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.

Complications and inappropriate shocks in pediatric patients receiving a subcutaneous implantable cardioverter defibrilator.

INTRODUCTION AND OBJECTIVES: There is limited evidence regarding the use of subcutaneous implantable cardioverter-defibrillators (S-ICD) in pediatric patients. The aim of this study was to determine the incidence of complications in these patients at our center, according to the type of ICD and patient size. METHODS: We included all patients aged<18 years who received an S-ICD since 2016 at our center. As a control group, we also included contemporary patients (since 2014) who received a transvenous ICD (TV-ICD). The primary endpoint was a composite of complications and inappropriate shocks. RESULTS: A total of 26 patients received an S-ICD (median age, 14 [5-17] years; body mass index [BMI], 20.2 kg/m2). Implantation was intermuscular in 23 patients (88%) and subserratus in the remainder. Two incisions were used in 24 patients (92%). In all patients, 2 zones were programmed: a conditional zone set at 230 (220-230) bpm, and a shock zone set at 250 bpm. Nineteen patients received a TV-ICD (median age, 11 [range, 5-16] years; BMI, 19.2 kg/m2, 79% single-chamber). Survival free from the primary endpoint at 5 years was 80% in the S-ICD group and 63% in the TV-ICD group (P=.54). Survival free from inappropriate shocks was similar (85% vs 89%, P=.86), while survival free from complications was higher in the S-ICD group (96% vs 57%, cloglog P=.016). There were no therapy failures in the S-ICD group, and no increased complication rates were observed in patients with BMI ≤20 kg/m2. CONCLUSIONS: With contemporary implantation techniques and programming, S-ICD is a safe and effective therapy in pediatric patients. The number of inappropriate shocks is similar to TV-ICD, with fewer short- and mid-term complications.

Bayesian analysis of the Substrate Ablation vs. Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia trial.

BACKGROUND AND AIMS: Bayesian analyses can provide additional insights into the results of clinical trials, aiding in the decision-making process. We analysed the Substrate Ablation vs. Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia (SURVIVE-VT) trial using Bayesian survival models. METHODS AND RESULTS: The SURVIVE-VT trial randomized patients with ischaemic cardiomyopathy and monomorphic ventricular tachycardia (VT) to catheter ablation or antiarrhythmic drugs (AAD) as a first-line strategy. The primary outcome was a composite of cardiovascular death, appropriate implantable cardioverter-defibrillator shocks, unplanned heart failure hospitalizations, or severe treatment-related complications. We used informative, skeptical, and non-informative priors with different probabilities of large effects to compute the posterior distributions using Markov Chain Monte Carlo methods. We calculated the probabilities of hazard ratios (HR) being <1, <0.9, and <0.75, as well as 2-year survival estimates. Of the 144 randomized patients, 71 underwent catheter ablation and 73 received AAD. Regardless of the prior, catheter ablation had a >98% probability of reducing the primary outcome (HR < 1) and a >96% probability of achieving a reduction of >10% (HR < 0.9). The probability of a >25% (HR < 0.75) reduction of treatment-related complications was >90%. Catheter ablation had a high probability (>93%) of reducing incessant/slow undetected VT/electric storm, unplanned hospitalizations for ventricular arrhythmias, and overall cardiovascular admissions > 25%, with absolute differences of 15.2%, 21.2%, and 20.2%, respectively. CONCLUSION: In patients with ischaemic cardiomyopathy and VT, catheter ablation as a first-line therapy resulted in a high probability of reducing several clinical outcomes compared to AAD. Our study highlights the value of Bayesian analysis in clinical trials and its potential for guiding treatment decisions. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03734562.

Effects of Cardiac Stem Cell on Postinfarction Arrhythmogenic Substrate.

