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The latest medical research on Clinical Cardiac Electrophysiology

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Maintenance of Sinus Rhythm Is Associated With Lower Incidence of Stroke in Patients With Drug-Refractory Atrial Fibrillation.

Pacing Clin Electrophysiol

Recent studies have demonstrated that early rhythm control for first-line treatment of atrial fibrillation (AF) improved cardiovascular outcomes. However, there is limited data regarding the long-term outcome of patients who failed antiarrhythmic drugs and who refuse radiofrequency catheter ablation (RFCA).

Patients with AF who were refractory to antiarrhythmic drugs and had refused further rhythm control attempts via RFCA were retrospectively identified and propensity-score (PS) matched with those who had been treated with RFCA. The primary outcome of interest was all-cause mortality or ischemic stroke.

A total of 169 patients who refused rhythm control with RFCA and PS matched 169 patients who had been treated with RFCA were included for analysis. During a mean follow-up of 4.3 (2.3;6.9) years, maintenance of sinus rhythm was more achieved in RFCA group (7 [4.1%] in Refuse group vs. 133 [78.7%] in RFCA group, p < 0.001). The incidence of ischemic stroke was significantly higher in patients who refused RFCA compared with patients who underwent RFCA (2.96 per 100 person-years in the Refused group vs. 0.74 per 100 person-years in the RFCA group, log-rank p < 0.001), but all-cause mortality was not significantly different (log-rank p = 0.8). Refusal of attempted rhythm control via RFCA was an independent risk factor for ischemic stroke on multivariate Cox analysis (hazard ratio [HR] 3.2; 95% confidence interval [CI] 1.2-8.53, p = 0.02).

In patients with antiarrhythmic drug-refractory AF, the risk of stroke was significantly higher in patients who refused rhythm control via RFCA compared with that of those treated with RFCA.

Warfarin and Aspirin Versus Warfarin Alone in Patients With HeartMate 3 Left Ventricular Assist Device: A Systematic Review and Meta-Analysis.

Pacing Clin Electrophysiol

HeartMate 3 (HM3), a fully magnetically levitated ventricular assist device (LVAD), has been associated with reduced thromboembolic events compared to HeartMate II. However, bleeding events remained significant. Among patients undergoing HM3 implantation, the standard antithrombotic regimen comprises both warfarin and aspirin (ASA), but there is a lack of evidence on the optimum antithrombotic therapy. We performed a systematic review and meta-analysis assessing the impact of combined ASA and warfarin therapy compared to warfarin alone on the incidence of non-surgical bleeding events in patients with HM3 LVAD.

MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and observational studies comparing warfarin alone with warfarin combined with ASA in patients with HM3 LVAD. Binary endpoints were analyzed using computed risk ratios (RRs) with 95% confidence intervals (CIs). A random-effect model was applied for all endpoints.

Five studies (one RCT and four observational) encompassing 869 patients were included, with 424 (48.8%) prescribed warfarin alone, and 662 (76.2%) being male. Compared with the combined anticoagulation regimen, warfarin alone significantly reduced non-surgical bleeding (RR 0.30; 95% CI 0.09-0.95; p = 0.04) and gastrointestinal bleeding (RR 0.26; 95% CI 0.12-0.58; p < 0.001). There was no statistically significant difference between the groups for all-cause mortality (RR 1.02; 95% CI 0.45-2.32; p = 0.963).

Our findings indicate that the use of warfarin alone for anticoagulation in HM3 patients is associated with a reduced risk of bleeding events when compared to the combined therapy with ASA.

A Case of Very Early Lead Fracture in an Implantable Cardioverter-Defibrillator: Management and Follow-Up.

Pacing Clin Electrophysiol

Implantable cardioverter defibrillators (ICDs) lead fractures are rare but serious complications, often leading to inappropriate shocks. The early occurrence of such fractures post-implantation is exceptionally uncommon.

We present a case of a 53-year-old male with hypertrophic cardiomyopathy who experienced an inappropriate shock due to a lead fracture just 4 days after ICD implantation. The fractured lead was successfully extracted and replaced using a gooseneck snare passed through an oversized TightRail with no immediate complications.

