.

BACKGROUND: Pulmonary vein isolation is an effective treatment for atrial fibrillation (AF). Cryoballoon ablation using the Arctic Front cryoballoon (Medtronic) was found to be superior to antiarrhythmic drug treatment. Recently, a novel cryoballoon system was introduced (PolarX, Boston Scientific). OBJECTIVES: The purpose of this study was to compare the efficacy and safety of the 2 cryoballoons in a randomized controlled trial. METHODS: Patients with symptomatic paroxysmal AF were enrolled in 2 centers and randomized 1:1 to pulmonary vein isolation using the PolarX or the Arctic Front cryoballoon. All patients received an implantable cardiac monitor. The primary endpoint was first recurrence of atrial tachyarrhythmia (AF, atrial flutter, or atrial tachycardia [AT]) between days 91 and 365. Procedural safety was assessed by a composite of tamponade, phrenic nerve palsy lasting >24 hours, vascular complications, stroke/transient ischemic attack, atrioesophageal fistula or death up to 30 days. RESULTS: A total of 201 patients were enrolled. At 1 year, recurrence of atrial tachyarrhythmia had occurred in 41 of 99 patients (41.6%) assigned to the PolarX group and in 48 of 102 patients (47.1%) assigned to the Arctic Front group (HR: 0.85 [95% CI: 0.56-1.30]; P = 0.03 for noninferiority; P = 0.46 for superiority). The safety endpoint occurred in 5 patients (5%) in the PolarX group (n = 5 phrenic nerve palsies lasting >24 hours), whereas no safety endpoints occurred in the Arctic Front group (P = 0.03). CONCLUSIONS: In this randomized controlled trial using implantable cardiac monitors for continuous rhythm monitoring, the novel PolarX cryoballoon was noninferior compared with the Arctic Front cryoballoon regarding efficacy. However, the PolarX balloon resulted in significantly more phrenic nerve palsies. (Comparison of PolarX and the Arctic Front Cryoballoons for PVI in Patients With Symptomatic Paroxysmal AF [COMPARE-CRYO]; NCT04704986).

Pulsed-field vs cryoballoon vs radiofrequency ablation: Outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation.

BACKGROUND: Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patients with paroxysmal atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to compare the procedural and long-term outcomes in patients with persistent AF undergoing PVI using PFA, CBA, or RFA. METHODS: Consecutive patients with persistent AF undergoing first PVI with PFA, CBA, or RFA were included. Patients underwent 7-day Holter electrocardiography at 3, 6, and 12 months postablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events. RESULTS: A total of 533 patients with persistent AF underwent PVI using PFA (n = 214, 39%), CBA (n = 190, 36%), or RFA (n = 129, 24%). Procedures with PFA guided by fluoroscopy were shorter than those with CBA (median 60 minutes; interquartile range [IQR] 53-80 minutes vs 84 minutes; IQR 68-101 minutes; P ≤ .001), and procedures with PFA in combination with 3-dimensional electroanatomic mapping were shorter than those with RFA (median 101 minutes; IQR 85-126 minutes vs 171 minutes; IQR 141-204 minutes; P < .001). Acute safety events occurred in 2.3%, 2.6%, and 0.8% in the PFA, CBA, and RFA groups, respectively (P = .545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA, and 48.3% for RFA (CBA vs PFA: P = .79; CBA vs RFA: P = .009; PFA vs RFA: P = .010). CONCLUSION: In patients with persistent AF undergoing first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA than with RFA.

Durability of CLOSE-Guided Pulmonary Vein Isolation in Persistent Atrial Fibrillation: A Prospective Remapping Study.