Clinical data suggest that cardiosphere-derived cells (CDCs) could modify post-infarction scar and ventricular remodeling and reduce the incidence of ventricular tachycardia (VT). This paper assesses the effect of CDCs on VT substrate in a pig model of postinfarction monomorphic VT. We studied the effect of CDCs on the electrophysiological properties and histological structure of dense scar and heterogeneous tissue (HT). Optical mapping and histological evaluation were performed 16 weeks after the induction of a myocardial infarction by transient occlusion of the left anterior descending (LAD) artery in 21 pigs. Four weeks after LAD occlusion, pigs were randomized to receive intracoronary plus trans-myocardial CDCs (IC+TM group, n: 10) or to a control group. Optical mapping (OM) showed an action potential duration (APD) gradient between HT and normal tissue in both groups. CDCs increased conduction velocity (53 ± 5 vs. 45 ± 6 cm/s, p < 0.01), prolonged APD (280 ± 30 ms vs. 220 ± 40 ms, p < 0.01) and decreased APD dispersion in the HT. During OM, a VT was induced in one and seven of the IC+TM and control hearts (p = 0.03), respectively; five of these VTs had their critical isthmus located in intra-scar HT found adjacent to the coronary arteries. Histological evaluation of HT revealed less fibrosis (p < 0.01), lower density of myofibroblasts (p = 0.001), and higher density of connexin-43 in the IC+TM group. Scar and left ventricular volumes did not show differences between groups. Allogeneic CDCs early after myocardial infarction can modify the structure and electrophysiology of post-infarction scar. These findings pave the way for novel therapeutic properties of CDCs.

Combined atrial fibrillation ablation and balloon mitral commissurotomy in patients with rheumatic mitral stenosis.

INTRODUCTION: Ablation of atrial fibrillation (AF) is usually not considered in patients with rheumatic mitral stenosis (RMS). We analyzed the results of a combined procedure of AF ablation and percutaneous balloon mitral commissurotomy (PBMC). METHODS: We prospectively included 22 patients with severe RMS to undergo a combined PBMC + AF ablation procedure. Noninvasive mapping of the atria was also performed. A historical sample of propensity-scored matched patients who underwent PBMC alone was used as controls. The primary endpoint was freedom from AF/AT at 1-year. Multivariate analysis evaluated sinus rhythm (SR) predictors. RESULTS: Successful pulmonary vein isolation and electrocardiographic imaging-based drivers ablation was performed in 20 patients following PBMC. At 1-year, 75% of the patients in the combined group were in SR compared to 40% in the propensity-score matched group (p = 0.004). The composite of AF recurrence, need for mitral surgery and all-cause mortality was also more frequent in the control group (65% vs. 30%; p = 0.005). Catheter ablation (odds ratio [OR] 1.58; 95% confidence interval [CI] [1.17-17.37]; p = 0.04) and AF type (OR 1.46; 95% CI [1.05-82.64]; p < 0.001) were the only independent predictors of SR at 1-year. Noninvasive mapping in the combined group showed that the number of simultaneous rotors (OR 2.10; 95% CI [1.41-10.2]; p = 0.04) was the only independent predictor of AF. CONCLUSION: A combined procedure of AF ablation and PBMC significantly increased the proportion of patients in sinus rhythm at 1-year. Noninvasive mapping may help to improve AF characterization and guide personalized AF treatment.

Cardiovascular Diseases in the Digital Health Era: A Translational Approach from the Lab to the Clinic.

Translational science has been introduced as the nexus among the scientific and the clinical field, which allows researchers to provide and demonstrate that the evidence-based research can connect the gaps present between basic and clinical levels. This type of research has played a major role in the field of cardiovascular diseases, where the main objective has been to identify and transfer potential treatments identified at preclinical stages into clinical practice. This transfer has been enhanced by the intromission of digital health solutions into both basic research and clinical scenarios. This review aimed to identify and summarize the most important translational advances in the last years in the cardiovascular field together with the potential challenges that still remain in basic research, clinical scenarios, and regulatory agencies.

In Vitro Evaluation of the Retentive Effectiveness of Axial Attachments Used in Implant-Retained Overdentures After 1 Year of Function.