Early lead fractures can occur shortly after ICD implantation, leading to inappropriate shocks. Successful management, including extraction and reimplantation, is possible even in these early cases. Clinicians should remain vigilant, and remote monitoring can play a crucial role in the timely detection of such complications.

Five Criteria Predict Induction and Ablation of Supraventricular Tachycardia.

Journal of Cardiovascular Magnetic Resonance

Current guidelines recommend electrophysiological study (EPS) and ablation for primary treatment of supraventricular tachycardia (SVT), but there is little information to guide patient selection for the procedure. The purpose of this study was to identify preoperative features that would predict whether patients with signs or symptoms of tachycardia were likely to have SVT induced and ablated at EPS.

We performed a retrospective chart review of 1089 patients referred for EPS and ablation of SVT at 2 high volume centers. The population consisted of a derivation cohort of 810 patients and a validation cohort of 279 patients. We evaluated various clinical, EKG, and monitor features to determine which ones correlated with SVT induction or ablation.

Five preoperative findings predicted a high probability that SVT would be induced and ablated at EPS: 1. A characteristic EKG recording of SVT. 2. Termination of SVT with adenosine. 3. Termination of SVT or symptoms with vagal maneuvers. 4. An episode of SVT lasting ≥ 30 s on a monitor recording. 5. Pre-excitation on the baseline EKG. Patients exhibiting at least one of these features had a high probability of SVT induction and ablation, while those exhibiting none had a low probability (Induction, 76% vs. 19%, RR = 3.96 (2.76-5.69), p < .001; Ablation, 88% versus 26%, RR = 3.32 (2.48-4.46), p < .001). A point-based score was derived and validated that can be used to estimate the probability of induction and ablation for individual patients.

Simple criteria classify patients as having a high or low probability of SVT induction and ablation at EPS. They can be used as a guide for clinical decision making when considering invasive testing for patients with symptoms of tachycardia.

Electrocardiographic Characteristics of Brugada Syndrome Type I During Exercise Stress Test.

Journal of Cardiovascular Magnetic Resonance

Brugada syndrome (BS) is a genetic channelopathy characterized by an increased risk of sudden cardiac death (SCD) in the absence of structural heart disease. Prognostic stratification is necessary to determine which patients are candidates for implantable cardioverter defibrillator (ICD). The present study aims to evaluate EKG changes during exercise stress tests in patients with BS and to identify any poor prognosis variables.

This was an observational, case-control study. Three comparison groups were created: patients with Type 1 BS with or without prior arrhythmic events (BE and BNoE subgroups) and age- and sex-matched healthy individuals. Patients underwent EST and electrocardiographic variables were analyzed.

The study recruited 36 patients with type 1 BS, 12 with prior Event (BE) and 24 without (BNoE). Patients in the BE group, in all postexercise recordings, had lower heart rates, notably in the first minute. A significant difference was also observed in the HR drop in the recovery phase, with a greater drop in relation to maximum HR in the first minute in the group of patients who had events.

BS patients with prior events had a lower capacity to increase heart rate at peak effort and a greater proportional drop in the recovery phase. No relationship was observed between the occurrence of arrhythmic events and ST-segment elevation during the exercise test.

Limitation of Unipolar Electrograms in Guiding Successful RFCA of Idiopathic Ventricular Arrhythmias Associated With Discrete Pre-Potential.

Journal of Cardiovascular Magnetic Resonance

Activation mapping for idiopathic ventricular arrhythmias (IVAs) typically relies on identifying the earliest bipolar electrograms and unipolar electrograms characterized by an initial QS morphology preceding the intrinsic deflection. However, the utility of unipolar electrogram morphology, particularly when associated with discrete pre-potentials, in guiding IVA mapping is not well understood.

We retrospectively analyzed 537 patients who underwent successful radiofrequency catheter ablation (RFCA) for IVAs between March 2016 and August 2023. Among them, 23 patients (4.3%) exhibited discrete bipolar pre-potentials with an isoelectric line between the end of the discrete pre-potential and the onset of the QRS complex during IVAs at the successful RFCA site. These cases were included in this study.

