Orthogonal high-density mapping with ventricular tachycardia isthmus analysis vs. pure substrate ventricular tachycardia ablation: A case–control study

Substrate-based ablation has become a successful technique for ventricular tachycardia (VT) ablation. High-density (HD) mapping catheters provide high-resolution electroanatomical maps and better discrimination of local abnormal electrograms. The HD Grid Mapping Catheter is an HD catheter with the ability to map orthogonal signals on top of conventional bipolar signals, which could provide better discrimination of the arrhythmic substrate. On the other hand, conventional mapping techniques, such as activation mapping, when possible, help to identify the isthmus of the tachycardia.The purpose of this study was to compare clinical outcomes after using two different VT ablation strategies: one based on extensive mapping with the HD Grid Mapping Catheter, including VT isthmus analysis, and the other based on pure substrate ablation.Forty consecutive patients undergoing VT ablation with extensive HD mapping method in the hospital clinic (November 2018-November 2019) were included. Clinical outcomes were compared with a historical cohort of 26 consecutive patients who underwent ablation using a scar dechanneling technique before 2018.The density of mapping points was higher in the extensive mapping group (2370.24 ± 920.78 vs. 576.45 ± 294.46; p < 0.001). After 1 year of follow-up, VT recurred in 18.4% of patients in the extensive mapping group vs. 34.6% of patients in the historical control group (p = 0.14), with a significantly greater reduction of VT burden: VT episodes (81.7 ± 7.79 vs. 43.4 ± 19.9%, p < 0.05), antitachycardia pacing (99.45 ± 2.29 vs. 33.9 ± 102.5%, p < 0.001), and implantable cardioverter defibrillator (ICD) shocks (99 ± 4.5 vs. 64.7 ± 59.9%, p = 0.02).The use of a method based on extensive mapping with the HD Grid Mapping Catheter and VT isthmus analysis allows better discrimination of the arrhythmic substrate and could be associated with a greater decrease in VT burden.Copyright © 2022 Vázquez-Calvo, Garre, Sanchez-Somonte, Borras, Quinto, Caixal, Pujol-Lopez, Althoff, Guasch, Arbelo, Tolosana, Brugada, Mont and Roca-Luque

Failure-free survival of the Riata implantable cardioverter-defibrillator lead after a very long-term follow-up

Aims: Riata® implantable cardioverter-defibrillator (ICD) leads from St. Jude Medical are prone to malfunction. This study aimed to describe the rate of this lead's malfunction in a very long-term follow-up. Methods: This single-centre observational study included 50 patients who received a Riata 7Fr dual-coil lead between 2003 and 2008. Follow-up was conducted both in person and remotely, and analysed at 8-month intervals. We evaluated the rates of cable externalization (CE), electrical failure (EF), and the interaction of these two complications. Structural lead failure was defined as radiographic CE. Oversensing of non-cardiac signal or sudden changes in impedance, sensing, or pacing thresholds constituted EF. Results: During a mean follow-up of 10.2 ± 2.9 years, 16 patients (32%) died. We observed lead malfunction in 13 patients (26%): three (23%) due to CE, six (46%) to EF and four (31%) to both complications. Of the malfunctioning leads, 77% failed after seven years of follow-up. The incidence rate (IR) of overall malfunction per 100 patients per year was 0.9 during the first seven years post-implantation, increased to 7.0 after the 7th year and more than doubled (to 16.7) after 10 years. Beyond seven years post-implantation, IR per 100 patient-years increased in both EF and CE (from 0.6 to 5.6 vs. 0.3 to 4.2, respectively). Presence of CE was associated with a 4-fold increase in the proportion of EF. Conclusion: The incidence of Riata ICD lead malfunction, both for EF and CE, increased dramatically after seven years and then more than doubled after 10 years post-implantation

Invasive pulmonary aspergillosis in heart transplant recipients: Is mortality decreasing

Introduction: Infection remains a major complication among heart transplant (HT) recipients, causing approximately 20% of deaths in the first year after transplantation. In this population, Aspergillus spp. can have various clinical presentations including invasive pulmonary aspergillosis (IPA), with high mortality (53-78%). Objectives: To establish the characteristics of IPA infection in HT recipients and their outcomes in our center. Methods: Among 328 HTs performed in our center between 1998 and 2016, we identified five cases of IPA. Patient medical records were examined and clinical variables were extracted. Results: All cases were male, and mean age was 62 years. The most common indication for HT was non-ischemic dilated cardiomyopathy. Productive cough was reported as the main symptom. The radiological assessment was based on chest X-ray and chest computed tomography. The most commonly reported radiographic abnormality was multiple nodular opacities in both techniques. Bronchoscopy was performed in all patients and Aspergillus fumigatus was isolated in four cases on bronchoalveolar lavage culture. Treatment included amphotericin in four patients, subsequently changed to voriconazole in three, and posaconazole in one patient, with total treatment lasting an average of 12 months. Neutropenia was found in only one patient, renal failure was observed in two patients, and concurrent cytomegalovirus infection in three patients. All patients were alive after a mean follow-up of 18 months. Conclusions: IPA is a potentially lethal complication after HT. Early diagnosis and prompt initiation of aggressive treatment are the cornerstone of better survival