PURPOSE: The aim of this study was to measure and compare the retention degrees of different attachment systems before and after 1 year of mastication and removal/insertion simulations. MATERIALS AND METHODS: A 4 × 10-mm implant embedded in self-curing acrylic resin was placed inside a rectangular metal frame installed in a plastic container with artificial saliva at 37°C. Three different attachment systems were connected to the implants: Dalbo Classic, Locator (with blue, pink, and clear inserts), and Klockner Rotula. A loading test at 100 N and 1.25 Hz frequency was repeated 10 times for each attachment (changing the matrix component or plastic insert) until a total of 300,000 cycles and 1,095 removal/ insertion sequences. The retention force was assessed at baseline until the end of the test (1 year) after 3-month intervals of simulation. One-way analysis of variance (ANOVA) and post hoc Tukey test (P < .05) were performed for statistical analyses. RESULTS: Klockner Rotula showed the highest retention values at the beginning (69.6 ± 9.2 N; 7.1 ± 0.9 kg) and the end of the test (51.4 ± 5.4 N; 5.2 ± 0.6 kg), while Dalbo Classic showed the lowest values both at the beginning (13.1 ± 1.7 N; 1.3 ± 0.2 kg) and the end of the test (6.7 ± 1.6 N; 0.7 ± 0.2 kg). Locator with clear insert exhibited the lowest retention loss ratio (20.4%), while Locator with blue insert showed the highest (50.8%). At the end of the test, all attachment systems showed a significant decrease in retention force in comparison with the initial retention (P < .001). CONCLUSION: Locator attachments with clear and pink inserts and the Klockner Rotula attachment system showed retention forces > 20 N (2 kg) after 1 year of mastication and prosthesis insertion/removal simulation. All attachment systems showed a progressive loss of retention, which was higher for Locator attachments with blue and pink inserts and Dalbo Classic. The Klockner Rotula attachment system showed the highest retention values both at the beginning and the end of the test.

Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia.

BACKGROUND: In patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD), catheter ablation and antiarrhythmic drugs (AADs) reduce ICD shocks, but the most effective approach remains uncertain. OBJECTIVES: This trial compares the efficacy and safety of catheter ablation vs AAD as first-line therapy in ICD patients with symptomatic ventricular tachycardias (VTs). METHODS: The SURVIVE-VT (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia) is a prospective, multicenter, randomized trial including patients with ischemic cardiomyopathy and appropriated ICD shock. Patients were 1:1 randomized to complete endocardial substrate-based catheter ablation or antiarrhythmic therapy (amiodarone + beta-blockers, amiodarone alone, or sotalol ± beta-blockers). The primary outcome was a composite of cardiovascular death, appropriate ICD shock, unplanned hospitalization for worsening heart failure, or severe treatment-related complications. RESULTS: In this trial, 144 patients (median age, 70 years; 96% male) were randomized to catheter ablation (71 patients) or AAD (73 patients). After 24 months, the primary outcome occurred in 28.2% of patients in the ablation group and 46.6% of those in the AAD group (hazard ratio [HR]: 0.52; 95% CI: 0.30-0.90; P = 0.021). This difference was driven by a significant reduction in severe treatment-related complications (9.9% vs 28.8%, HR: 0.30; 95% CI: 0.13-0.71; P = 0.006). Eight patients were hospitalized for heart failure in the ablation group and 13 in the AAD group (HR: 0.56; 95% CI: 0.23-1.35; P = 0.198). There was no difference in cardiac mortality (HR: 0.93; 95% CI: 0.19-4.61; P = 0.929). CONCLUSIONS: In ICD patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD. (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia [SURVIVE-VT]: NCT03734562).

Structural Remodeling and Rotational Activity in Persistent/Long-Lasting Atrial Fibrillation: Gender-Effect Differences and Impact on Post-ablation Outcome.

Background: Structural and post-ablation gender differences are reported in atrial fibrillation (AF). We analyzed the gender differences in structural remodeling and AF mechanisms in patients with persistent/long-lasting AF who underwent wide area circumferential pulmonary vein isolation (WACPVI). Materials and Methods: Ultra-high-density mapping was used to study atrial remodeling and AF drivers in 85 consecutive patients. Focal and rotational activity (RAc) were identified with the CartoFinder system and activation sequence analysis. The impact of RAc location on post-ablation outcomes was analyzed. Results: This study included 64 men and 21 women. RAc was detected in 73.4% of men and 38.1% of women (p = 0.003). RAc patients had higher left atrium (LA) voltage (0.64 ± 0.3 vs. 0.50 ± 0.2 mV; p = 0.01), RAc sites had higher voltage than non-RAc sites 0.77 ± 0.46 vs. 0.53 ± 0.37 mV (p < 0.001). Women had lower LA voltage than men (0.42 vs. 0.64 mV; p < 0.001), including pulmonary vein (PV) antra (0.16 vs. 0.30 mV; p < 0.001) and posterior wall (0.34 vs. 0.51 mV; p < 0.001). RAc in the posterior atrium was recorded in few women (23.8 vs. 54.7% in men; p = 0.014). AF recurrence rate was higher in patients with RAc outside WACPVI than those with all RAc inside WACPVI or no RAc (63.4 vs. 11.1 and 31.0%; p = 0.008 and p = 0.01). Comparison of selected patients using propensity score matching confirmed lower atrial voltage (0.4 ± 0.2 vs. 0.7 ± 0.3 mV; p = 0.007) and less RAc (38 vs. 75%; p = 0.02) in women. Conclusion: Women have shown more advanced structural remodeling at ablation, which is associated with a lower incidence of RAc (usually located outside the WACPVI). These findings could explain post-ablation gender differences.

