Circulation. Arrhythmia and electrophysiology最新文献

{"title":"Empiric Nonpulmonary Vein Trigger Ablation for Management of Atrial Fibrillation: Is Cryoballoon Isolation of the Superior Vena Cava the Answer?","authors":"Fatima M Ezzeddine, Yong-Mei Cha","doi":"10.1161/CIRCEP.124.013637","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013637","url":null,"abstract":"","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013637"},"PeriodicalIF":9.1,"publicationDate":"2025-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142930724","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Empowerment in the Management of Atrial Fibrillation: The Missing Link for Improved Outcomes.","authors":"Ratika Parkash","doi":"10.1161/CIRCEP.124.013638","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013638","url":null,"abstract":"","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013638"},"PeriodicalIF":9.1,"publicationDate":"2025-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142930725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preprocedural Screening Tool to Guide Nonpulmonary Vein Trigger Testing in First-Time Atrial Fibrillation Ablation.","authors":"Alireza Oraii, Corentin Chaumont, Oriol Rodriguez-Queralto, Michal Wasiak, Munveer Thind, Carli J Peters, Erica Zado, Balaram Krishna J Hanumanthu, Timothy M Markman, Matthew C Hyman, Cory M Tschabrunn, Gustavo Guandalini, Andres Enriquez, Poojita Shivamurthy, Ramanan Kumareswaran, Michael P Riley, David Lin, Robert D Schaller, Saman Nazarian, David J Callans, Gregory E Supple, Fermin C Garcia, David S Frankel, Sanjay Dixit, Francis E Marchlinski","doi":"10.1161/CIRCEP.124.013351","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013351","url":null,"abstract":"<p><strong>Background: </strong>Patients undergoing first-time atrial fibrillation (AF) ablation can benefit from targeting non-pulmonary vein (PV) triggers. Preprocedural identification of high-risk individuals can guide planning of ablation strategy. This study aimed to create a preprocedural screening tool to identify patients at risk of non-PV triggers during first-time AF ablation.</p><p><strong>Methods: </strong>All patients who underwent first-time AF ablation at the Hospital of the University of Pennsylvania between 2018 and 2022 were identified. Those who underwent non-PV trigger provocative maneuvers or had spontaneous non-PV trigger firing were included. Non-PV triggers were defined as non-PV ectopic beats triggering AF or sustained focal atrial tachycardia that occurred spontaneously, after AF cardioversion, or after standard provocative maneuvers. The provocative maneuvers included incremental isoproterenol infusion (3, 6, 12, and 20-30 µg/min) and an atrial burst pacing protocol. Risk factors associated with non-PV triggers in a stepwise multivariable logistic regression model with backward elimination were used to create a risk score.</p><p><strong>Results: </strong>In all, 163 (8.0%) of 2038 patients had non-PV triggers during first-time AF ablation. Based on the multivariable model, we created a risk score using female sex (1 point; odds ratio [OR], 1.90 [95% CI, 1.36-2.67]), sinus node dysfunction (1 point; OR, 1.84 [95% CI, 1.04-3.24]), prior cardiac surgery (1 point; OR, 2.26 [95% CI, 1.45-3.53]), moderate to severe left atrial enlargement (2 points; OR, 3.43 [95% CI, 2.46-4.79]), and cardiac sarcoidosis/amyloidosis (4 points; OR, 7.24 [95% CI, 3.03-17.33]). Internal validation using bootstrap resampling showed an optimism-adjusted C statistic of 0.715 (95% CI, 0.678-0.751). Among all first-time AF ablations, 68.1% of procedures were low-risk for non-PV triggers (scores 0-1, 4.3% risk), 17.8% were intermediate-risk (score 2, 10.5% risk), and 14.1% were high-risk (score ≥3, 22.6% risk).</p><p><strong>Conclusions: </strong>A preprocedural screening tool can classify patients based on their risk of non-PV triggers during first-time AF ablation. This risk score can guide operators to identify patients who would benefit most from adjunctive non-PV trigger testing. However, further validation is needed to confirm these findings.