Initial experience with zero-fluoroscopy pulmonary vein isolation in patients with atrial fibrillation: single-center observational trial.

Pulmonary vein isolation (PVI) stands as a widely practiced cardiac ablation procedure on a global scale, conventionally guided by fluoroscopy. The concurrent application of electroanatomical mapping systems (EAMS) and intracardiac echocardiography offers a means to curtail radiation exposure. This study aimed to compare procedural outcomes between conventional and our initial zero-fluoroscopy cases in patients with paroxysmal or persistent atrial fibrillation (AF), undergoing point-by-point PVI. Our prospective observational study included 100 consecutive patients with AF who underwent point-by-point radiofrequency PVI. The standard technique was used in the first 50 cases (Standard group), while the fluoroless technique was used in the subsequent 50 patients (Zero group). The zero-fluoroscopy approach exhibited significantly shorter procedural time (59.6 ± 10.7 min vs. 74.6 ± 13.2 min, p < 0.0001), attributed to a reduced access time (17 [16; 20] min vs. 31 [23; 34.5] min, p < 0.001). Comparable results were found for the number of RF applications, total ablation energy, and left atrial dwelling time. In the Zero group, all procedures were achieved without fluoroscopy, resulting in significantly lower fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p < 0.0001) and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p < 0.0001). The acute success rate was 100%, with no major complications. Zero-fluoroscopy PVI is feasible, safe, and associated with shorter procedure times compared to the standard approach, even in cases without prior experience in zero-fluoroscopy PVI.

EFFICACY AND SAFETY OF THE SUBCUTANEOUS IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR IN PATIENTS WITH AND WITHOUT OBESITY: A META-ANALYSIS.

BACKGROUND: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as an alternative to transvenous systems for preventing sudden cardiac death. However, concerns have been raised regarding its efficacy and safety in obese individuals. OBJECTIVE: This meta-analysis aims to evaluate the efficacy and safety of the S-ICD in patients with obesity by assessing the relationship between body mass index (BMI) and clinical outcomes. METHODS: A comprehensive search of multiple databases was conducted for English-language peer-reviewed studies reporting clinical outcomes in S-ICD recipients with (BMI ≥30 kg/m2) and without obesity (BMI <30 kg/m2). Data on pre-implantation screening failure, defibrillation testing, complications, appropriate and inappropriate shocks, and survival were analysed using standard random-effect meta-analytical techniques. RESULTS: Twenty-nine studies involving 20,486 patients were included. There was no statistically significant difference in the mean BMI values of patients with failed or successful preimplantation screening (mean difference -0.60 kg/m2, 95% CI -2.06 to 0.86). Obesity was associated with higher rates of failed defibrillation testing at ≤65J (OR 2.16, 95% CI 1.39-3.35), and mal-/suboptimal positioning occurred more frequently in obese compared to non-obese patients (OR 3.37, 95% CI 1.76-6.44). Increased BMI as a continuous variable (per increase in 1 kg/m2 BMI) was associated with elevated defibrillation thresholds (OR 1.05, 95% CI 1.03-1.08), a higher risk of complications (HR 1.04, 95% CI 1.02-1.05), a trend towards increased number of appropriate shocks (HR 1.02, 95% CI 1.00-1.04), and no significant increase in the risk for inappropriate shocks (HR 1.01, 95% CI 0.99-1.03). CONCLUSION: This meta-analysis underscores the importance of considering obesity in S-ICD implantation decisions. While S-ICD remains effective in obese patients, attention to potential technical challenges and higher complication rates is warranted.

The Influence of Different Multipolar Mapping Catheter Types on Procedural Outcomes in Patients Undergoing Pulmonary Vein Isolation for Atrial Fibrillation.