Convolutional Neural Networks for Mechanistic Driver Detection in Atrial Fibrillation.

The maintaining and initiating mechanisms of atrial fibrillation (AF) remain controversial. Deep learning is emerging as a powerful tool to better understand AF and improve its treatment, which remains suboptimal. This paper aims to provide a solution to automatically identify rotational activity drivers in endocardial electrograms (EGMs) with convolutional recurrent neural networks (CRNNs). The CRNN model was compared with two other state-of-the-art methods (SimpleCNN and attention-based time-incremental convolutional neural network (ATI-CNN)) for different input signals (unipolar EGMs, bipolar EGMs, and unipolar local activation times), sampling frequencies, and signal lengths. The proposed CRNN obtained a detection score based on the Matthews correlation coefficient of 0.680, an ATI-CNN score of 0.401, and a SimpleCNN score of 0.118, with bipolar EGMs as input signals exhibiting better overall performance. In terms of signal length and sampling frequency, no significant differences were found. The proposed architecture opens the way for new ablation strategies and driver detection methods to better understand the AF problem and its treatment.

Association of age with clinical features and ablation outcomes of paroxysmal supraventricular tachycardias.

OBJECTIVE: The role of age in clinical characteristics and catheter ablation outcomes of atrioventricular nodal re-entrant tachycardia (AVNRT) or orthodromic atrioventricular re-entrant tachycardia (AVRT) has been assessed in retrospective studies categorising age by arbitrary cut-offs, but contemporary analyses of age-related trends are lacking. We aimed to study the relationship of age with epidemiological, clinical features and catheter ablation outcomes of AVNRT and AVRT. METHODS: We recruited 600 patients (median age 56 years, 60% female) with a confirmed diagnosis of AVNRT (n=455) or AVRT (n=145) by means of an electrophysiological study. They were interrogated for arrhythmia-related symptoms with a structured questionnaire and followed up to 1 year. We analysed age as a continuous variable using regression models and adjusting for relevant covariables. RESULTS: Both typical and atypical forms of AVNRT upraised with age while AVRT decreased (p<0.001 by regression). Female sex predominance in AVNRT was not observed in older patients. Overall, these tachycardias became more symptomatic with ageing despite a longer tachycardia cycle length (p<0.001) and regardless of the presence of structural heart disease, with a higher proportion of dizziness, syncope, chest pain or dyspnoea (p<0.005 for all) and a lower presence of palpitations or neck pounding (p<0.001 for both). Age was not associated with catheter ablation acute success, periprocedural complications or 1-year recurrence rates (p>0.05 for all). CONCLUSIONS: Age, evaluated as a continuous variable, had a significant association with the clinical profile of patients with AVNRT and AVRT. Nevertheless, catheter ablation outcomes and complications were not significantly related to patients' age.

Effect of abutment finish lines on the mechanical behavior and marginal fit of screw-retained implant crowns: An in vitro study.

STATEMENT OF PROBLEM: The design of the implant-abutment connection has been widely researched, but the impact of different crown-abutment geometries remains unclear. PURPOSE: The purpose of this in vitro study was to evaluate the effect of different crown-abutment margin geometries on the mechanical behavior and fit of screw-retained implant-supported single-crown restorations by using mechanical static and fatigue tests and mastication simulation. MATERIAL AND METHODS: A total of 45 cobalt-chromium premolar-shaped metal frameworks were fabricated for single-unit implant-supported screw-retained restorations on stock abutments and internal hexagon Ø4.25×11-mm cylindrical implants. They were divided into 3 groups according to margin geometry: S, shoulder; C, chamfer; and F, feather-edge. Three static load until fracture and 24 dynamic load tests were performed by using the International Organization for Standardization 14801:2016 standard (ISO 14801:2016) (number of cycles limit: 5×106 cycles, frequency: 6 Hz). The ProFatigue software program was used to optimize the procedure (S, n=12 specimens; C, n=7 specimens; and F, n=5 specimens). Six additional specimens from each group were subjected to a mastication simulation (limit number of cycles: 1×106 cycles, cyclic loading from Pmin=30 N to Pmax=300 N, frequency: 6 Hz). Results from the fatigue tests were reported descriptively, and the Fisher exact test was used to analyze the difference in failure modes. Data from maximum misfit were evaluated by photogrammetry and statistically analyzed with the Anderson-Darling test and the Kruskal-Wallis and Dunn multiple comparison tests (α=.05). RESULTS: The fatigue limit was 456 N for group S, 512 N for group C, and 514 N for group F. The mean ±standard deviation misfit was 2.6 ±0.1 µm for group S, 3.8 ±1.1 µm for group C, and 3.6 ±0.8 µm for group F. Differences in misfit between groups S and C and between groups S and F were statistically significant (P<.05). CONCLUSIONS: Crown-abutment connections with chamfer and feather-edge margins showed better mechanical behavior, while shoulder margin exhibited better fit. However, high levels of fit were achieved for all the evaluated geometries.

