Transoesophageal echocardiography prior to catheter ablation could be avoided in atrial fibrillation patients with a low risk of stroke and without filling defects in the late-phase MDCT scan: A retrospective analysis of 783 patients.

OBJECTIVES: To test whether multidetector computed tomography (MDCT) could completely replace transoesophageal echocardiography (TEE) to detect left atrial appendage (LAA) thrombi in atrial fibrillation (AF) patients using a large sample size. METHODS: 783 patients with AF who underwent MDCT and TEE before catheter ablation were retrospectively included. Demographic data were obtained. Two radiologists blinded to clinical data made the imaging diagnosis. RESULTS: Most of the patients (96.2 %) had a CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years old (doubled), diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65-74 years, female sex) ≤ 3. Eight thrombi were identified by TEE, all of which were detected by MDCT; no thrombus was observed with TEE without the observation of filling defects by late-phase MDCT scanning in any of the patients. Using TEE as reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of MDCT for thrombus detection were 100 %, 95.74 % (95 % CI 94.33 %-97.15 %), 19.51 % (95 % CI 16.73 %-22.29 %) and 100 %, respectively. CONCLUSIONS: For AF patients with low risk of stroke, when MDCT images showed no filling defect in the late phase, TEE prior to catheter ablation can be avoided. KEY POINTS: • MDCT can help detect the presence of LAA thrombus. • TEE can be avoided when late-phase MDCT shows no filling defect. • TEE is required in patients whose MDCT images indicate thrombus.

Relationship between 24 h blood pressure variability and mortality in acute myocardial infarction patients.

BACKGROUND: In recent years, the mortality of patients with AMI has not declined significantly. The relationship between blood pressure variability (BPV) and acute myocardial infarction (AMI) is unclear. We explored the relationship between 24-h BPV and mortality in patients with AMI. HYPOTHESIS: The mortality of patients with AMI is related to BPV. We hope to provide therapeutic ideas for reducing the risk of death in patients with AMI. METHODS: This is a retrospective cohort study. We extracted and analyzed data from the MIMIC-IV 2.0, which was established in 1999 under the auspices of the National Institutes of Health (America). The average real variability (ARV) was calculated for the first 24-h blood pressure measurement after patients with AMI were admitted to the intensive care unit (ICU). Patients were divided into four groups according to ARV quartiles. The outcomes were 30-day, 1-year, and 3-year all-cause mortalities. Data were analyzed using Cox regression, Kaplan-Meier curves, and restricted cubic spline (RCS) curves. RESULTS: We enrolled 1291 patients with AMI, including 475 female. The patients were divided into four groups according to the qualities of diastolic blood pressure (DBP)-ARV. There were significant differences in the 30-day, 1-year and 3-year mortality among the four groups (p = .02, p < .001, p < .001, respectively). After adjustment for confounding factors, systolic blood pressure (SBP)-ARV could not predict AMI patient mortality (p > .05), while the highest DBP-ARV was associated strongly with increased 30-day mortality (HR: 2.291, 95% CI 1.260-4.168), 1-year mortality (HR: 1.933, 95% CI 1.316-2.840) and 3-year mortality (HR: 1.743, 95% CI 1.235-2.461). Kaplan-Meier curves demonstrated that, regardless of SBP or DBP, the long-term survival probabilities of patients in the highest ARV group were significantly lower than that of those in other groups. RCS curves showed that the death risk of patients with AMI first decreased and then increased with the increase in ARV when DBP-ARV < 8.04. The 30-day death risk first increased and then decreased, and the 1-year and 3-year death risks increased and then stabilized with ARV increase when DBP-ARV > 8.04. CONCLUSION: This study showed that patients with AMI may have an increased risk of short- and long-term death if their DBP-ARV is higher or lower during the first 24-h in ICU.

Design and rationale of the ATTRACTIVE trial: a randomised trial of intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion in ST-segment elevation myocardial infarction patients with high thrombus burden.