(1) Background: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), multipolar mapping catheters (MMC) are often used. We aimed to compare the procedural outcomes of two MMCs, specifically a circular-shaped and a five-spline-shaped MMC. (2) Methods: We enrolled 70 consecutive patients in our prospective, observational trial undergoing PVI procedures for paroxysmal AF. The initial 35 patients underwent PVI procedures with circular-shaped MMC guidance (Lasso Group), and the procedures for the latter 35 cases were performed using five-spline-shaped MMC (PentaRay Group). (3) Results: No significant differences were identified between the two groups in total procedure time (80.2 ± 17.7 min vs. 75.7 ± 14.8 min, p = 0.13), time from femoral vein puncture to the initiation of the mapping (31.2 ± 7 min vs. 28.9 ± 6.8, p = 0.80), mapping time (8 (6; 13) min vs. 9 (6.5; 10.5) min, p = 0.73), duration between the first and last ablation (32 (30; 36) min vs. 33 (26; 40) min, p = 0.52), validation time (3 (2; 4) min vs. 3 (1; 5) min, p = 0.46), first pass success rates (89% vs. 91%, p = 0.71), left atrial dwelling time (46 (37; 53) min vs. 45 (36.5; 53) min, p = 0.56), fluoroscopy data (time: 150 ± 71 s vs. 143 ± 56 s, p = 0.14; dose: 6.7 ± 4 mGy vs. 7.4 ± 4.4 mGy, p = 0.90), total ablation time (1187 (1063; 1534) s vs. 1150.5 (1053; 1393.5) s, p = 0.49), the number of ablations (78 (73; 93) vs. 83 (71.3; 92.8), p = 0.60), and total ablation energy (52,300 (47,265; 66,804) J vs. 49,666 (46,395; 56,502) J, p = 0.35). (4) Conclusions: This study finds comparable procedural outcomes bet-ween circular-shaped and five-spline-shaped MMCs for PVI in paroxysmal AF, supporting their interchangeability in clinical practice for anatomical mapping.

Feasibility and safety of cavotricuspid isthmus ablation using exclusive intracardiac echocardiography guidance: a proof-of-concept, observational trial.

Introduction: Catheter ablation is the preferred treatment for typical atrial flutter (AFl), but it can be challenging due to anatomical abnormalities. The use of 3D electroanatomical mapping systems (EAMS) has reduced fluoroscopy exposure during AFl ablation. Intracardiac echocardiography (ICE) has also shown benefits in reducing radiation exposure during AFl ablation. However, there is a lack of evidence on the feasibility of ICE-guided, zero-fluoroscopy AFl ablation without the use of EAMS. Methods: In this prospective study, we enrolled 80 patients with CTI-dependent AFl. The first 40 patients underwent standard fluoroscopy + ICE-guided ablation (Standard ICE group), while the other 40 patients underwent zero-fluoroscopy ablation using only ICE (Zero ICE group). Procedure outcomes, including acute success, procedure time, fluoroscopy time, radiation dose, and complications, were compared between the groups. Results: The acute success rate was 100% in both groups. Out of the 40 cases, the zero-fluoroscopy strategy was successfully implemented in 39 cases (97.5%) in the Zero ICE group. There were no significant differences in procedure time [55.5 (46.5; 66.8) min vs. 51.5 (44.0; 65.5), p = 0.50] and puncture to first ablation time [18 (13.5; 23) min vs. 19 (15; 23.5) min, p = 0.50] between the groups. The Zero ICE group had significantly lower fluoroscopy time [57 (36.3; 90) sec vs. 0 (0; 0) sec, p < 0.001] and dose [3.17 (2.27; 5.63) mGy vs. 0 (0; 0) mGy, p < 0.001] compared to the Standard ICE group. Total ablation time was longer in the Standard ICE group [597 (447; 908) sec vs. 430 (260; 750), p = 0.02], but total ablation energy [22,458 (14,836; 31,116) Ws vs. 17,043 (10,533; 29,302) Ws, p = 0.10] did not differ significantly. First-pass bidirectional conduction block of the CTI and acute reconnection rates were similar between the groups. No complications or recurrences were observed during the follow-up period. Conclusion: Our study suggests that zero-fluoroscopy CTI ablation guided solely by ICE for AFl is feasible and safe. Further investigation is warranted for broader validation.

Intracardiac Echocardiography Guidance Improves Procedural Outcomes in Patients Undergoing Cavotricuspidal Isthmus Ablation for Typical Atrial Flutter.