Artificial Intelligence-Driven Algorithm for Drug Effect Prediction on Atrial Fibrillation: An in silico Population of Models Approach.

Background: Antiarrhythmic drugs are the first-line treatment for atrial fibrillation (AF), but their effect is highly dependent on the characteristics of the patient. Moreover, anatomical variability, and specifically atrial size, have also a strong influence on AF recurrence. Objective: We performed a proof-of-concept study using artificial intelligence (AI) that enabled us to identify proarrhythmic profiles based on pattern identification from in silico simulations. Methods: A population of models consisting of 127 electrophysiological profiles with a variation of nine electrophysiological variables (G Na , I NaK , G K1, G CaL , G Kur , I KCa , [Na] ext , and [K] ext and diffusion) was simulated using the Koivumaki atrial model on square planes corresponding to a normal (16 cm2) and dilated (22.5 cm2) atrium. The simple pore channel equation was used for drug implementation including three drugs (isoproterenol, flecainide, and verapamil). We analyzed the effect of every ionic channel combination to evaluate arrhythmia induction. A Random Forest algorithm was trained using the population of models and AF inducibility as input and output, respectively. The algorithm was trained with 80% of the data (N = 832) and 20% of the data was used for testing with a k-fold cross-validation (k = 5). Results: We found two electrophysiological patterns derived from the AI algorithm that was associated with proarrhythmic behavior in most of the profiles, where G K1 was identified as the most important current for classifying the proarrhythmicity of a given profile. Additionally, we found different effects of the drugs depending on the electrophysiological profile and a higher tendency of the dilated tissue to fibrillate (Small tissue: 80 profiles vs Dilated tissue: 87 profiles). Conclusion: Artificial intelligence algorithms appear as a novel tool for electrophysiological pattern identification and analysis of the effect of antiarrhythmic drugs on a heterogeneous population of patients with AF.

Zirconia vs. Titanium Dental Implants: Primary Stability In-Vitro Analysis.

The present experimental trial uses two types of dental implants, one made of titanium (Ti6Al4V) and the other one of zirconia (ZrO2), but both of identical design, to compare their stability and micro-movements values under load. One of each type of implant (n = 42) was placed into 21 cow ribs, recording the insertion torque and the resonance frequency using a specific transducer. Subsequently, a prosthetic crown made of PMMA was screwed onto each of the implants in the sample. They were then subjected to a static compression load on the vestibular cusp of the crown. The resulting micromovements were measured. The zirconia implants obtained a higher mean of both IT and RFA when compared with those of titanium, with statistically significant differences in both cases (p = 0.0483 and p = 0.0296). However, the micromovement values when load was applied were very similar for both types, with the differences between them (p = 0.3867) not found to be statistically significant. The results show that zirconia implants have higher implant stability values than titanium implants. However, the fact that there are no differences in micromobility values implies that caution should be exercised when applying clinical protocols for zirconia based on RFA, which only has evidence for titanium.

Logistic Regression Analysis of the Factors Involved in the Failure of Osseointegration and Survival of Dental Implants with an Internal Connection and Machined Collar: A 6-Year Retrospective Cohort Study.