BACKGROUND: Recurrence of paroxysmal atrial fibrillation (AF) following pulmonary vein isolation (PVI) is presumably caused by pulmonary vein (PV) reconnections. However, there is little data available on the durability of PVI and incidence of arrhythmia recurrence in patients with persistent AF. OBJECTIVES: To evaluate the lesion durability by means of an a priori planned remapping procedure in patients with persistent AF undergoing CLOSE-guided PVI. METHODS: In a prospective study, we included patients with symptomatic, persistent AF undergoing CLOSE-guided radiofrequency ablation. Irrespective of AF recurrence, a redo procedure was mandated 6 months following the index procedure to evaluate PV reconnections. The outcome of AF ablation was based on clinical recurrence and 7-day Holter electrocardiogram 3 and 6 months after the index procedure and 3, 6, and 12 months after the redo procedure. RESULTS: Of 30 patients included, 26 (81% men; median age 68 years) underwent the planned remapping study a median of 6 months after the index procedure, whereas 4 patients without recurrence refused a repeat procedure. In total, 78 of 102 (76%) PVs showed durable isolation and 15 patients (58%) presented complete isolation of all PVs. Beyond the blanking period, 6 of 26 patients (23%) had arrhythmia recurrence before the redo procedure. Recurrence had occurred in 33% of patients with complete isolation of all veins and in 9% of patients with PV reconnections (P = 0.197). After re-PVI in patients with PV reconnections and additional ablation in patients with recurrence but durable PVI, 17 of 26 patients (65%) were free of arrhythmia after 12 months. CONCLUSIONS: In patients with persistent AF, CLOSE-guided PVI resulted in durable rate of PVI on a per-vein and per-patient level of 76% and 58%, respectively. Arrhythmia recurrence was numerically higher in patients with durable PVI compared with patients without.

Impact of atrial fibrillation phenotype and left atrial volume on outcome after pulmonary vein isolation.

AIMS: Pulmonary vein isolation (PVI) is increasingly performed in patients with atrial fibrillation (AF). Both AF phenotype and left atrial (LA) volume have been shown to influence ablation outcome. The inter-relationship of the two is incompletely understood. We aimed to investigate the impact of AF phenotype vs. LA volume on outcome after PVI. METHODS AND RESULTS: In a retrospective analysis of a prospective registry of patients undergoing a first PVI, the association of AF phenotype and LA volume index (LAVI) was assessed as well as their impact on AF recurrence during follow-up. Overall, 476 patients were enrolled (median age 63 years, 29% females, 65.8% paroxysmal AF). Obesity, hypertension, chronic kidney disease, and heart failure were all significantly more frequent in persistent AF. After 1 year, single-procedure, freedom from arrhythmia recurrence was 61.5%. Patients with paroxysmal AF had better outcomes compared with patients with persistent AF (65.6 vs. 52.7%, P = 0.003), as had patients with no/mild vs. moderate/severe LA dilation (LAVI <42 mL/m2 67.1% vs. LAVI ≥42 mL/m2 53%, P < 0.001). The combination of both parameters refined prediction of 1-year recurrence (P < 0.001). After adjustment for additional clinical risk factors in multivariable Cox proportional hazard analysis, both AF phenotype and LAVI ≥42 mL/m2 contributed significantly towards the prediction of 1-year recurrence. CONCLUSION: Atrial fibrillation phenotype and LA volume are independent predictors of outcome after PVI. Persistent AF with no/mild LA dilation has a similar risk of recurrence as paroxysmal AF with a moderate/severe LA dilation and should be given similar priority for ablation.

Patient characteristics, predictors and outcome of pacemaker patients upgraded to an implantable cardioverter defibrillator.

AIMS: Pacemaker (PM) patients may require a subsequent upgrade to an implantable cardioverter defibrillator (ICD). Limited data exists on this patient population. We sought to characterize this population, to assess predictors for ICD upgrade, and to report the outcome. METHODS: From our prospective PM and ICD implantation registry, all patients who underwent PM and/or ICD implantations at our center were analyzed. Patient characteristics and outcomes of PM patients with subsequent ICD upgrade were compared to age- and sex-matched patients with de novo ICD implantation, and to PM patients without subsequent upgrade. RESULTS: Of 1'301 ICD implantations, 60 (5%) were upgraded from PMs. Median time from PM implantation to ICD upgrade was 2.6 years (IQR 1.3-5.4). Of 2'195 PM patients, 28 patients underwent subsequent ICD upgrades, corresponding to an estimated annual incidence of an ICD upgrade of at least 0.33%. Lower LVEF (p = .05) and male sex (p = .038) were independent predictors for ICD upgrade. Survival without death, transplant and LVAD implantation were worse both for upgraded ICD patients compared to matched patients with de novo ICD implantation (p = .05), as well as for PM patients with subsequent upgrade compared to matched PM patients not requiring an upgrade (p = .036). CONCLUSIONS: One of 20 ICD implantations are upgrade of patients with a PM. At least one of 30 PM patients will require an ICD upgrade in the following 10 years. Predictors for ICD upgrade are male sex and lower LVEF at PM implantation. Upgraded patients have worse outcomes.