Atrial flutter (AFL) represents a prevalent variant of supraventricular tachycardia, distinguished by a macro-reentrant pathway encompassing the cavotricuspid isthmus (CTI). Radiofrequency (RF) catheter ablation stands as the favored therapeutic modality for managing recurring CTI-dependent AFL. Intracardiac echocardiography (ICE) has been proposed as a method to reduce radiation exposure during CTI ablation. This study aims to comprehensively compare procedural parameters between ICE-guided CTI ablation and fluoroscopy-only procedures. A total of 370 consecutive patients were enrolled in our single-center retrospective study. In 151 patients, procedures were performed using fluoroscopy guidance only, while 219 patients underwent ICE-guided CTI ablation. ICE guidance significantly reduced fluoroscopy time (73 (36; 175) s vs. 900 (566; 1179) s; p < 0.001), fluoroscopy dose (2.45 (0.6; 5.1) mGy vs. 40.5 (25.7; 62.9) mGy; p < 0.001), and total procedure time (70 (52; 90) min vs. 87.5 (60; 102.5) min; p < 0.001). Total ablation time (657 (412; 981) s vs. 910 (616; 1367) s; p < 0.001) and the time from the first to last ablation (20 (11; 36) min vs. 40 (25; 55) min; p < 0.01) were also significantly shorter in the ICE-guided group. Acute success rate was 100% in both groups, and no major complications occurred in either group. ICE-guided CTI ablation in patients with AFL resulted in shorter procedure times, reduced fluoroscopy exposure, and decreased ablation times, compared to the standard fluoroscopy-only approach.

Electroanatomical Mapping System-Guided vs. Intracardiac Echocardiography-Guided Slow Pathway Ablation: A Randomized, Single-Center Trial.

Radiofrequency (RF) catheter ablation is an effective treatment option for targeting the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT). Previous data suggested that using intracardiac echocardiography (ICE) guidance could improve procedural outcomes when compared to using fluoroscopy alone. In this prospective study, we aimed to compare the effectiveness of an electroanatomical mapping system (EAMS)-guided approach with an ICE-guided approach for SP ablation. Eighty patients undergoing SP ablation for AVNRT were randomly assigned to either the ICE-guided or EAMS-guided group. If the procedural endpoint was not achieved after 8 RF applications; patients were allowed to crossover to the ICE-guided group. The ICE-guided approach reduced the total procedure time (61.0 (56.0; 66.8) min vs. 71.5 (61.0; 80.8) min, p < 0.01). However, the total fluoroscopy time was shorter (0 (0-0) s vs. 83.5 (58.5-133.25) s, p < 0.001) and the radiation dose was lower (0 (0-0) mGy vs. 3.3 (2.0-4.7) mGy, p < 0.001) with EAMS-guidance. The ICE-guided group had a lower number of RF applications (4 (3-5) vs. 5 (3.0-7.8), p = 0.03) and total ablation time (98.5 (66.8-186) s vs. 136.5 (100.5-215.8) s, p = 0.02). Nine out of 40 patients (22.5%) in the EAMS-guided group crossed over to the ICE-guided group, and they were successfully treated with similar RF applications in terms of number, time, and energy compared to the ICE-guided group. There were no recurrences during the follow-up period. In conclusion, the utilization of ICE guidance during SP ablation has demonstrated notable reductions in procedural time and RF delivery when compared to procedures guided by EAMS. In challenging cases, an early switch to ICE-guided ablation may be the optimal choice for achieving successful treatment.

Zero fluoroscopy catheter ablation for atrial fibrillation: a systematic review and meta-analysis.

