Procedural efficiency is enhanced combining the pentaspline pulsed field ablation catheter with three-dimensional electroanatomical mapping system for pulmonary vein isolation.

BACKGROUND: Pulsed field ablation (PFA) offers a safe, non-thermal alternative for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Currently, the pentaspline PFA-system relies heavily on fluoroscopy for catheter manipulation, which poses challenges due to the complexity of left atrium anatomy. Incorporating three-dimensional electroanatomical mapping (3D-EAM) could improve procedural efficiency reducing dependency on fluoroscopy guidance. This study aims to evaluate the effects of integration of 3D-EAM with PFA during PVI. METHODS: Between September 2022 and December 2023, we retrospectively enrolled 248 patients with paroxysmal or persistent AF undergoing PVI at our center using the pentaspline PFA catheter. The control group (n = 104) received conventional PFA with fluoroscopic guidance alone, while the intervention group (n = 144) underwent PVI with PFA with 3D-EAM integration. Primary outcomes were procedural time, fluoroscopy time (FT), and dose area product (DAP). Secondary endpoints included acute procedural success and incidence of periprocedural complications. RESULTS: In the 3D-EAM-PFA group, procedural time was 63.3 ± 14.3 min, compared to 65.6 ± 14.9 min in the control group (p = 0.22). The 3D-EAM group experienced significantly reduced FT (9.7 ± 4.4 min vs. 16.7 ± 5.2 min) and DAP (119.2 ± 121.7 cGycm2 vs. 338.7 ± 229.9 cGycm2) compared to the control group, respectively (p < 0.001). Acute procedural success was achieved in all cases. No major complications were observed in either group. CONCLUSION: Integration of 3D-EAM with the pentaspline PFA catheter for PVI in AF treatment offers a promising approach, with significantly reduced fluoroscopy exposure without compromising procedural time and efficacy.

Hyperoxemia after reperfusion in cardiac arrest patients: a potential dose-response association with 30-day survival.

BACKGROUND: Hyperoxemia may aggravate reperfusion brain injury after cardiac arrest. The aim of this study was to study the associations between different levels of hyperoxemia in the reperfusion period after cardiac arrest and 30-day survival. METHODS: Nationwide observational study using data from four compulsory Swedish registries. Adult in- and out-of-hospital cardiac arrest patients admitted to an ICU, requiring mechanical ventilation, between January 2010 and March 2021, were included. The partial oxygen pressure (PaO2) was collected in a standardized way at ICU admission (± one hour) according to the simplified acute physiology score 3 reflecting the time interval with oxygen treatment from return of spontaneous circulation to ICU admission. Subsequently, patients were divided into groups based on the registered PaO2 at ICU admission. Hyperoxemia was categorized into mild (13.4-20 kPa), moderate (20.1-30 kPa) severe (30.1-40 kPa) and extreme (> 40 kPa), and normoxemia as PaO2 8-13.3 kPa. Hypoxemia was defined as PaO2 < 8 kPa. Primary outcome was 30-day survival and relative risks (RR) were estimated by multivariable modified Poisson regression. RESULTS: In total, 9735 patients were included of which 4344 (44.6%) were hyperoxemic at ICU admission. Among these, 2217 were classified as mild, 1091 as moderate, 507 as severe, and 529 as extreme hyperoxemia. Normoxemia was present in 4366 (44.8%) patients and 1025 (10.5%) had hypoxemia. Compared to the normoxemia group, the adjusted RR for 30-day survival in the whole hyperoxemia group was 0.87 (95% CI 0.82-0.91). The corresponding results for the different hyperoxemia subgroups were; mild 0.91 (95% CI 0.85-0.97), moderate 0.88 (95% CI 0.82-0.95), severe 0.79 (95% CI 0.7-0.89), and extreme 0.68 (95% CI 0.58-0.79). Adjusted 30-day survival for the hypoxemia compared to normoxemia group was 0.83 (95% CI 0.74-0.92). Similar associations were seen in both out-of-hospital and in-hospital cardiac arrests. CONCLUSION: In this nationwide observational study comprising both in- and out-of-hospital cardiac arrest patients, hyperoxemia at ICU admission was associated with lower 30-day survival.