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.

Epicardial adipose tissue dispersion at CT and recurrent atrial fibrillation after pulmonary vein isolation.

OBJECTIVES: Epicardial adipose tissue (EAT) remodeling is associated with atrial fibrillation (AF). Left atrial (LA) EAT dispersion on cardiac CT is a non-invasive imaging biomarker reflecting EAT heterogeneity. We aimed to investigate the association of LA EAT dispersion with AF recurrence after pulmonary vein isolation (PVI). METHODS: In a prospective registry of consecutive patients undergoing first PVI, mean EAT attenuation values were measured on contrast-enhanced cardiac CT scans in Hounsfield units (HU) within low (- 195 to - 45 HU) and high (- 44 to - 15 HU) threshold EAT compartments around the left atrium (LA). EAT dispersion was defined as the difference between the mean HU values within the two EAT compartments. Continuous variables were compared between groups using the Mann-Whitney U test and cox proportional hazard models were used to calculate hazard ratios of predictors of 1-year AF recurrence. RESULTS: A total of 208 patients were included, 135 with paroxysmal AF and 73 with persistent AF. LA EAT dispersion was significantly larger in patients with persistent compared to paroxysmal AF (52.6 HU vs. 49.9 HU; p = 0.001). After 1 year of follow-up, LA EAT dispersion above the mean (> 50.8 HU) was associated with a higher risk of AF recurrence (HR 2.3, 95% CI 1.5-3.6; p < 0.001). It retained its predictive value when corrected for age, sex, body mass index, LA volume, and AF type (HR 2.8, 95% CI 1.6-4.6; p < 0.001). CONCLUSION: A larger LA EAT dispersion on contrast-enhanced cardiac CT scans, reflecting EAT heterogeneity, is independently associated with AF recurrence after PVI. CLINICAL RELEVANCE STATEMENT: Based on LA EAT dispersion assessment, a more accurate risk stratification and patient selection may be possible based on a pre-procedural cardiac CT when planning PVI. KEY POINTS: • Epicardial adipose tissue (EAT) remodeling is associated with atrial fibrillation (AF). • A larger left atrial EAT dispersion in a pre-procedural cardiac CT was associated with a higher 1-year AF recurrence risk after pulmonary vein isolation. • A pre-procedural cardiac CT with left atrial EAT dispersion assessment may provide a more accurate risk stratification and patient selection for PVI.

The influence of cardiac arrhythmias on the detection of heartbeats in the photoplethysmogram: benchmarking open-source algorithms.

Objective.Cardiac arrhythmias are a leading cause of mortality worldwide. Wearable devices based on photoplethysmography give the opportunity to screen large populations, hence allowing for an earlier detection of pathological rhythms that might reduce the risks of complications and medical costs. While most of beat detection algorithms have been evaluated on normal sinus rhythm or atrial fibrillation recordings, the performance of these algorithms in patients with other cardiac arrhythmias, such as ventricular tachycardia or bigeminy, remain unknown to date.Approach. ThePPG-beatsopen-source framework, developed by Charlton and colleagues, evaluates the performance of the beat detectors namedQPPG,MSPTDandABDamong others. We applied thePPG-beatsframework on two newly acquired datasets, one containing seven different types of cardiac arrhythmia in hospital settings, and another dataset including two cardiac arrhythmias in ambulatory settings.Main Results. In a clinical setting, theQPPGbeat detector performed best on atrial fibrillation (with a medianF1score of 94.4%), atrial flutter (95.2%), atrial tachycardia (87.0%), sinus rhythm (97.7%), ventricular tachycardia (83.9%) and was ranked 2nd for bigeminy (75.7%) behindABDdetector (76.1%). In an ambulatory setting, theMSPTDbeat detector performed best on normal sinus rhythm (94.6%), and theQPPGdetector on atrial fibrillation (91.6%) and bigeminy (80.0%).Significance. Overall, the PPG beat detectorsQPPG,MSPTDandABDconsistently achieved higher performances than other detectors. However, the detection of beats from wrist-PPG signals is compromised in presence of bigeminy or ventricular tachycardia.

