Explore JACC Science Presented at Heart Rhythm 2023

The following science presented at Heart Rhythm 2023 in New Orleans, LA, was published online Thursday, May 18 in JACC and JACC: Clinical Electrophysiology. Explore all JACC Journals publications throughout the meeting on JACC.org.


Incidence, Treatment and Outcomes of Lead-Related Venous Obstruction Among Patients With CIEDs

Among 649,524 patients who underwent cardiovascular implantable electric device (CIED) implantation, one of every 20 patients developed lead-related venous obstruction. Enrico G. Ferro, MD, et al., additionally identified independent predictors of the condition, including CIEDs with >1 lead and chronic kidney disease and malignancies. The most common intervention was device extraction, which was associated with significant reductions in recurrent health care utilization (adjusted rate ratio, 0.58; 95% CI, 0.52-0.66) compared to conservative management. Learn more.

Individualized Family Screening For ARVC Risk

Using data from the Netherlands ACM Registry, Steven A. Muller, MD, et al., looked at 136 relatives at-risk of developing arrhythmogenic right ventricular cardiomyopathy (ARVC), of which 33% progressed to definite ARVC after 8.1 years of follow-up. The study authors identified symptomatic individuals (p=0.014) and those 20 to 30 years old (p=0.002) with borderline ARVC at greater risk of developing definite ARVC, noting that prioritizing these relatives for frequent follow-up may lead to more efficient patient care. Learn more.

JACC: Clinical Electrophysiology

Omnipolar vs. Bipolar Voltage Maps in Identifying PVRS in AFib

In a study evaluating the accuracy of omnipolar vs. bipolar voltage maps in identifying pulmonary vein reconnection sites (PVRS) in atrial fibrillation (AFib), Charles Butcher, BSc, PhD, et al., found that omnipolar voltage AFib maps were more accurate in detecting gaps in wide area circumferential ablation lines at PVRS. Researchers also noted that the omnipolar voltage AFib maps “improve voltage assessment by overcoming the impact of wavefront collision and fractionation.” Learn more. In an accompanying editorial comment, Amir Jadidi, MD, PhD, and Axel Loewe, PhD, add: “This is a step forward to a more universal and reproducible atrial substrate characterization and should be complemented. Yet a number of questions remain to be addressed by future studies.”

Intrinsic Antitachycardia Pacing Failure and Potential Proarrhythmic Effects

With a collection of case studies, Anvi Raina, MD, et al., document the failures and potential proarrhythmic effects of using intrinsic antitachycardia pacing, a novel, automated algorithm meant to terminate ventricular tachycardia (VT). “[Intrinsic antitachycardia pacing] is a novel feature in Medtronic Cobalt XT ICD and CRT-D models that offers individualized [antitachycardia pacing] therapy that may be more efficacious than traditional algorithms,” state the authors. “In routine clinical practice, we present this first case series of [intrinsic antitachycardia pacing] failure with detailed episode analyses.” Learn more.

Epicardial RMAT After AFib Ablation

Assessing a cohort of 44 patients with roof-dependent macro–re-entrant tachycardia (RMAT) following AFib ablation, Yiwei Lai, MD, et al., found that 34% exhibited features of epicardial RMAT. The authors note that “an explicable activation pattern with a conduction obstacle in the dome and appropriate entrainment” were essential to diagnose epicardial RMAT, a condition not uncommon following roof or posterior wall ablation. They also caution that effectiveness of posterior wall ablation may be reduced due to the risk associated with esophagus impairment. Learn more. In an accompanying editorial comment, Jeremy William, MBBS, and Aleksandr Voskoboinik, MBBS, PhD, write: “This paper from Lai, et al., joins the growing compendium of research confirming the prevalence of epicardial reconnections in recurrent atrial arrhythmias after [pulmonary vein isolation].”

Fluoropolymer-Coated Watchman FLX Shows Enhanced Thromboresistance and Endothelialization

In a canine study comparing the thrombogenicity and endothelial coverage following left atrial appendage closure with a conventional uncoated Watchman FLX vs. a novel fluoropolymer-coated Watchman FLX, Walid I. Saliba, MD, FACC, et al., found the fluoropolymer-coated device showed significantly less thrombus and reduced inflammation. Additional studies involving the mechanics of the device revealed the fluoropolymer coating binds more albumin, contributing to reduced platelet binding, less inflammation and greater endothelial coverage. Learn more.

REAL-AF Same-Day Discharge Protocol in Patients Undergoing AFib Ablation

In a prospective multicenter study, Anil B. Rajendra, MD, FACC, et al., investigated the efficacy and safety of the REAL-AF standardized same-day discharge (SDD) protocol for patients undergoing AFib ablation. They found that 86.1% of the 1,982 patients identified as potential candidates experienced successful SDD. The readmission rate for SDD vs. non-SDD was similar (0.8% vs. 0.9%; p=0.924) and the SDD group had a lower acute complication rate (0.8% vs. 2.9%; p<0.001), indicating the safety of standardized SDD after catheter ablation of paroxysmal and persistent AFib. Learn more. In an accompanying editorial comment, Marc W. Deyell, MD, MSc, and Jason G. Andrade, MD, write, “the evidence suggests that patient factors themselves are unlikely to be adequately predictive of the ability to achieve [SDD], complications following discharge are rare, and that [SDD] is safe and feasible in the vast majority of patients.”