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013351"},"PeriodicalIF":9.1,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142863545","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Magnetic Resonance Imaging in the Assessment of the Risk of Sudden Death in Cardiac Sarcoidosis: What Is Extensive or Significant Late Gadolinium Enhancement?","authors":"Pauli Pöyhönen, Jukka Lehtonen, Suvi Syväranta, Diana Velikanova, Henriikka Mälkönen, Piia Simonen, Hanna-Kaisa Nordenswan, Valtteri Uusitalo, Tapani Vihinen, Kari Kaikkonen, Petri Haataja, Tuomas Kerola, Tuomas T Rissanen, Ville Vepsäläinen, Aleksi Alatalo, Päivi Pietilä-Effati, Markku Kupari","doi":"10.1161/CIRCEP.124.013239","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013239","url":null,"abstract":"<p><strong>Background: </strong>Cardiac sarcoidosis involves a significant but difficult-to-define risk of sudden cardiac death (SCD). Current guidelines recommend consideration of an implantable cardioverter defibrillator for patients with extensive or significant myocardial late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging. However, extensive/significant LGE is not defined.</p><p><strong>Methods: </strong>A nationwide cardiac sarcoidosis registry was screened for patients entered before 2020 with cardiac magnetic resonance imaging done before or <3 months after diagnosis. Available studies were re-analyzed for LGE mass as a percentage of left ventricular (LV) mass and the number of LGE-positive LV segments in a 17-segment model. The occurrence of fatal or aborted SCD and ventricular tachycardia (VT) prompting therapy was recorded until the end of 2020 and subjected to cumulative incidence analyses, including competing events (LV assist device implantations, heart transplantations, and fatalities other than SCD). The predictors of SCD/VT were assessed using Fine and Gray modeling and time-dependent receiver operating characteristic analysis.</p><p><strong>Results: </strong>Altogether, 305 patients (66% women, median age 51) with clinically manifest, definite (45%) or probable cardiac sarcoidosis (55%) were analyzed. On follow-up (median, 4.0 years), 21 SCDs, 60 VTs, and 14 competing events were noted. Both LGE mass and the number of LGE segments predicted the composite of SCD/VT (<i>P</i><0.001), with receiver operating characteristic analyses identifying LGE mass ≥9.9% and ≥6 LGE segments as discriminative thresholds. At presentation, 70 patients were free of class I and class IIa implantable cardioverter defibrillator indications unrelated to LGE. Their 5-year rate of SCD/VT was 6.3% (0.0-14.8%) with LGE mass <9.9% versus 21.5% (6.5-36.6%) with higher LGE mass, and 6.9% (0.0-16.3%) with <6 LGE segments versus 20.5% (5.9-35.2%) with ≥6 segments.</p><p><strong>Conclusions: </strong>In cardiac sarcoidosis, myocardial LGE making up ≥9.9% of LV mass or affecting ≥6 LV segments may suggest prognostically significant LV involvement and a high risk of SCD. However, prospective validation of the thresholds is needed.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013239"},"PeriodicalIF":9.1,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142863544","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cryoballoon Pulmonary Vein Isolation With Versus Without Additional Right Atrial Linear Ablation for Persistent Atrial Fibrillation: The CRALAL Randomized Clinical Trial.","authors":"Daehoon Kim, Hee Tae Yu, Jaemin Shim, Junbeom Park, Yong-Soo Baek, Sang Won Park, Dae-Kyeong Kim, Young-Ah Park, Tae-Hoon Kim, Jae-Sun Uhm, Boyoung Joung, Moon-Hyoung Lee, Hui-Nam Pak","doi":"10.1161/CIRCEP.124.013408","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013408","url":null,"abstract":"<p><strong>Background: </strong>Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with those with paroxysmal AF. We investigate whether additional linear ablation from the superior vena cava to the right atrial septum and cavotricuspid isthmus ablation improves the rhythm outcome of patients with persistent AF undergoing cryoballoon PVI (Cryo-PVI).</p><p><strong>Methods: </strong>In this investigator-initiated, multicenter, randomized clinical trial, 289 patients with persistent AF refractory to antiarrhythmic drug therapy were randomized 1:1 to either Cryo-PVI with additional right atrium (RA) linear ablation or Cryo-PVI alone. The primary end point was any documented atrial arrhythmia lasting ≥30 seconds after a 3-month blanking period after ablation. The secondary end points were atrial arrhythmia recurrence or antiarrhythmic drug use after a 3-month blanking period, complications, and total procedure time.</p><p><strong>Results: </strong>During the median follow-up of 24 months (median age, 63 years; 23.9% women), the atrial arrhythmia recurrence was less frequent in the additional RA ablation group (n=50, 37.5%) than in the Cryo-PVI alone group (n=69, 53.1%; absolute difference, -15.6% [95% CI, -27.9% to -3.4%]; hazard ratio, 0.66 [95% CI, 0.46-0.94]). Antiarrhythmic drugs were prescribed after the 3-month period to 72 (49.3%) patients in the additional RA ablation group and 79 (55.2%) patients in the Cryo-PVI alone group. No difference was found in complication rate between the 2 groups. Total procedure time was longer in the additional RA ablation group (median, 88 versus 72 minutes; <i>P</i><0.001).