BACKGROUND: Although the long-term success rate of dental implants is currently close to 95%, it is necessary to provide more evidence on the factors related to the failure of osseointegration and survival. PURPOSE: To establish the risk factors associated with the failure of osseointegration and survival of dental implants with an internal connection and machined collar and to establish a predictive statistical model. MATERIALS AND METHODS: An analytical, retrospective, and observational clinical study of a sample of 297 implants with a follow-up of up to 76 months. Independent variables related to the implant, patient, and surgical and rehabilitative procedures were identified. The dependent variables were failure of osseointegration and failure of implant survival after prosthetic loading. A survival analysis was carried out by applying the Kaplan-Meier model (significance for p < 0.05). The log-rank test and the Cox regression analysis were applied to the factors that presented differences. Finally, the regression logit function was used to determine whether it is possible to predict the risk of implant failure according to the analyzed variables with the data obtained in this study. RESULTS: The percentages of osseointegration and survival were 97.6 and 97.2%, respectively. For osseointegration, there were significant differences according to gender (p = 0.048), and the risk of nonosseointegration was 85% lower in women. Regarding survival, the Cox analysis converged on only two factors, which were smoking and treatment with anticoagulant drugs. The risk of loss was multiplied by 18.3 for patients smoking more than 10 cigarettes per day and by 28.2 for patients treated with anticoagulants. CONCLUSIONS: The indicated risk factors should be considered, but the analysis of the results is not sufficient to create a predictive model.

Personalized Evaluation of Atrial Complexity of Patients Undergoing Atrial Fibrillation Ablation: A Clinical Computational Study.

Current clinical guidelines establish Pulmonary Vein (PV) isolation as the indicated treatment for Atrial Fibrillation (AF). However, AF can also be triggered or sustained due to atrial drivers located elsewhere in the atria. We designed a new simulation workflow based on personalized computer simulations to characterize AF complexity of patients undergoing PV ablation, validated with non-invasive electrocardiographic imaging and evaluated at one year after ablation. We included 30 patients using atrial anatomies segmented from MRI and simulated an automata model for the electrical modelling, consisting of three states (resting, excited and refractory). In total, 100 different scenarios were simulated per anatomy varying rotor number and location. The 3 states were calibrated with Koivumaki action potential, entropy maps were obtained from the electrograms and compared with ECGi for each patient to analyze PV isolation outcome. The completion of the workflow indicated that successful AF ablation occurred in patients with rotors mainly located at the PV antrum, while unsuccessful procedures presented greater number of driving sites outside the PV area. The number of rotors attached to the PV was significantly higher in patients with favorable long-term ablation outcome (1-year freedom from AF: 1.61 ± 0.21 vs. AF recurrence: 1.40 ± 0.20; p-value = 0.018). The presented workflow could improve patient stratification for PV ablation by screening the complexity of the atria.

Predictores e impacto de la adopción de programación basada en la evidencia en la incidencia de terapias del desfibrilador automático implantable / Predictors of adoption and impact of evidence-based programming on the incidence of implantable cardioverter-defibrillator therapies

Introducción y objetivos El estudio ADVANCE III mostró una reducción de terapias del desfibrilador automático implantable (DAI) con el empleo de tiempos de detección de arritmia prolongados. Se describe la adopción y el impacto de dicha estrategia en la incidencia de terapias del DAI. Métodos Estudio observacional retrospectivo de pacientes con implante de DAI Medtronic (2005-2016) en un registro multicéntrico (UMBRELLA-NCT01561144). Se describe la evolución de la adopción de programación ADVANCE en relación con: publicación del estudio, implementación de una campaña de formación y publicación de un consenso de expertos. Se identificaron con regresión logística los predictores de la adopción. Se comparó la incidencia de terapias en pacientes con y sin programación ADVANCE estimando la razón de tasas de incidencia ajustada (RTIa) mediante regresión binomial negativa. Resultados Se incluyó a 3.528 pacientes. Se utilizó la estrategia ADVANCE en el 20% del total y el 44% al final del estudio. La adopción se incrementó tras publicarse el estudio ADVANCE, y en menor grado tras la campaña de formación y consenso de expertos. Predictores de la adopción: DAI con detección nominal 30/40 (ORa=4,4; IC95%, 3,5-5,4), implantador electrofisiólogo (ORa=1,7; IC95%, 1,4-2,2) y prevención secundaria (ORa=3,2; IC95%, 2,6-3,9). El implante de DAI bicameral (ORa=0,6; IC95%, 0,5-0,8) o tricameral (ORa=0,5; IC95%, 0,4-0,7) se asoció con menor adopción. La programación ADVANCE se asoció con reducción de terapias totales (RTIa=0,77; IC95%, 0,69-0,86) y choques inapropiados (RTIa=0,66; IC95%, 0,52-0,85). Conclusiones La adopción de la programación ADVANCE es poco amplia y puede mejorarse mediante una adecuada selección de los parámetros nominales. Emplearla se asocia con una reducción de las terapias del DAI. (AU)