INTRODUCTION: ST-segment elevation myocardial infarction (STEMI) with high thrombus burden is associated with a poor prognosis. Manual aspiration thrombectomy reduces coronary vessel distal embolisation, improves microvascular perfusion and reduces cardiovascular deaths, but it promotes more strokes and transient ischaemic attacks in the subgroup with high thrombus burden. Intrathrombus thrombolysis (ie, the local delivery of thrombolytics into the coronary thrombus) is a recently proposed treatment approach that theoretically reduces thrombus volume and the risk of microvascular dysfunction. However, the safety and efficacy of intrathrombus thrombolysis lack sufficient clinical evidence. METHODS AND ANALYSIS: The intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion trial is a multicentre, prospective, open-label, randomised controlled trial with the blinded assessment of outcomes. A total of 2500 STEMI patients with high thrombus burden who undergo primary percutaneous coronary intervention will be randomised 1:1 to intrathrombus thrombolysis with a pierced balloon or upfront routine manual aspiration thrombectomy. The primary outcome will be the composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, heart failure readmission, stent thrombosis and target-vessel revascularisation up to 180 days. ETHICS AND DISSEMINATION: The trial was approved by Ethics Committees of China-Japan Friendship Hospital (2022-KY-013) and all other participating study centres. The results of this trial will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05554588.

Interaction between electrical storm and left ventricular ejection fraction as predictors of mortality in patients with implantable cardioverter defibrillator: A Chinese cohort study.

Aims: To determine the interaction of electrical storm (ES) and impaired left ventircular ejection fraction (LVEF) on the mortality risk of patients with implantable cardioverter defibrillator (ICD). Methods and results: A total of 554 Chinese ICD recipients from 2010 to 2014 were retrospectively included and the mean follow-up was 58 months. The proportions of dilated cardiomyopathy and the hypertrophic cardiomyopathy were 26.0% (144/554) and 5.6% (31/554), respectively. There were 8 cases with long QT syndrome, 6 with arrhythmogenic right ventricular cardiomyopathy and 2 with Brugada syndrome. Patients with prior MI accounted for 15.5% (86/554) and pre-implantation syncope accounted for 23.3% (129/554). A total of 199 (35.9%) patients had primary prevention indications for ICD therapy. Both ES and impaired LVEF (<40%) were independent predictors for all-cause mortality [hazard ratio (HR) 2.40, 95% CI 1.57-3.68, P < 0.001; HR 1.94, 95% CI 1.30-2.90, P = 0.001, respectively] and cardiovascular mortality (HR 4.63, 95% CI 2.68-7.98, P < 0.001; HR 2.56, 95% CI 1.47-4.44, p = 0.001, respectively). Compared with patients with preserved LVEF (≥40%) and without ES, patients with impaired LVEF and ES had highest all-cause and cardiovascular mortality risks (HR 4.17, 95% CI 2.16-8.06, P < 0.001; HR 11.91, 95% CI 5.55-25.56, P < 0.001, respectively). In patients with impaired LVEF, ES increased the all-cause and cardiovascular mortality risks (HR 1.84, 95% CI 1.00-3.37, P = 0.034; HR 4.86, 95% CI 2.39-9.86, P < 0.001, respectively). In patients with ES, the deleterious effects of impaired LVEF seemed confined to cardiovascular mortality (HR 2.54, 95% CI 1.25-5.14, p = 0.038), and the HR for all-cause mortality was not significant statistically (HR 1.14, 95% CI 0.54-2.38, P = 0.735). Conclusion: Both ES and impaired LVEF are independent predictors of mortality risk in this Chinese cohort of ICD recipients. The interaction of ES and impaired LVEF in patients significantly amplifies the deleterious effects of each other as distinct disease.

Idiopathic Ventricular Arrhythmias Ablated in Different Subregions of the Aortic Sinuses of Valsalva: Anatomical Distribution, Precordial Electrocardiographic Notch Patterns, and Bipolar Electrographic Characteristics.