Conduction system pacing vs. biventricular pacing in patients with ventricular dysfunction and AV block

Background: It is unknown whether His-Purkinje conduction system pacing (HPCSP), as either His bundle or left bundle branch pacing, could be an alternative to cardiac resynchronization therapy (BiVCRT) for patients with left ventricular dysfunction needing ventricular pacing due to atrioventricular block. The aim of the study is to compare the echocardiographic response and clinical improvement between HPCSP and BiVCRT. Methods: Consecutive patients who successfully received HPCSP were compared with a historical cohort of BiVCRT patients. Patients were 1:1 matched by age, LVEF, atrial fibrillation, renal function and cardiomyopathy type. Responders were defined as patients who survived, did not require heart transplantation and increased LVEF ≥5 points at 6-month follow-up. Results: HPCSP was successfully achieved in 92.5% (25/27) of patients. During follow-up, 8% (2/25) of HPCSP patients died and 4% (1/25) received a heart transplant, whereas 4% (1/25) of those in the BiVCRT cohort died. LVEF improvement was 10% ± 8% HPCSP versus 7% ± 5% BiVCRT (p = .24), and the percentage of responders was 76% (19/25) HPCSP versus 64% (16/25) BiVCRT (p = .33). Among survivors, the percentage of patients who improved from baseline II-IV mitral regurgitation (MR) to 0-I MR was 9/11 (82%) versus 2/8 (25%) (p = .02). Compared to those with BiVCRT, patients with HPCSP achieved better NYHA improvement: 1 point versus 0.5 (OR 0.34; p = .02). Conclusion: HPCSP in patients with LVEF ≤45% and atrioventricular block improved the LVEF and induced a response similar to that of BiVCRT. HPCSP significantly improved MR and NYHA functional class. HPCSP may be an alternative to BiVCRT in these patients. (Figure 1. Central Illustration). [Figure: see text]

Advances in cardiac resynchronization therapy: Conduction system pacing as an alternative to optimized biventricular pacing & Benefits of optimization to equalize response between women and men

Programa de Doctorat en Medicina i Recerca Translacional / Tesi realitzada a l'Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)[eng] Stimulation of the conduction system has emerged as an alternative to biventricular pacing in patients with an indication for resynchronization therapy. Until now, in the case of a failed implant due to unfavorable venous anatomy or phrenic stimulation, an epicardial placement of the electrode was necessary, through cardiac surgery. On the other hand, a third of patients do not respond to biventricular stimulation. For these reasons, an easier alternative with better results to biventricular pacing is being sought. The first part of this thesis is dedicated to comparing conduction system stimulation with biventricular pacing to find out if they produce the same degree of electrical and mechanical resynchronization, ventricular reverse remodeling and clinical outcomes. At the same time, it is intended to provide a new criterion that guarantees ventricular resynchronization with left bundle branch stimulation. The second part of this thesis is dedicated to the study of the cause why women have a better response to resynchronization therapy. It studies how the shorter PR interval that women have on the observed response and how the fusion optimization method (FOI) can equalize the response to resynchronization therapy between sexes.[cat] L’estimulació del sistema de conducció ha sorgit com una alternativa a l’estimulació biventricular en pacients amb indicació de teràpia de resincronització. Fins ara, en cas d’implant fallit per anatomia venosa no favorable o estimulació frènica, calia una col·locació epicàrdica de l’electrode, a través de cirurgia cardíaca. D’altra banda, un terç dels malalts no responen a l’estimulació biventricular. Per aquests motius ,s’està buscant una alternativa més fàcil i amb més bon resultats a l’estimulació biventricular. La primera part d’aquesta Tesi està dedicada a comparar l’estimulació del sistema de conducció amb l’estimulació biventricular per esbrinar si produeixen el mateix grau de resincronització elèctrica i mecànica, remodelat invers ventricular i resultatsclínics.Alhora es pretén aportar un nou criteri que garanteixi la resincronització ventricularamb l’estimulació de branca esquerra. La segona part d’aquesta Tesi està dedicada a l’estudi de la causa per la qual les dones presenten una millor resposta a la teràpia de resincronització. S’estudia com pot influir l’interval PR més curt que tenen les dones en la resposta observada i com el mètode d’optimització amb fusió (FOI) pot igualar la resposta a la teràpia de resincronització entre sexes

Advances in cardiac resynchronization therapy: Conduction system pacing as an alternative to optimized biventricular pacing & Benefits of optimization to equalize response between women and men