Myocardial Performance Index Determined by Tissue Doppler Imaging in Patients With Systolic Heart Failure Predicts Poor Long-Term Prognosis: An Observational Cohort Study.

BACKGROUND: Myocardial performance index (MPI) is an echocardiographic parameter that reflects left ventricular (LV) function. MPI determined by means of tissue Doppler imaging (TDI) at different LV sites (global MPI) and its long-term prognostic implications in congestive heart failure (HF) have not been evaluated. METHODS AND RESULTS: A total of 110 patients with HF during acute hospitalization were followed for a mean of 5.0 years for survivors. The myocardial velocities at 4 different LV sites near the mitral annulus from apical views were recorded with the use of pulsed-wave TDI. From myocardial velocity profiles, the MPI at each LV site was calculated: MPI = (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. The global MPI was calculated as the mean from the 4 LV sites. Mean ejection fraction was 25%. A total of 61 patients died during the study period. On multivariate analysis, only MPI emerged as an independent predictor of mortality. With a cutoff value of 0.67, the hazard ratio for cardiovascular mortality during the follow-up period was 13 (95% confidence interval 5.03-34.44; P < .001). A cutoff MPI value of ≥0.67 identified patient mortality during the study period with a sensitivity of 86% and a specificity of 79%. CONCLUSION: Global TDI-derived MPI in patients with HF is a powerful predictor of cardiovascular mortality in patients with systolic HF.

Vulnerability to sympathetic stress does not persist in takotsubo stress cardiomyopathy.

OBJECTIVE: Our objective was to investigate whether dobutamine stress echocardiography (DSE) could induce abnormal cardiac function in takotsubo stress cardiomyopathy (TSC) patients in a stable condition after the acute attack. METHODS AND RESULTS: This was a case-control study and a substudy of the Stockholm Myocardial Infarction With Normal Coronaries (SMINC) study. Twenty-two patients with a previous episode of TSC and 22 sex- and age-matched control subjects were recruited from the SMINC study and investigated with the use of DSE. All TSC patients had a previous normal cardiovascular magnetic resonance investigation. Tissue Doppler imaging-derived time phases of the cardiac cycle were recorded to calculate myocardial performance index (MPI) to assess ventricular function. Compared with control subjects at rest, TSC patients had a slightly but significantly higher left ventricular MPI (LV-MPI; 0.53 vs 0.59; P = .01) and as a trend higher right ventricular MPI (0.38 vs 0.47; P = .08), although during DSE these variables did not differ significantly. CONCLUSION: We found no difference in standard diastolic parameters between TSC and control subjects, but a significant higher value in LV-MPI in the TSC group at rest. However, no such difference could be demonstrated during DSE between the groups, indicating that vulnerability to sympathetic stimulation does not persist in TSC patients.

The prognostic significance of right ventricular tissue Doppler parameters in patients with left ventricular systolic heart failure: an observational cohort study.

OBJECTIVES: To investigate the value of tissue Doppler imaging (TDI) measurements of right ventricular (RV) systolic and diastolic function as a predictor of long term cardiovascular outcomes in patients with left ventricular (LV) systolic heart failure. BACKGROUND: In patients with LV systolic heart failure, RV function has been shown to be an important predictor of outcome. TDI is probably a clinically useful method for assessing RV function. The studies published so far have had a rather short follow-up period and have excluded patients with atrial fibrillation. METHODS: 156 patients admitted to the cardiology department due to decompensated heart failure were included in this observational cohort study. 19% had atrial fibrillation. An echocardiographic examination was performed at entry to the study. The patients were then followed for a mean of 829 days. The primary endpoint was cardiovascular mortality or hospitalisation for decompensated heart failure. RESULTS: 43 patients (28%) died from cardiovascular causes and 55 patients (35%) patients were hospitalised. 80 patients (51%) reached the study endpoint. Only age and a combined systolic and diastolic TDI parameter (s'r + e'r < 18.5 cm/s) of the right ventricle were independent predictors of cardiovascular outcome (HR 1.99, p=0.007). CONCLUSION: A combined measure of RV systolic and diastolic function, using TDI, can be used as an independent predictor of outcome in patients with LV systolic heart failure.