Pulmonary vein isolation durability and lesion regression in patients with recurrent arrhythmia after pulsed-field ablation.

BACKGROUND: A novel multipolar pulsed-field ablation (PFA) catheter has recently been introduced for pulmonary vein isolation (PVI). Pre-market data showed high rates for PVI-durability during mandatory remapping studies. OBJECTIVE: To present post-market data in patients with recurrent arrhythmias. METHODS: Consecutive patients undergoing a redo procedure after an index PFA PVI using a bipolar-biphasic PFA system were included. 3-D electro-anatomical maps (3D-EAM) on redo procedure were compared to the 3D-EAM acquired after ablation during the index procedure. PVI durability was assessed on a per-vein and per-patient level and the sites of reconnections were identified. Furthermore, lesion extent around veins with durable isolation was compared to study lesion regression. RESULTS: Of 341 patients treated with a PFA PVI, 29 (8.5%) underwent a left atrial redo ablation due to arrhythmia recurrence. At the end of the index procedure, 110/112 veins (98%, four common ostia) were isolated. On redo procedures performed a median of 6 months after the first ablation, 3D-EAM identified 69/110 (63%) PVs with durable isolation. In 6 (21%) patients, all PVs were durably isolated. Reconnections were more often found on the right-sided veins and on the anterior aspects of the upper veins. Only minor lesion regression was observed between the index and redo procedure (a median of 3 mm (0 - 9.5) on the posterior wall). CONCLUSION: In patients with arrhythmia recurrence after PFA PVI using a first-generation PFA device, durable isolation was observed in 63% of the veins and 21% of the patients showed durable isolation of all previously isolated veins.

Pulsed-field vs. cryoballoon vs. radiofrequency ablation: a propensity score matched comparison of one-year outcomes after pulmonary vein isolation in patients with paroxysmal atrial fibrillation.

BACKGROUND: Pulsed-field ablation (PFA) has shown favourable data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI). We sought to compare procedural and 1-year follow-up data of patients with paroxysmal atrial fibrillation (AF) undergoing PVI using PFA, cryoballoon ablation (CBA) and radiofrequency ablation (RFA). METHODS: Consecutive patients with paroxysmal AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with paroxysmal AF undergoing a first PVI with CBA and RFA were selected using a 1:2:2 propensity score matching. The PFA group followed the standard 32-applications lesion-set protocol, the CBA group a time-to-effect plus 2-min strategy, and the RFA group the CLOSE protocol. Patients were followed with 7d-Holter ECGs 3, 6, and 12 months after ablation. The primary endpoint was recurrence of atrial tachyarrhythmia (ATa) following a blanking period of 3 months. RESULTS: A total of 200 patients were included (PFA n = 40; CBA n = 80; RFA n = 80). Median procedure times were shortest with CBA (75 min) followed by PFA (94 min) and RFA (182 min; p < 0.001). Fluoroscopy dose was lowest with RFA (1.6Gycm2) followed by PFA (5.0Gycm2) and CBA (5.7Gycm2; p < 0.001). After a 1-year follow-up, freedom from ATa recurrence was 85.0% with PFA, 66.2% with CBA and 73.8% with RFA (p = 0.12 PFA vs. CBA; p = 0.27 PFA vs. RFA). CONCLUSION: In a propensity score matched analysis of patients with paroxysmal AF, freedom from any ATa 1 year after PVI using PFA was favourable and at least as good as for PVI with CBA or RFA.

Patient satisfaction, safety and efficacy of nurse-led compared to physician-led implantation of cardiac monitors.