The time interval from the onset of the discrete pre-potential to the onset of the QRS complex was 66.4 ± 18.3 ms. The duration of the isoelectric line between the end of the discrete pre-potential and the onset of the QRS complex was 36.9 ± 13.6 ms. Unipolar electrograms associated with discrete pre-potentials exhibited an initial negative morphology in only 13 out of 23 patients (56.5%). In contrast, initial positive and isoelectric configurations in unipolar electrograms were observed in two patients (8.7%) and eight patients (34.8%), respectively. Perfect pace mapping was obtained in 21 patients (91.3%). RFCA was successful at the earliest site of the pre-potential within 3.5 ± 1.5 s in all 23 patients. During the 2.4 ± 1.2 years follow-up period, only one patient (4.3%) experienced a recurrence of clinical IVAs, with no complications reported during RFCA or follow-up.

Unipolar electrograms show limited reliability in guiding the identification of IVAs origins compared to bipolar electrograms associated with discrete pre-potentials.

Exploring the Molecular Interaction Between NR2E3 and NR1D1 in Retinitis Pigmentosa: A Docking and Molecular Dynamics Study.

Clinical Laboratory

Retinitis pigmentosa (RP) is a hereditary retinal disorder that gradually leads to vision loss due to photoreceptor cell degeneration. This study aims to investigate the clinical features and genetic underpinnings of RP within a large Iranian family. Our focus centered on mutations in the NR2E3 gene, which plays a critical role in the development and maintenance of the retina.

Twenty-five family members showed symptoms of RP, and fourteen of them underwent clinical examinations conducted by geneticists and ophthalmologists. The DNA samples of five individuals diagnosed with RP from the family were subjected to whole-exome sequencing (WES) as part of the study. The candidate variant identified through WES was subsequently confirmed using bidirectional sequencing in additional family members. Additionally, in silico analysis, including molecular modeling, protein-protein docking, and molecular dynamics simulation (MD), was employed to assess potential pathogenic effects associated with the candidate variants.

Ophthalmic examination revealed night blindness, which is a common symptom among affected individuals. Genetic analysis identified a homozygous missense variant (c.934G>A/p.R311Q) in NR2E3 exon 6, which co-segregates with other affected family members. Furthermore, molecular docking analysis indicated potential disruption in the binding affinity between NR2E3 and NR1D1 proteins. In-depth, molecular dynamics analysis, considering parameters such as RMSD, RMSF, and hydrogen bonding, revealed notable differences between normal and mutant protein complexes.

Exploring the molecular interaction between NR2E3 and NR1D1 provides new insights into the pathogenic mechanism of the p.R311Q mutation in RP.

Determining the Relationship Between Sleep Problems, Shock Pain, and Shock Anxiety in Patients With ICD.

Pacing Clin Electrophysiol

This study aimed to determine the relationship between sleep problems, shock pain, and shock anxiety in patients with implantable cardioverter defibrillator (ICD) and the affecting factors.

The population of this descriptive cross-sectional study consisted of all patients who underwent ICD implantation in university hospital (N = 200), and the sample consisted of patients who met the inclusion criteria of the study (n = 132). Data were obtained using a "General Information Form", the "Florida Shock Anxiety Scale (FSAS)", the "Epworth Sleepiness Scale (ESS)", the "Pittsburgh Sleep Quality Index (PSQI)", and the "Visual Pain Scale (VPS)". The mean age of the patients was 66.13 years. The VPS was 6.40 ± 3.36; the mean FSAS score was 29.98 ± 8.46; the mean PSQI score was 8.02 ± 3.81; the mean ESS score was 7.59 ± 4.10. PSQI had a statistically significant correlation with the total FSAS score (p < 0.001) and a statistically insignificant correlation with ESS (p > 0.001). Age, sex, marital status, smoking status, cohabitants, previous ICD shocks, the status of lying on ICD, and fear of dislocation of ICD affected the total FSAS score; sex, employment status, history of heart attack, defined sleep disorder, awakening from sleep due to nightmares, and cessation of breathing during sleep affected the total PSQI score; history of previously defined sleep disorder, history of heart attack, use of medication for a sleep disorder, the pain felt when lying on ICD, and pain experienced during ICD shocks affected the total ESS score. The mean shock VPS scores differed between patients who received an ICD shock during sleep and those who were awakened by nightmares.