[eng] Stimulation of the conduction system has emerged as an alternative to biventricular pacing in patients with an indication for resynchronization therapy. Until now, in the case of a failed implant due to unfavorable venous anatomy or phrenic stimulation, an epicardial placement of the electrode was necessary, through cardiac surgery. On the other hand, a third of patients do not respond to biventricular stimulation. For these reasons, an easier alternative with better results to biventricular pacing is being sought. The first part of this thesis is dedicated to comparing conduction system stimulation with biventricular pacing to find out if they produce the same degree of electrical and mechanical resynchronization, ventricular reverse remodeling and clinical outcomes. At the same time, it is intended to provide a new criterion that guarantees ventricular resynchronization with left bundle branch stimulation. The second part of this thesis is dedicated to the study of the cause why women have a better response to resynchronization therapy. It studies how the shorter PR interval that women have on the observed response and how the fusion optimization method (FOI) can equalize the response to resynchronization therapy between sexes.[cat] L’estimulació del sistema de conducció ha sorgit com una alternativa a l’estimulació biventricular en pacients amb indicació de teràpia de resincronització. Fins ara, en cas d’implant fallit per anatomia venosa no favorable o estimulació frènica, calia una col·locació epicàrdica de l’electrode, a través de cirurgia cardíaca. D’altra banda, un terç dels malalts no responen a l’estimulació biventricular. Per aquests motius ,s’està buscant una alternativa més fàcil i amb més bon resultats a l’estimulació biventricular. La primera part d’aquesta Tesi està dedicada a comparar l’estimulació del sistema de conducció amb l’estimulació biventricular per esbrinar si produeixen el mateix grau de resincronització elèctrica i mecànica, remodelat invers ventricular i resultatsclínics.Alhora es pretén aportar un nou criteri que garanteixi la resincronització ventricularamb l’estimulació de branca esquerra. La segona part d’aquesta Tesi està dedicada a l’estudi de la causa per la qual les dones presenten una millor resposta a la teràpia de resincronització. S’estudia com pot influir l’interval PR més curt que tenen les dones en la resposta observada i com el mètode d’optimització amb fusió (FOI) pot igualar la resposta a la teràpia de resincronització entre sexes

In silico experiments explain the non-consistent benefit of conduction system pacing over cardiac resynchronization therapy. The need to personalize therapy

Conduction system pacing (CSP) has emerged as an alternative treatment for patients with indication for cardiac resynchronization therapy (CRT). As opposed to biventricular CRT (BIV-CRT), which is based on left epicardial stimulation, CSP aims to restore the conduction through the His-Purkinje system pacing distally to level of block. Randomized evidence with His bundle pacing (HBP)(1–3) and left bundle branch pacing (LBBP)(4,5) is not extensive compared with the available BIV-CRT data. Non-inferiority of CSP as compared to BIV-CRT has been proven in a randomized trial (LEVEL-AT)(4); furthermore, the LBBP-RESYNC trial(5) has shown greater left ventricular (LV) ejection fraction improvement with LBBP versus BiV-CRT in non-ischemic patients with left bundle branch block (LBBB)

miRNA Update: A Review Focus on Clinical Implications of miRNA in Vascular Remodeling

MicroRNAs (miRNAs) are small non-coding RNAs that regulate gene expression at the post-transcriptional level. Through specific base pairing with their targets messenger RNAs (mRNA), miRNA can modify cell phenotype and function. Several miRNAs are aberrantly expressed in diseased arteries and may influence different features of vascular remodeling, including neointimal formation and diminished re-endothelialization. This review will discuss the clinical implications of miRNAs in the field of vascular remodeling and their potential role as diagnostic and therapeutic tools. miRNA modulation offers a promising strategy for therapeutic intervention to inhibit smooth muscle cell proliferation and enhance endothelial regeneration after percutaneous coronary intervention (PCI) in order to reduce restenosis and late thrombosis

Septal Flash Correction with His-Purkinje Pacing Predicts Echocardiographic Response in Patients with Indication for Resynchronization Therapy

Background: His-Purkinje conduction system pacing (HPCSP) has been proposed as an alternative to Cardiac Resynchronization Therapy (CRT); however, predictors of echocardiographic response have not been described in this population. Septal flash (SF), a fast contraction and relaxation of the septum, is a marker of intraventricular dyssynchrony. Methods: The study aimed to analyze whether HPCSP corrects SF in patients with CRT indication, and if correction of SF predicts echocardiographic response. This retrospective analysis of prospectively collected data included 30 patients. Left ventricular ejection fraction (LVEF) was measured with echocardiography at baseline and at 6-month follow-up. Echocardiographic response was defined as increase in five points in LVEF. Results: HPCSP shortened QRS duration by 48 ± 21 ms and SF was significantly decreased (baseline 3.6 ± 2.2 mm vs. HPCSP 1.5 ± 1.5 mm p < .0001). At 6-month follow-up, mean LVEF improvement was 8.6% ± 8.7% and 64% of patients were responders. There was a significant correlation between SF correction and increased LVEF (r = .61, p = .004). A correction of ≥1.5 mm (baseline SF - paced SF) had a sensitivity of 81% and 80% specificity to predict echocardiographic response (area under the curve 0.856, p = .019). Conclusion: HPCSP improves intraventricular dyssynchrony and results in 64% echocardiographic responders at 6-month follow-up. Dyssynchrony improvement with SF correction may predict echocardiographic response at 6-month follow-up