</p><p><strong>Conclusions: </strong>Additional RA linear ablation beyond Cryo-PVI improved the ablation outcome compared with that of PVI alone in persistent AF patients.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013408"},"PeriodicalIF":9.1,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142853252","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nurse-Led Multicomponent Behavioral Activation Intervention for Patients With Atrial Fibrillation: A Randomized Controlled Trial.","authors":"Polly W C Li, Doris S F Yu, Bryan P Yan","doi":"10.1161/CIRCEP.124.013236","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013236","url":null,"abstract":"<p><strong>Background: </strong>Patients with atrial fibrillation (AF) are often ill-equipped for shared decision-making. This study investigated the effects of a patient empowerment care model on patient-reported health outcomes and treatment decision-making in patients with AF.</p><p><strong>Methods: </strong>This randomized controlled trial prospectively randomized patients with AF to receive standard care (n=194) or a 13-week nurse-led multicomponent behavioral activation intervention (n=198). The intervention consisted of risk profile assessments, empowered shared decision-making regarding the use of oral anticoagulants (OACs), empowered AF self-management, and increased access to professional advice. The primary outcome was health-related quality of life measured after the completion of the intervention (T1), while the secondary outcomes were patient-physician decision concordance regarding OAC use, actual OAC use, AF knowledge, medication adherence, anxiety, and depression.</p><p><strong>Results: </strong>The intervention group showed significantly greater improvements in health-related quality of life (β, -6.702 [95% CI, -9.556 to -3.847]; <i>P</i><0.001), AF knowledge (β, -1.989 [95% CI, -2.342 to -1.635]; <i>P</i><0.001), and medication adherence (β, 0.340 [95% CI, 0.148-0.532]; <i>P</i><0.001) at immediate post-intervention compared with the control group, and the improvements were sustained at 6 months for all outcomes. A higher proportion of patients in the intervention group were prescribed an OAC compared with the control group at 6 months (odds ratio, 5.870 [95% CI, 1.957-12.331]; <i>P</i>=0.012). No significant between-group differences were detected for patient-physician decision concordance regarding OAC use, anxiety, or depression at both time points.</p><p><strong>Conclusions: </strong>The nurse-led multicomponent behavioral activation intervention improved patient-reported outcomes and increased OAC prescription among patients with AF.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013236"},"PeriodicalIF":9.1,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142853254","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pulsed Field Ablation Using Focal Contact Force-Sensing Catheters for Treatment of Atrial Fibrillation: 1-Year Outcomes of the ECLIPSE AF Study.","authors":"Ante Anić, Thomas Phlips, Toni Brešković, Vikramaditya Mediratta, Steven Girouard, Zrinka Jurišić, Ivan Sikirić, Lucija Lisica, Pieter Koopman, Nathalie Antole, Johan Vijgen","doi":"10.1161/CIRCEP.124.012794","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.012794","url":null,"abstract":"<p><strong>Background: </strong>Pulsed field ablation (PFA) is a promising treatment for atrial fibrillation. We report 1-year freedom from atrial arrhythmia outcomes using monopolar PFA delivered through 3 commercial, contact force-sensing focal catheters.</p><p><strong>Methods: </strong>ECLIPSE AF (NCT04523545) was a prospective, single-arm, multicenter study evaluating acute and chronic safety and performance using the CENTAURI system to deliver focal PFA with TactiCath SE, StablePoint, and ThermoCool ST. Patients with paroxysmal or persistent atrial fibrillation underwent pulmonary vein (PV) isolation under deep sedation or general anesthesia and returned for remapping at 90 days to evaluate chronic durability. Freedom from atrial arrhythmia was evaluated continuously through 12 months using standard rhythm monitoring for symptomatic episodes and 24-hour Holter at 6 and 12 months.