It was found that the shock anxiety and shock pain scores of ICD patients were above average, that they had poor sleep quality, and that their sleepiness was at the level of "normal but increased daytime sleepiness".

A narrow complex tachycardia with a short HV interval: What is the mechanism?

Pacing Clin Electrophysiol

The case was a 15-year-old male with a history of paroxysmal supraventricular tachycardia refractory to medical therapy and prior catheter. A repea...

Submyocardial Pacing Threshold Distribution During Cold Saline Application; Exploring Reversible Arrhythmia Inhibition.

Pacing Clin Electrophysiol

Cold saline application through an irrigation catheter may induce reversible inhibition of submyocardial excitation, which may be used to identify in advance an ideal site for radiofrequency (RF) energy delivery around delicate areas.

An open irrigation catheter was positioned vertically or parallel with 10-g contact on coronary perfusing porcine hearts and the contacted myocardium was cooled by cold saline at 4°C (20 mL/min). A temperature electrode was inserted 2 mm below the myocardial surface (intra-myocardial temperature at approximately 2 mm below the surface [Temp-BS]). Pacing threshold inside the ventricular wall was measured using an eight-pole electrode plunge needle inserted 5-8 mm close to the ablation catheter, and percent increase of the pacing threshold by the cold saline application (%increase-PT) was calculated.

During cooling, pacing at 10 V from the myocardial surface interrupted constant capture in 7/10 experiments in vertical and in 9/10 experiments in parallel ablation catheter contact. Minimum Temp-BS was not different in both catheter contact positions (25.9 ± 4.0°C in vertical vs. 25.4 ± 2.6°C in parallel). Large % increase-PT on the surface myocardium decreased as the myocardial depth became deeper, and > 150% increase was at a depth approximately 2-3 mm from the surface and > 120% increase around 6-7 mm from the surface. After cessation of cold saline application, the increased %increase-PT recovered to the pre-cooling values.

Cold saline application through an irrigation catheter reversibly inhibited submyocardial excitation. This simple method may have the potential to pre-determine the ideal ablation site in sensitive areas of the heart, although further studies and technological adjustments are required before clinical use.

Electrophysiological Characteristics and Mechanism of His-Bundle Pacing Guided by Electrocardiograms in Uninterrupted Real-Time Monitoring Technique.

Pacing Clin Electrophysiol

His-bundle pacing (HBP) is a pacing mode that provides near-physiological pacing and has more advantages over standard right ventricle (RV) septum pacing in positive clinical results. However, traditional HBP cannot accurately and stably place the lead tip into the His-Purkinje system. Hence, this study aimed to establish a novel strategy for HBP to strike a balance between an excellent pacing threshold and minor injuries to the conduction system.

HBP, using continuous and real-time monitoring of unipolar His-bundle (HB) electrograms along with electrocardiograms, was performed in 29 consecutive atrial fibrillation patients. We analyzed the unipolar HB intracardiac electrogram (EGM) and electrophysiological characteristics during HBP using John Jiang's connecting cable and an electrophysiology recording system. All patients were followed up for 12 months.

Of the 29 patients, 28 (96.55%) successfully received HBP. Twenty-one (75%) patients were confirmed to have the negative deflection of His potential with a negative amplitude of ≥ 0.1 mV in HB EGM. The subgroup with a deep negative deflection was recorded with an HBP threshold (0.71 ± 0.41 V), significantly lower than those thresholds with no deep negative deflection (1.83 ± 0.76 V) (p < 0.05). The selective HBP rate was significantly different between the two groups: 20 (95.24%) in the deep negative deflection group and three (42.86%) in the non-deep negative deflection group (p < 0.05); five (17.24%) patients presented right bundle branch block (RBBB) during the lead placement.

This study supports the safety and feasibility of using an uninterrupted real-time monitoring technique for HBP. An uninterrupted real-time monitoring technique can guide the accurate placement of the HB lead and may provide a balance between an excellent pacing threshold and minor injury to the conduction system.

Atrioventricular Block in the Setting of Immune Myocarditis: A Pragmatic Approach to Diagnosis and Treatment.

Pacing Clin Electrophysiol

Immunotherapy has revolutionized cancer treatment in the last decade and has significantly improved patient survival. However, immunotherapy is ass...