Potential Septal Fascicle Involvement in Fascicular VT

Christopher X. Wong, MBBS, MSc, PhD, FACC, et al., review cases of left posterior fascicular VT and hypothesize involvement of the septal fascicular network in this state-of-the-art review. They maintain their work has “mechanistic and therapeutic implications for the spectrum of fascicular arrhythmias,” and that their proposed schema “provides a new framework for formulating an ablation strategy.” Learn more.

Shockwave Intravascular Lithotripsy-Facilitated Transvenous Lead Extraction

In a retrospective analysis of 65 patients (median age 67; lead well time 10.7) undergoing transvenous lead extraction at Essentia Health in Duluth, MN, from October 2019 to April 2023, 14 received intravascular lithotripsy pretreatment, resulting in an average of 25 (9-42) fewer minutes actively extracting leads (p=0.007). Christopher A. Latanich, MD, and John A. Anderson, DO, state the pretreatment was “performed using 7- and 8-mm balloons with up to 300 pulses delivered in close proximity to the leads via a retrograde approach,” leading to a “significant reduction in the amount of time spent engaging in the highest risk phase of the procedure.” Learn more.

Electric Isolation of Abnormal Substrate in Patients With ARVC

In a study looking at eight ARVC patients with extensive right ventricular free wall (RVFW) abnormal substrate, Nan Wu, MD, et al., examine the feasibility and efficacy of RVFW abnormal substrate isolation to control VT. Electrical isolation of abnormal substrate was successful in five of eight patients (62.5%) using an endocardial approach alone and three of eight patients (37.5%) using a combination of endocardial and epicardial approaches. While VT was induced in six patients before the procedure, all eight patients were noninducible following ablation, with seven of eight patients (87.5%) remaining free of sustained VT throughout a median 43-month follow-up period. Learn more.

Conduction Velocity Dispersion Predicts Post-Infarct VT Circuit Sites; Associated With Lipomatous Metaplasia

In a study comparing the association of conduction velocity dispersion vs. repolarization dispersion with VT circuit sites among 33 post-infarct patients, Lingyu Xu, MD, PhD, et al., found that “regional [conduction velocity] dispersion more strongly predicts VT circuit sites than repolarization dispersion,” and identified lipomatous metaplasia as “a critical substrate for [conduction velocity] dispersion.” Learn more.

SAFER Epicardial Access Approach Associated With Lower Complication Rates

In a multicenter study, Jorge E. Romero, MD, FACC, et al., included 105 patients undergoing epicardial access using the SAFER technique from June 2021 to February 2023 with 93.4% of cases for VT ablation, 5.7% for left atrial appendage closure and 0.9% for phrenic nerve displacement. Epicardial access was successful in all patients, with no cases of right ventricular perforation, major bloody pericardial effusion or bleeding requiring surgical intervention. With an overall complication rate of 0.9%, the study authors report that the SAFER epicardial access approach “is associated with lower complication rates than previously reported techniques for [epicardial access].” Learn more.

Improved Outcomes For AFib Ablation With High-Frequency Low-Tidal-Volume Ventilation

Jose Osorio, MD, FACC, et al., present a prospective multicenter study that found the use of high-frequency, low-tidal-volume ventilation during paroxysmal AFib ablation, as opposed to standard ventilation, was associated with shorter procedure times (66 [IQR, 31] vs. 80 [IQR, 49] minutes; p<0.001), with a higher incidence of first-pass pulmonary vein isolation (66.6% vs. 63.8%; p=0.036). At 12 months, study authors saw a 6.3% absolute reduction in all-atrial arrhythmia recurrence for the high-frequency, low-tidal volume cohort, along with a lower rate of AFib-related symptoms (12.5% vs. 18.9%; p=0.046) and AFib-related hospitalizations (1.4% vs. 4.7%; p=0.043). Learn more.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Pericardial Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement

Keywords: Hospitalization, Metaplasia, Infarction, Lithotripsy, Tachycardia, Ventricular, Retrospective Studies, Pericardial Effusion, Tidal Volume, Animals, Dogs, Multicenter Studies as Topic, Inflammation, Albumins, Thrombosis, Catheter Ablation, Prospective Studies, Patient Readmission, Patient Discharge, Fluorocarbon Polymers, Algorithms, Esophagus, Tachycardia, Prevalence, Atrial Fibrillation, Electrophysiology, Renal Insufficiency, Chronic, Registries, Netherlands, Follow-Up Studies, Conservative Treatment, Adult, Young Adult

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