</p><p><strong>Results: </strong>Eighty-two patients (74% male, 51.2% paroxysmal, and 58.5% deep sedation) were treated. PV isolation was achieved in 100% of targeted veins (322/322) with first-pass isolation in 92.2% (297/322). There were 4 primary safety events in 4 patients (4.9%, 4/82); 1 nonembolic stroke due to exacerbated cardiac tamponade secondary to catheter perforation and 3 hemorrhagic vascular access complications. There were no incidences of adverse event fistula, diaphragmatic paralysis, MI, pericarditis, thromboembolism, PV stenosis, transient ischemic attack, or death. Eighty patients (98%) underwent remapping. Optimized PFA cohorts 3, 4, and 5 showed per-patient isolation rates of 60%, 73%, and 81% and per-PV isolation rates of 84%, 90%, and 92%, respectively. One-year freedom from atrial arrhythmia was 80.2% (95% CI, 69.7%-87.4%) for the entire patient sample, including 41 patients who underwent repeat focal PFA with the CENTAURI system at remapping.</p><p><strong>Conclusions: </strong>This study demonstrated that optimization of focal PFA with 3 contact force-sensing, solid-tip ablation catheters resulted in the progressive improvement of PV isolation durability at 3-month remapping and high freedom from atrial arrhythmia survival rates, providing a promising focal PFA treatment option integrated with current ablation workflows.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e012794"},"PeriodicalIF":9.1,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142853256","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Superior Vena Cava Isolation With Cryoballoon in AF Ablation: Randomized CAVAC AF Trial.","authors":"Víctor Castro-Urda, Melodie Segura-Dominguez, Diego Jiménez-Sánchez, Cristina Aguilera-Agudo, Paula Vela-Martín, Alvaro Lorente-Ros, Daniel García-Rodriguez, David Sánchez-Ortiz, Chinh Pham-Trung, Eusebio García-Izquierdo, Susana Mingo-Santos, Jorge Toquero-Ramos, Ignacio Fernández-Lozano","doi":"10.1161/CIRCEP.124.012917","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.012917","url":null,"abstract":"<p><strong>Background: </strong>Superior vena cava (SVC) has been considered a specific trigger in atrial fibrillation development.</p><p><strong>Methods: </strong>We investigated the efficacy and safety of combining cryoballoon pulmonary vein isolation (PVI) with SVC ablation compared with PVI alone in 100 patients with paroxysmal or non-long-standing persistent atrial fibrillation. Patients were randomly assigned to either the PVI+SVC ablation group or the PVI-only group. Each patient was given a mobile device to record a daily ECG and detect atrial tachyarrhythmias.</p><p><strong>Results: </strong>The primary end point, freedom from any atrial tachyarrhythmia recurrence between 91 and 365 days post-catheter ablation, did not significantly differ between the 2 groups (62.9% versus 72%; <i>P</i>=0.41). However, the PVI+SVC group exhibited higher rates of phrenic nerve paralysis (20.8% versus 6%; <i>P</i>=0.003) and transient sinus node injury (18.8% versus 0%; <i>P</i>=0.001) compared with the PVI-only group. The median burden of atrial tachyarrhythmia showed no significant difference (<i>P</i>=0.91).</p><p><strong>Conclusions: </strong>The addition of SVC ablation to PVI did not enhance freedom from atrial tachyarrhythmia at 12 months, and it led to increased complications. These findings do not support the routine inclusion of SVC ablation in cryoballoon procedures for first-time catheter ablation in patients with paroxysmal or non-long-standing persistent atrial fibrillation.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e012917"},"PeriodicalIF":9.1,"publicationDate":"2024-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142827402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Engineering of Generative Artificial Intelligence and Natural Language Processing Models to Accurately Identify Arrhythmia Recurrence.","authors":"Ruibin Feng, Kelly A Brennan, Zahra Azizi, Jatin Goyal, Brototo Deb, Hui Ju Chang, Prasanth Ganesan, Paul Clopton, Maxime Pedron, Samuel Ruipe Rez-Campillo, Yaanik Desai, Hugo De Larochellière, Tina Baykaner, Marco Perez, Miguel Rodrigo, Albert J Rogers, Sanjiv M Narayan","doi":"10.1161/CIRCEP.124.013023","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013023","url":null,"abstract":"<p><strong>Background: </strong>Large language models (LLMs), such as ChatGPT, excel at interpreting unstructured data from public sources, yet are limited when responding to queries on private repositories, such as electronic health records (EHRs). We hypothesized that prompt engineering could enhance the accuracy of LLMs for interpreting EHR data without requiring domain knowledge, thus expanding their utility for patients and personalized diagnostics.