Prognostic value of pulse-wave tissue Doppler parameters in patients with systolic heart failure.

The aim was to study the prognostic value of left ventricular (LV) function using pulse-wave tissue Doppler imaging (TDI) in an ordinary population with heart failure (HF). One hundred fifty-six patients hospitalized for HF and LV ejection fraction < or =40% were examined using conventional echocardiography and pulse-wave TDI for the assessment of longitudinal LV function. Mitral annular systolic and early diastolic (e') velocities were recorded from a mean of 4 annular sites from the apical 2- and 4-chamber views. Noninvasive LV filling pressure was calculated from the ratio between transmitral early inflow velocity (E) and e'. All patients were followed up for 2 years, and data from the National Registry of Deaths were collected. Mean LV ejection fraction was 24.7 +/- 7.2%. TDI recordings showed a mean mitral annular systolic velocity of 5.0 +/- 1.0 cm/s and e' velocity of 6.2 +/- 1.9 cm/s. E/e' ratio was 14.1 +/- 4.8. Thirty patients (19%) had atrial fibrillation. During follow-up, 27 patients (17%) died of a cardiovascular cause. Multivariate analysis showed that only E/e' ratio and age were predictors of cardiovascular mortality. A cut-off value for E/e' ratio >13 had sensitivity of 84% and specificity of 45% to identify patients who died within 2 years of cardiac reasons. In conclusion, in the acute stage of HF, E/e' ratio is a strong independent predictor of long-term cardiovascular mortality in an ordinary population with HF and systolic dysfunction. Systolic and diastolic velocities had no independent prognostic value.

Characteristics of left ventricular diastolic function in patients with systolic heart failure: a Doppler tissue imaging study.

OBJECTIVE: Our aim was to characterize myocardial velocity profiles in different types of diastolic dysfunction for patients with severely decreased left ventricular (LV) systolic function. METHODS: A total of 126 patients with congestive heart failure and an LV ejection fraction of 35% or less were included. Patients underwent an echocardiographic Doppler examination, with measurement of the transmitral inflow pattern, and Doppler tissue imaging of the mitral annulus. RESULTS: Compared with age-matched control subjects, the patients had decreased systolic (9.5 vs 4.9 cm/s, P < .001) and early diastolic (11.6 vs 5.6 cm/s, P < .001) mitral annular velocities. According to the transmitral inflow pattern, 56 patients had signs of a LV restrictive pattern, 36 had a pseudonormalization pattern, and 34 had an abnormal relaxation pattern. The peak systolic and early diastolic mitral annular velocities were quite similarly reduced in different diastolic groups (systolic velocities of 4.6, 5.0, and 5.3 cm/s, and early diastolic velocities of 5.7, 5.8, and 5.1 cm/s at restrictive, pseudonormal, and abnormal relaxation, respectively). The ratio of the transmitral early wave and mitral annular early velocity, an expression of LV filling pressure, was highest in the restrictive group compared with other groups (17.0, 14.6, and 11.7 in the above 3 groups, respectively, P < .001 among groups). The ratio of the transmitral early wave and mitral annular early velocity was also higher in the pseudonormal group than in a control group of patients with ejection fraction of 35% or more with signs of a normal/pseudonormal pattern (14.6 vs 9.0, P < .001). CONCLUSION: Doppler tissue imaging may enhance the estimates of diastolic dysfunction in patients with decreased LV systolic function, and help to disclose abnormal diastolic function especially in a pseudonormal group.