AIMS: Implantation of an implantable cardiac monitor (ICM) is a simple procedure, but adds significant and increasing workload to the arrhythmia service. In 2020, we established a nurse-led ICM implantation service. We aimed to analyze patient satisfaction, adverse events during implant and ICM re-interventions with nurse-led ICM implantation (N-Implant) compared to physician-led ICM implantation (P-Implant). METHOD AND RESULTS: From January 2020 to December 2021 we included all consecutive patients implanted with an ICM in a prospective registry. We collected data on patient characteristics, implant procedure and follow-up. Patients were interviewed by phone four weeks after ICM implantation.Of 321 patients implanted with an ICM (median age 67 years; 33% women), 189 (59%) were N-Implants. More N-Implants were performed in the outpatient clinic compared to P-Implants (95% vs. 8%; p<0.001). Two N-Implant patients experienced vaso-vagal reaction during implantation (1%), whereas no adverse events occurred during P-Implant (p=0.51). 297 patients (93%) completed the questionnaire. Duration of pain was shorter and wound closure after 2 weeks better following N-Implant (p=0.019 and p=0.018). A minor bruise or swelling at the implant site was reported more frequently after N-Implant (p=0.003 and p=0.041). Patient satisfaction was excellent with both N-Implant and P-Implant (99% and 97%; p=0.16). After a median follow-up of 242 days (range 7-725 days), five ICMs (2%) were explanted prematurely, without differences among groups. Reasons for premature explants were local discomfort (n=2), infection, MRI and ICM malfunction. CONCLUSION: Nurse-led ICM implantation has excellent patient satisfaction without compromising safety. N-Implant both expands nursing competencies and reduces physician workload.

Comparison of the PolarX and the Arctic Front cryoballoon for pulmonary vein isolation in patients with symptomatic paroxysmal atrial fibrillation (COMPARE CRYO) - Study protocol for a randomized controlled trial.

INTRODUCTION: Single-shot devices are increasingly used for pulmonary vein isolation (PVI) in atrial fibrillation (AF). The Arctic Front cryoballoon (Medtronic) is the most frequently used single-shot technology. A recently developed novel cryoballoon has been introduced (PolarX, Boston Scientific) with the aim to address limitations of the Arctic Front system. METHODS: COMPARE CRYO is a multicentre, randomized, controlled trial with blinded endpoint adjudication by an independent clinical events committee. A total of 200 patients with paroxysmal AF undergoing their first PVI are randomized 1:1 between PolarX cryoballoon ablation and Arctic Front cryoballoon ablation. Continuous monitoring during follow-up is performed using an implantable cardiac monitor (ICM) in all patients. The primary endpoint is time to first recurrence of any atrial tachyarrhythmia (AF, atrial flutter, and/or atrial tachycardia) ≥ 120 s between days 91 and 365 post ablation as detected on the (ICM). Procedural safety is assessed by a composite of cardiac tamponade, persistent phrenic nerve palsy >24 h, vascular complications requiring intervention, stroke/transient ischemic attack, atrioesophageal fistula or death occurring during or up to 30 days after the procedure. Key secondary endpoints include (1) procedure and fluoroscopy times, (2) AF burden, (3) proportion of patients with recurrence in the blanking period, (4) proportion of patients undergoing repeat ablation, and (5) quality of life changes at 12 months compared to baseline. CONCLUSION: COMPARE CRYO will compare the efficacy and safety of the novel PolarX cryoballoon and the standard-of-practice Arctic Front cryoballoon for first PVI performed in patients with symptomatic paroxysmal AF. TRIAL REGISTRATION: (ClinicalTrials.gov ID: NCT04704986).

Validation of a clinical model for predicting left versus right ventricular outflow tract origin of idiopathic ventricular arrhythmias.