Introduction and objectives The ADVANCE III trial showed that a delayed-detection strategy reduces implantable cardioverter-defibrillator (ICD) therapies. Here, we describe the adherence to and predictors of ADVANCE adoption and compare ICD therapy rates between patients with and without ADVANCE programming. Methods This observational retrospective study analyzed patients implanted with Medtronic ICDs included from 2005 to 2016 in a Spanish national multicenter registry (UMBRELLA database; ClinicalTrials.gov, NCT01561144). Changes in ADVANCE programming adoption were described in relation to a) publication of the ADVANCE trial, b) implementation of an “ADVANCE awareness” campaign, and c) publication of an expert consensus statement. Multivariate logistic regression identified predictors of adoption. Therapy incidence rates were compared between groups by estimating the adjusted incidence rate ratio (aIRR) using negative binomial regression. Results A total of 3528 patients were included. An ADVANCE strategy was used in 20% overall and in 44% at the end of the study. ADVANCE III adoption increased after trial publication, with less growth after an “ADVANCE awareness” campaign and after expert consensus statement publication. Predictors of ADVANCE adoption were as follows: ICD device with a nominal number of intervals to detect 30/40 (aOR, 4.4; 95%CI, 3.5-5.4), implantation by an electrophysiologist (aOR, 1.7; 95%CI, 1.4-2.2), and secondary prevention (aOR, 3.2; 95%CI, 2.6-3.9). Dual-chamber ICDs (aOR, 0.6; 95%CI, 0.5-0.8) and cardiac resynchronization-defibrillators (aOR, 0.5; 95%CI, 0.4-0.7) were associated with lower adoption. ADVANCE programming was associated with reduced total therapy burden (aIRR, 0.77; 95%CI, 0.69-0.86) and fewer inappropriate shocks (aIRR, 0.66; 95%CI, 0.52-0.85). Conclusions ADVANCE adoption remains modest and can be improved through evidence-driven selection of nominal ICD settings. ... (AU)

Predictors of adoption and impact of evidence-based programming on the incidence of implantable cardioverter-defibrillator therapies.

INTRODUCTION AND OBJECTIVES: The ADVANCE III trial showed that a delayed-detection strategy reduces implantable cardioverter-defibrillator (ICD) therapies. Here, we describe the adherence to and predictors of ADVANCE adoption and compare ICD therapy rates between patients with and without ADVANCE programming. METHODS: This observational retrospective study analyzed patients implanted with Medtronic ICDs included from 2005 to 2016 in a Spanish national multicenter registry (UMBRELLA database; ClinicalTrials.gov, NCT01561144). Changes in ADVANCE programming adoption were described in relation to a) publication of the ADVANCE trial, b) implementation of an "ADVANCE awareness" campaign, and c) publication of an expert consensus statement. Multivariate logistic regression identified predictors of adoption. Therapy incidence rates were compared between groups by estimating the adjusted incidence rate ratio (aIRR) using negative binomial regression. RESULTS: A total of 3528 patients were included. An ADVANCE strategy was used in 20% overall and in 44% at the end of the study. ADVANCE III adoption increased after trial publication, with less growth after an "ADVANCE awareness" campaign and after expert consensus statement publication. Predictors of ADVANCE adoption were as follows: ICD device with a nominal number of intervals to detect 30/40 (aOR, 4.4; 95%CI, 3.5-5.4), implantation by an electrophysiologist (aOR, 1.7; 95%CI, 1.4-2.2), and secondary prevention (aOR, 3.2; 95%CI, 2.6-3.9). Dual-chamber ICDs (aOR, 0.6; 95%CI, 0.5-0.8) and cardiac resynchronization-defibrillators (aOR, 0.5; 95%CI, 0.4-0.7) were associated with lower adoption. ADVANCE programming was associated with reduced total therapy burden (aIRR, 0.77; 95%CI, 0.69-0.86) and fewer inappropriate shocks (aIRR, 0.66; 95%CI, 0.52-0.85). CONCLUSIONS: ADVANCE adoption remains modest and can be improved through evidence-driven selection of nominal ICD settings. ADVANCE programming is associated with reduced therapy rates in real-world ICD recipients.