Background: Little is known about the differences among ventricular arrhythmias (VAs) ablated in different subregions of the aortic sinuses of Valsalva (ASVs). We aim to investigate the distribution, precordial electrocardiographic patterns, and bipolar electrogram characteristics of VAs ablated in different subregions of the ASVs. Methods: We divided the right ASV and the left ASV into a total of 6 subregions and studied 51 idiopathic VAs ablated first time successfully in the ASVs. Results: These 51 VAs were inhomogeneously distributed among the 6 subregions, which comprised the right-lateral ASV (1/51), the right-anterior ASV (11/51), the regions along the right (13/51) and left (9/51) sides of the ASV junction, the left-anterior ASV (5/51), and the left-lateral ASV (12/51). Fractionated potentials were dominant (39/51, 76%) among the 3 types of target electrograms. From the right-lateral ASV to the left-lateral ASV, the percentage of fractionated potentials gradually decreased from 100 to 59%. A precordial rebound notch in V3-V4 or V4-V5 had sensitivity of 90.9%, specificity of 85.0%, and negative predictive value (NPV) of 97.1% to predict VAs ablated in the right-anterior ASV. A precordial rebound notch in V2-V3 had sensitivity of 50.0%, specificity of 94.9%, and NPV of 86.0% to predict VAs ablated in the left-lateral ASV. Conclusion: VA targets were mainly distributed in the anterior and the left-lateral ASVs. Fractionated potentials were common among target electrograms, especially in theright-anterolateral ASV. Precordial electrocardiographic rebound notch has high predictive accuracy in identifying different subregions of the ASVs as target ablation sites.

Association Between the Coronary Sinus Ostial Size and Atrioventricular Nodal Reentrant Tachycardia in Patients With Pulmonary Arterial Hypertension.

AIMS: The incidence of atrioventricular nodal reentrant tachycardia (AVNRT) is higher in pulmonary arterial hypertension (PAH) patients than in the general population. AVNRT is reportedly associated with a larger coronary sinus (CS) ostium (CSo). However, the correlation between AVNRT and CSo size in PAH patients is poorly investigated. We aimed to investigate the impact of CSo size on AVNRT and identify its risk factors in PAH. METHODS AND RESULTS: Of 102 PAH patients with catheter ablation of supraventricular tachycardia (SVT), twelve with a confirmed AVNRT diagnosis who underwent computed tomographic angiography were retrospectively enrolled as the study group. The control group (PAH without SVT, n = 24) was matched for sex and BMI at a 2:1 ratio. All baseline and imaging data were collected. Mean pulmonary artery pressure was not significantly different between the two groups (65.3 ± 16.8 vs. 64.5 ± 17.6 mmHg, P = 0.328). PAH patients with AVNRT were older (45.9 ± 14.8 vs. 32.1 ± 7.6 years, P = 0.025), had a larger right atrial volume (224.4 ± 129.6 vs. 165.3 ± 71.7 cm3, P = 0.044), larger CSo in the left anterior oblique (LAO) plane (18.6 ± 3.3 vs. 14.8 ± 4.0 mm, P = 0.011), and larger CSo surface area (2.08 ± 1.35 vs. 1.45 ± 0.73 cm2, P = 0.039) and were more likely to have a windsock-shape CS (75% vs. 16.7%, P = 0.001) than those without AVNRT. A linear correlation was shown between CSo diameter in the LAO-plane and the atrial fractionation of the ablation target for AVNRT (R 2 = 0.622, P = 0.012). CONCLUSION: Anatomical dilation of the CSo is a risk factor for AVNRT development in patients with PAH.

Radiofrequency Catheter Ablation of Supraventricular Tachycardia in Patients With Pulmonary Hypertension: Feasibility and Long-Term Outcome.

BACKGROUND: Supraventricular tachycardia (SVT) occurs commonly and is strongly correlated with clinical deterioration in patients with pulmonary hypertension (PH). This study aimed to investigate the feasibility and long-term outcome of radiofrequency catheter ablation (RFCA) in PH patients with SVT. MATERIALS AND METHODS: Consecutive PH patients with SVT who were scheduled to undergo electrophysiological study and RFCA between September 2010 and July 2019 were included. The acute results and long-term success of RFCA were assessed after the procedure. RESULTS: In total, 71 PH patients with 76 episodes of SVT were analyzed. Cavotricuspid isthmus-dependent atrial flutter (n = 33, 43.5%) was the most common SVT type, followed by atrioventricular nodal reentrant tachycardia (n = 16, 21.1%). Of the 71 patients, 60 (84.5%) underwent successful electrophysiological study and were subsequently treated by RFCA. Among them, acute sinus rhythm was restored in 54 (90.0%) patients, and procedure-related complications were observed in 4 (6.7%) patients. Univariate logistic regression analysis showed that cavotricuspid isthmus-independent atrial flutter [odds ratio (OR) 25.00, 95% confidence interval (CI) 3.45-180.98, p = 0.001] and wider pulmonary artery diameter (OR 1.19, 95% CI 1.03-1.38; p = 0.016) were associated with RFCA failure. During a median follow-up of 36 (range, 3-108) months, 7 patients with atrial flutter experienced recurrence, yielding a 78.3% 3-year success rate for RFCA treatment. CONCLUSION: The findings suggest that RFCA of SVT in PH patients is feasible and has a good long-term success rate. Cavotricuspid isthmus-independent atrial flutter and a wider PAD could increase the risk for ablation failure.