BACKGROUND: Prediction of the chamber of origin in patients with outflow tract ventricular arrhythmias (OTVA) remains challenging. A clinical risk score based on age, sex and presence of hypertension was associated with a left ventricular outflow tract (LVOT) origin. We aimed to validate this clinical score to predict an LVOT origin in patients with OTVA. METHODS: In a two-center observational cohort study, unselected patients undergoing catheter ablation (CA) for OTVA were enrolled. All procedures were performed using an electroanatomical mapping system. Successful ablation was defined as a ≥80% reduction of the initial overall PVC burden after 3 months of follow-up. Patients with unsuccessful ablation were excluded from this analysis. RESULTS: We included 187 consecutive patients with successful CA of idiopathic OTVA. Mean age was 52 ± 15 years, 102 patients (55%) were female, and 74 (40%) suffered from hypertension. A LVOT origin was found in 64 patients (34%). A score incorporating age, sex and presence of hypertension reached 73% sensitivity and 67% specificity for a low (0-1) and high (2-3) score, to predict an LVOT origin. The combination of one ECG algorithm (V2 S/V3 R-index) with the clinical score resulted in a sensitivity and specificity of 81% and 70% for PVCs with R/S transition at V3 . CONCLUSION: The published clinical score yielded a lower sensitivity and specificity in our cohort. However, for PVCs with R/S transition at V3, the combination with an existing ECG algorithm can improve the predictability of LVOT origin.

Acute and long-term outcomes of quadripolar IS-4 versus bipolar IS-1 left ventricular leads in cardiac resynchronization therapy: A retrospective registry study.

BACKGROUND: The implantation procedure of left ventricular (LV) leads and the management of cardiac resynchronization therapy (CRT) patients can be challenging. The IS-4 standard for CRT offers additional pacing vectors compared to bipolar leads (IS-1). IS-4 leads improve procedural outcome and may also result in lower adverse events during follow-up (FU) and improve clinical outcome in CRT patients. Further long-term FU data comparing the two lead designs are necessary. METHODS: In this retrospective, single-center study we included adult patients implanted with a CRT-Defibrillator (CRT-D) or CRT-Pacemaker (CRT-P) with a quadripolar (IS-4 group) or bipolar (IS-1 group) LV lead and with available ≥3 years clinical FU. The combined primary endpoint was a combination of predefined, lead-related adverse events. Secondary endpoints were all single components of the primary endpoint. RESULTS: Overall, 133 patients (IS-4 n = 66; IS-1 n = 67) with a mean FU of 4.03 ± 1.93 years were included. Lead-related adverse events were less frequent in patients with an IS-4 lead than with an IS-1 lead (n = 8, 12.1% vs. n = 23, 34.3%; p = .002). The secondary outcomes showed a lower rate of LV lead deactivation/explantation and LV lead dislodgement/dysfunction (4.5% vs. 22.4%; p = .003; 4.5% vs. 17.9%; p = .015, respectively) in the IS-4 patient group. Less patients suffered from unresolved phrenic nerve stimulation with an IS-4 lead (3.0% vs. 13.4%; p = .029). LV lead-related re-interventions were fewer in case of an IS-4 lead (6.1% vs. 17.9%; p = .036). CONCLUSION: In this retrospective analysis, the IS-4 LV lead is associated with lower lead-related complication rates than the IS-1 lead at long-term FU.

Eliminating transseptal sheath exchange for pulsed field ablation procedures using a direct over-the-needle transseptal access with the Faradrive sheath.

AIMS: Pulsed field ablation (PFA) for pulmonary vein isolation (PVI) combines the benefits of high procedural efficacy and safety. Transseptal puncture (TSP) to obtain left atrial (LA) access during PVI remains an important source of complications during LA procedures. For PFA procedures, TSP is generally performed using a standard transseptal sheath that is then exchanged over the wire for a dedicated PFA sheath, which might be a potential source for air embolism. We aimed to prospectively evaluate the feasibility and safety of a simplified workflow using the PFA sheath (Faradrive, Boston Scientific) directly for TSP. METHODS AND RESULTS: We prospectively enrolled 100 patients undergoing PVI using PFA at two centres. TSP was performed using the PFA sheath and a standard 98 cm transseptal needle under fluoroscopic guidance. TSP via the PFA sheath was successfully performed in all patients and no complications occurred. The median time from the first groin puncture to the completed LA access was 12 min (IQR 8-16 min). CONCLUSION: An over-the-needle TSP directly with the PFA sheath proved feasible and safe in our study. This simplified workflow has the potential to reduce the risk of air embolism, to shorten procedure time, and to reduce cost.