</p><p><strong>Methods: </strong>We designed and systematically tested prompt engineering techniques to improve the ability of LLMs to interpret EHRs for nuanced diagnostic questions, referenced to a panel of medical experts. In 490 full-text EHR notes from 125 patients with prior life-threatening heart rhythm disorders, we asked GPT-4-turbo to identify recurrent arrhythmias distinct from prior events and tested 220 563 queries. To provide context, results were compared with rule-based natural language processing and BERT-based language models. Experiments were repeated for 2 additional LLMs.</p><p><strong>Results: </strong>In an independent hold-out set of 389 notes, GPT-4-turbo had a balanced accuracy of 64.3%±4.7% out-of-the-box at baseline. This increased when asking GPT-4-turbo to provide a rationale for its answers, requiring a structured data output, and providing in-context exemplars, rose to a balanced accuracy of 91.4%±3.8% (<i>P</i><0.05). This surpassed the traditional logic-based natural language processing and BERT-based models (<i>P</i><0.05). Results were consistent for GPT-3.5-turbo and Jurassic-2 LLMs.</p><p><strong>Conclusions: </strong>The use of prompt engineering strategies enables LLMs to identify clinical end points from EHRs with an accuracy that surpassed natural language processing and approximated experts, yet without the need for expert knowledge. These approaches could be applied to LLM queries for other domains, to facilitate automated analysis of nuanced data sets with high accuracy by nonexperts.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013023"},"PeriodicalIF":9.1,"publicationDate":"2024-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142827497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Approach to the Diagnosis and Management of Complex Fascicular Ventricular Tachycardias.","authors":"Christopher X Wong, Henry H Hsia, Adam C Lee, Robert M Hayward, Coleen J Johnson, Edgar Antezana-Chavez, Pichmanil Khmao, Melvin M Scheinman","doi":"10.1161/CIRCEP.124.013450","DOIUrl":"https://doi.org/10.1161/CIRCEP.124.013450","url":null,"abstract":"<p><p>Complex ventricular tachycardias involving the fascicular system (fascicular ventricular tachycardias [FVTs]) can be challenging. In this review, we describe our approach to the diagnosis and ablation of these arrhythmias with 10 illustrative cases that involve (1) differentiation from supraventricular tachycardia; (2) assessment for atypical bundle branch reentry and other interfascicular FVTs; (3) examination of P1/P2 activation sequences in sinus rhythm, pacing, and tachycardia; and (4) entrainment techniques to establish the tachycardia mechanism and aid circuit localization. To summarize, 5 cases had prior ablation with 2 previously misdiagnosed as supraventricular tachycardia. A short His-ventricular interval supported ventricular tachycardia. Atrial stimulation could initiate and entrain 4 FVTs. P1 potentials were recorded in all cases of left posterior FVT. Entrainment at P1 and P1 to P2 connection sites at the mid-septal region, and the postablation emergence of a late P1 with decremental properties, is consistent with the left septal fascicle being the slowly conducting, retrograde limb of the left posterior FVT circuit. Ablation targeting the mid-septal left septal fascicle and P1 to P2 connection sites successfully eliminated left posterior FVT. Right ventricular apical pacing was useful in differentiating bundle branch reentry and focal FVTs from reentrant FVTs. Two cases exhibited bundle branch reentry and other interfascicular FVTs. Three cases were postinfarct FVTs involving the LPF, where pacing and entrainment at sites of conduction system potentials were able to localize sites critical for ablation, in contrast to previously unsuccessful substrate modification. In conclusion, several ventricular tachycardia mechanisms involving the fascicular system can occur in both structurally normal and abnormal hearts. A high index of suspicion is required given their rarity and potential for misdiagnosis. Once identified, we emphasize a structured approach to the diagnosis and management of FVTs to confirm the mechanism and localize suitable ablation targets involving careful recording of conduction system potentials and pacing/entrainment maneuvers.</p>","PeriodicalId":10319,"journal":{"name":"Circulation. Arrhythmia and electrophysiology","volume":" ","pages":"e013450"},"PeriodicalIF":9.1,"publicationDate":"2024-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142827372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}