Experience of left atrial appendage occlusion with the WATCHMAN device in Chinese patients.

OBJECTIVE: Little is known about left atrial appendage occlusion (LAAO) with WATCHMAN device in patients with atrial fibrillation (AF) in China. The aim of the present study was to evaluate the acute procedural performance and complication rate of LAAO procedures and patient selection in China. METHODS: A total of 658 consecutive Chinese patients who were referred to receive LAAO procedures with the WATCHMAN device between 2014 and 2017 were retrospectively included in the study. Patients were divided into four groups according to the year of procedures: Group 2014, Group 2015, Group 2016, and Group 2017. The procedural success, complication rates, and characteristics of Chinese patients, as well as the trends of patients' selection and management, were analyzed. RESULTS: The average age of the patients was 67.7+-9.2 years, the CHA2DS2-VASc score was 3.7+-1.6, and the HAS-BLED score was 2.5+-1.1. Both scores of patients in different years show obvious increasing trends (r=0.126, p=0.001 and r=0.145, p<0.001, respectively). Indications for LAAO included increased bleeding risk (45.6%), recent bleeding under oral anticoagulation (OAC) (9.0%), and non-compliance with OAC (51.4%). The implantation was successful in 643 (97.7%) patients, with a procedural complication rate of 0.6%. Approximately 80.1% of the patients received OAC after LAAO. CONCLUSION: In China, LAAO with WATCHMAN devices in patients with AF can be performed successfully with a low complication rate. Most of the target population had increased bleeding risk or non-compliance for OAC as indications and received OAC for antithrombotic therapy after the procedure.

Chronic median nerve modulation reduces ventricular arrhythmia and improves ventricular function in a postmyocardial infarction rabbit model.

AIM: Median nerve stimulation (MNS) is a novel neuromodulation approach for treatment of ventricular arrhythmia, but little is known about its chronic effects. The aim of this study was to investigate the effects of chronic MNS on ventricular arrhythmia and ventricular dysfunction postmyocardial infarction (MI). METHOD: Two weeks after MI, 12 rabbits were randomly divided into control and MNS groups, and chronic MNS was performed in MNS group for 2 weeks. Ventricular function and arrhythmias; sympathetic innervation and activity; and interleukin-1 ß (IL-1 ß) and norepinephrine (NE) levels were analyzed. RESULTS: Both the total number of premature ventricular complex and episodes of ventricular tachycardia were lower in MNS group than in control group (20 560 ± 10 314 beats vs 70 079 ± 37 184 beats, P = .021, and 115 ± 63 episodes vs 307 ± 164 episodes, P = .034, respectively). Compared with control group, MNS decreased the cardiac sympathetic nerve density and level of circulating NE in MNS group (1798.42 ± 644.07 µm2 /mm2 vs 1003.79 ± 453.00 µm2 /mm2, P = .041, and 20.86 ± 4.54 pg/mL vs 11.07 ± 1.43 pg/mL, P = .002, respectively). MNS also improved the left ventricular ejection fraction (59.07 ± 1.91% vs 49.77 ± 3.47%, P = .003) and inhibited the level of IL-1 ß in serum (69.19 ± 4.71 pg/mL vs 85.93 ± 12.80 pg/mL, P = .013). CONCLUSION: Chronic MNS appears to protect against ventricular arrhythmia and improves ventricular function post-MI, which may be mediated by suppressing cardiac sympathetic activity and anti-inflammatory effects.