Validation of the accuracy of contact force measurement by contemporary force-sensing ablation catheters.

INTRODUCTION: Contact force sensing catheters are widely used for ablation of cardiac arrhythmias. They allow quantification of catheter-to-tissue contact, which is an important determinant for lesion formation and may reduce the risk of complications. The accuracy of these sensors may vary across the measurement range, catheter-to-tissue angle, and amongst manufacturers. We aim to compare the accuracy and reproducibility of four different force sensing ablation catheters. METHODS: A measurement setup containing a heated saline water bath with an integrated force measurement unit was constructed and validated. Subsequently, we investigated four different catheter models, each equipped with a unique measurement technology: Tacticath Quartz (Abbott), AcQBlate Force (Biotronik/Acutus), Stablepoint (Boston Scientific), and Smarttouch SF (Biosense Webster). For each model, the accuracy of three different catheters was measured within the range of 0-60 g and at contact angles of 0°, 30°, 45°, 60°, and 90°. RESULTS: In total, 6685 measurements were performed using 4 × 3 catheters (median of 568, interquartile range: 511-606 measurements per catheter). Over the entire measurement-range, the force measured by the catheters deviated from the real force by the following absolute mean values: Tacticath 1.29 ± 0.99 g, AcQBlate Force 2.87 ± 2.37 g, Stablepoint 1.38 ± 1.29 g, and Smarttouch 2.26 ± 2.70 g. For some models, significant under- and overestimation of >10 g were observed at higher forces. Mean absolute errors of all models across the range of 10-40 g were <3 g. CONCLUSION: Contact measured by force-sensing catheters is accurate with 1-3 g deviation within the range of 10-40 g. Significant errors can occur at higher forces with potential clinical consequences.

Pulsed-field ablation for the treatment of left atrial reentry tachycardia.

BACKGROUND: We describe our initial experience using a multipolar pulsed-field ablation catheter for the treatment of left atrial (LA) reentry tachycardia. METHODS: We included all patients with LA reentry tachycardia treated with PFA at our institution between September 2021 and March 2022. The tachycardia mechanism was identified using 3D electro-anatomical mapping (3D-EAM). Subsequently, a roof line, anterior line, or mitral isthmus line was ablated as appropriate. Roof line ablation was always combined with LA posterior wall (LAPW) ablation. Positioning of the PFA catheter was guided by a 3D-EAM system and by fluoroscopy. Bidirectional block across lines was verified using standard criteria. Additional radiofrequency ablation (RFA) was used to achieve bidirectional block as necessary. RESULTS: Among 22 patients (median age 70 (59-75) years; 9 females), we identified 27 LA reentry tachycardia: seven roof dependent macro-reentries, one posterior-wall micro-reentry, twelve peri-mitral macro-reentries, and seven anterior-wall micro-reentries. We ablated a total of 20 roof lines, 13 anterior lines, and 6 mitral isthmus lines. Additional RFA was necessary for two anterior lines (15%) and three mitral isthmus lines (50%). Bidirectional block was achieved across all roof lines, 92% of anterior lines, and 83% of mitral isthmus lines. We observed no acute procedural complications. CONCLUSION: Ablation of a roof line and of the LAPW is feasible, effective, and safe using this multipolar PFA catheter. However, the catheter is less suited for ablation of the mitral isthmus and the anterior line. A focal pulsed-field ablation catheter may be more effective for ablation of these lines. This study shows the feasibility to ablate linear lesions with a multipolar pulsed-field ablation catheter. 27 left atrial reentry tachycardia were treated in 22 patients.

Posterior wall ablation by pulsed-field ablation: procedural safety, efficacy, and findings on redo procedures.

