Congenital aortic stenosis in adults: rate of progression and predictors of clinical outcome: Reply

Dear Editor,We thank Dr. Ramaraj for his interest in our analysis on the progression of congenital aortic stenosis. Age should be regarded as an important risk factor for faster stenosis progression. The mechanism for faster progression is probably valve calcification occurring at an earlier age, promoted by the abnormal mechanical and shear stresses associated with a bicuspid aortic valve. Recent insights into the pathogenesis of calcification of the aortic valve suggest that this is an active, rather than a passive process, with features reminiscent of atherosclerosis. Inflammation, lipid infiltration, dystrophic calcification, ossification, and endothelial dysfunction have been observed in both diseases. [...

Congenital Aortic Stenosis in Adults: Update on clinical outcome, diagnostic methods and pregnancy

Background and aim of the study: The pulmonary autograft has been recommended as the valve of choice for aortic valve replacement (AVR) in young women contemplating pregnancy. However, current information on maternal and perinatal outcome of pregnancy in women with pulmonary autograft valve replacement is limited. Methods: Using a nationwide Dutch registry (CONCOR) and a local Belgian tertiary care centre database, 17 women (age range: 18-45 years) with pulmonary autograft valve replacement were enrolled into the study. Twelve pregnancies were observed among five different women, including one miscarriage and one elective abortion. Results: Clinically significant (non-)cardiac complications were documented in two of 10 completed pregnancies. Complications included: (I) placental abruption necessitating Cesarean delivery at 29 weeks’ gestation, further complicated by postpartum hemorrhage; and (II) preterm premature rupture of the membranes resulting in premature delivery at 29 weeks’ gestation with postpartum demise of the immature born child. Two women reported primary female infertility, but both became pregnant after hormonal substitution therapy. Four women reported irregularities of their natural menstrual cycle (menorrhagia, dysmenorrhea, polymenorrhea, oligomenorrhea, or amenorrhea). Conclusions: Successful pregnancy in women with pulmonary autograft valve replacement is possible, although serious and clinically significant events occurred during gestation. Infertility and menstrual cycle disorders appear to be more prevalent

Comparison of the acute outcome of two cryoballoon technologies for pulmonary vein isolation:An updated systematic review and meta-analysis

Initial experience suggests that the POLARx cryoballoon system (Boston Scientific) has a similar procedural efficacy and safety as Arctic Front Advance Pro (AFA-Pro, Medtronic). We performed an updated systematic review and meta-analysis comparing POLARx and AFA-Pro. Embase, MEDLINE, Web of Science, Cochrane, and Google Scholar databases were searched until 12/01/2022 for studies comparing POLARx versus AFA-Pro in patients undergoing pulmonary vein (PV) isolation for AF. A total of 8 studies, involving 1146 patients from 11 European centers were included (POLARx n = 317; AFA-Pro n = 819). There were no differences in acute PV isolation, procedure time, fluoroscopy time, ablation time, minimal esophageal temperature, and risk of phrenic nerve palsy or thromboembolic events. Balloon nadir temperatures were lower for POLARx in all PVs. Compared with AFA-Pro, POLARx had a higher rate of first freeze isolation in the left inferior PV (LIPV) (odds ratio [OR]: 2.60; 95 % confidence interval [CI]: 1.06 to 6.43; P = 0.04), higher likelihood of time-to-isolation (TTI) recording in LIPV (OR: 2.91; 95 % CI: 1.54 to 5.49; P = 0.001) and right inferior PV (OR: 3.23; 95 % CI: 1.35 to 7.74; P = 0.008). In contrast, the TTI in LIPV was longer with POLARx in comparison to AFA-Pro (mean difference: 7.61 sec; 95 % CI 2.43 to 12.8 sec; P = 0.004). In conclusion, POLARx and AFA-Pro have a similar acute outcome. Interestingly, there was a higher rate of TTI recording in the inferior PVs with POLARx. This updated meta-analysis provides new safety data on esophageal temperature and thromboembolic events

Pathophysiological Mechanisms of Premature Ventricular Complexes

Premature ventricular complexes (PVCs) are the most common ventricular arrhythmia. Despite the high prevalence, the cause of PVCs remains elusive in most patients. A better understanding of the underlying pathophysiological mechanism may help to steer future research. This review aims to provide an overview of the potential pathophysiological mechanisms of PVCs and their differentiation

Acute human defibrillation performance of a subcutaneous implantable cardioverter-defibrillator with an additional coil electrode

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) delivers 80 J shocks from an 8 cm left-parasternal coil to a 59 cm3 left lateral pulse generator (PG). A system that defibrillates with lower energy could significantly reduce PG size. Computer modeling and animal studies suggested that a second shock coil either parallel to the left-parasternal coil or transverse from the xiphoid to the PG pocket would significantly reduce the defibrillation threshold. Objective: The purpose of this study was to acutely assess the defibrillation efficacy of parallel and transverse configurations in patients receiving an S-ICD. Methods: Testing was performed in patients receiving a conventional S-ICD system. Success at 65 J was required before investigational testing. A second electrode was temporarily inserted from the xiphoid incision connected to the PG with an investigational Y-adapter. Phase 1 (n = 11) tested the parallel configuration. Phase 2 (n = 21) tested both parallel and transverse configurations in random order.Results: This study enrolled 35 patients (28 males (80%); mean age 51 ± 17 years; left ventricular ejection fraction 40% ± 15%; body mass index 26 ± 4 kg/m2; prior myocardial infarction 46%; congestive heart failure 49%; cardiomyopathy 63%). Compared to the conventional S-ICD system, mean shock impedance decreased for both parallel (69 ± 15 Ω vs 86 ± 20 Ω; n = 33; P &lt; .001) and transverse (56 ± 14 Ω vs 81 ± 21 Ω; n = 20; P &lt; .001) configurations. Shock success rates at 20, 30, and 40 J were 55%, 79%, 97%, and 25%, 70%, 90% for parallel and transverse configurations, respectively. Defibrillation threshold testing was well tolerated with no serious adverse events. Conclusion: Adding a second shock coil, particularly in the parallel configuration, significantly reduced the impedance and had a high likelihood of defibrillation success at energies ≤40 J. This may enable the development of a smaller S-ICD.</p

Reducing radiation exposure in second-generation cryoballoon ablation without compromising clinical outcome

Purpose: Pulmonary vein isolation (PVI) using cryoballoon (CB) ablation is associated with an increased radiation exposure compared with radiofrequency ablation. Previous studies showed that radiation exposure in CB PVI can be reduced by optimizing the fluoroscopy protocol without comprising acute efficacy and safety. We evaluated the mid-term outcome of a modified fluoroscopy protocol in patients undergoing CB PVI. Methods: The study population comprised 90 consecutive patients who underwent second-generation CB-based PVI. The first 46 patients underwent CB PVI with conventional fl