AIMS: The left atrial posterior wall is a potential ablation target in patients with recurrent atrial fibrillation despite durable pulmonary vein isolation or in patients with roof-dependent atrial tachycardia (AT). Pulsed-field ablation (PFA) offers efficient and safe posterior wall ablation (PWA), but available data are scarce. METHODS AND RESULTS: Consecutive patients undergoing PWA using PFA were included. Posterior wall ablation was performed using a pentaspline PFA catheter and verified by 3D-electroanatomical mapping. Follow-up was performed using 7-day Holter ECGs 3, 6, and 12 months after ablation. Recurrence of any atrial arrhythmia lasting more than 30 s was defined as failure. Lesion durability was assessed during redo procedures. Posterior wall ablation was performed in 215 patients (70% males, median age 70 [IQR 61-75] years, 67% redo procedures) and was successful in all patients (100%) by applying a median of 36 (IQR 32-44) PFA lesions. Severe adverse events were cardiac tamponade and vascular access complication in one patient each (0.9%). Median follow-up was 7.3 (IQR 5.0-11.8) months. One-year arrhythmia-free outcome in Kaplan-Meier analysis was 53%. A redo procedure was performed in 26 patients (12%) after a median of 6.9 (IQR 2.4-11) months and showed durable PWA in 22 patients (85%) with only minor lesion regression. Among four patients with posterior wall reconnection, three (75%) presented with roof-dependent AT. CONCLUSION: Posterior wall ablation with this pentaspline PFA catheter can be safely and efficiently performed with a high durability observed during redo procedures. The added value of durable PWA for the treatment of atrial fibrillation remains to be evaluated.

Conduction System Pacing Today and Tomorrow.

Conduction system pacing (CSP) encompassing His bundle (HBP) and left bundle branch area pacing (LBBAP) is gaining increasing attention in the electrophysiology community. These relatively novel physiological pacing modalities have the potential to outperform conventional pacing approaches with respect to clinical endpoints, although data are currently still limited. While HBP represents the most physiological form of cardiac stimulation, success rates, bundle branch correction, and electrical lead performance over time remain a concern. LBBAP systems may overcome these limitations. In this review article, we provide a comprehensive overview of the current evidence, implantation technique, device programming, and follow-up considerations concerning CSP systems. Moreover, we discuss ongoing technical developments and future perspectives of CSP.

Association of Chronic Covert Cerebral Infarctions and White Matter Hyperintensities With Atrial Fibrillation Detection on Post-Stroke Cardiac Rhythm Monitoring: A Cohort Study.

Background This study was conducted to explore the association of different phenotypes, count, and location of chronic covert brain infarctions (CBIs) with detection of atrial fibrillation (AF) on prolonged post-stroke cardiac rhythm monitoring (PCM). Methods and Results We conducted a cohort single-center study of consecutive first-ever ischemic stroke or transient ischemic attack patients undergoing PCM between January 2015 and December 2017. We blindly rated CBI phenotypes according to established definitions and white matter hyperintensities (WMHs) according to the age-related white matter changes rating scale. We used (multiple) regression models to assess the association of the imaging biomarkers and incident AF on PCM. A total of 795 patients (median [interquartile range]) aged 69 (57-78) years, 41% women, median National Institutes of Health Stroke Scale score 2 (0-5), median PCM duration 14 (7-14) days, and AF detection in 61 patients (7.7%) were included. On univariate analysis, WMHs (per point odds ratio, 1.35 [95% CI, 1.03-1.78]) but not CBIs (odds ratio, 0.90 [95% CI, 0.52-1.56]) were associated with AF detection. Neither CBI phenotype, count, nor location were associated with AF detection. After adjustment for age, hypertension, and stroke severity, neither increasing WMHs (per point adjusted odds ratio, 0.85 [95% CI, 0.60-1.20]) nor CBIs (adjusted odds ratio, 0.60 [95% CI, 0.33-1.09]) were independently associated with AF detection. Conclusions Although WMHs and CBIs represent surrogate biomarkers of vascular risk factors, neither WMHs nor CBIs, including their phenotypes, count, and location, were independently associated with AF detection on PCM. In patients with manifest ischemic stroke or transient ischemic attack, the presence of imaging biomarkers of chronic ischemic injury does not seem promising to further refine prediction tools for AF detection on PCM.