Introduction: Catheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed safely with minimal radiation exposure or even without the use of fluoroscopy, thanks to advances in 3-dimensional electroanatomical mapping systems and/or intracardiac echocardiography. The aim of this study was to conduct a meta-analysis to compare the effectiveness of zero fluoroscopy (ZF) versus non-zero fluoroscopy (NZF) strategies for AF ablation procedures. Methods: Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of ZF vs. NZF approaches in patients undergoing catheter ablation for AF. We used a random-effects model to derive the mean difference (MD) and risk ratios (RR) with a 95% confidence interval (CI). Results: Our meta-analysis included seven studies comprising 1,593 patients. The ZF approach was found to be feasible in 95.1% of patients. Compared to the NZF approach, the ZF approach significantly reduced procedure time [mean difference (MD): -9.11 min (95% CI: -12.93 to -5.30 min; p < 0.01)], fluoroscopy time [MD: -5.21 min (95% CI: -5.51 to -4.91 min; p < 0.01)], and fluoroscopy dose [MD: -3.96 mGy (95% CI: -4.27 to -3.64; p < 0.01)]. However, there was no significant difference between the two groups in terms of total ablation time [MD: -104.26 s (95% CI: -183.37 to -25.14; p = 0.12)]. Furthermore, there was no significant difference in the acute [risk ratio (RR): 1.01, 95% CI: 1.00-1.02; p = 0.72] and long-term success rates (RR: 0.96, 95% CI: 0.90-1.03; p = 0.56) between the ZF and NZF methods. The complication rate was 2.76% in the entire study population and did not differ between the groups (RR: 0.94, 95% CI: 0.41-2.15; p = 0.89). Conclusion: The ZF approach is a feasible method for AF ablation procedures. It significantly reduces procedure time and radiation exposure without compromising the acute and long-term success rates or complication rates.

Ultrasound guidance for femoral venous access in patients undergoing pulmonary vein isolation: A quasi-randomized study.

INTRODUCTION: Routine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized-trial data. METHODS: Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi-random allocation to either US-guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US-guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation). RESULTS: Of the 457 patients 199 were allocated to the US-guided puncture group, while the conventional, palpation-based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p < .0001), including both major (4.26% vs. 1.01%, p = .038) and minor (7.36% vs. 1.01%, p = .001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US-guided puncture group (5.04% vs. 1.01%, p = .032). CONCLUSION: The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi-randomized comparison strongly supports adapting routine use of US for AF ablation procedures.

Geno- and phenotypic characteristics and clinical outcomes of CACNA1C gene mutation associated Timothy syndrome, "cardiac only" Timothy syndrome and isolated long QT syndrome 8: A systematic review.

Background: Mutations in the CACNA1C gene-encoding for the major Ca2+ channel of the heart-may exhibit a variety of clinical manifestations. These include typical or atypical Timothy syndromes (TS) which are associated with multiple organ manifestations, and cardiac involvement in form of malignant arrhythmias, QTc prolongation, or AV block. "Cardiac only" Timothy syndrome (COTS) shows no extracardiac manifestation, whereas some CACNA1C gene mutations are associated with QTc prolongation alone (isolated long QT syndrome 8, LQT8). Methods: A systematic search of the literature reporting cases of CACNA1C gene mutation associated syndromes, including TS, COTS and isolated LQT8 via major databases published from 2004 through 2019 was performed. Detailed patient-level phenotypic and genotypic characteristics, as well as long-term outcome measures were collected and compared between pre-specified patient groups, defined both on phenotype and genotype. Results: A total of 59 TS, 6 COTS, and 20 isolated LQT8 index cases were identified. Apart of syndactyly or baldness, there were no major differences regarding clinical manifestations or outcome measures between TS subtypes, either defining TS subtypes on the genotype or based on the phenotype. Both subtypes were characterized by an extreme degree of QTc prolongation (median ≥600 ms) which were reflected in high major adverse cardiac event rate. On the other hand, there were marked differences between TS, COTS, and isolated LQT8. Timothy syndrome was characterized by a much earlier disease onset, much more pronounced QTc prolongation and much higher mortality rate than COTS or isolated LQT8. Similar differences were observed comparing CACNA1C exon 8/8A vs. non-exon 8/8A mutation carriers. TS showed a high degree of genetic homogeneity, as the p.Gly406Arg mutation either in exon 8 or exon 8A alone was responsible for 70% of the cases. Conclusions: Clinical phenotypes associated with mutations in the CACNA1C gene show important clinical differences. Timothy syndrome is associated with the most severe clinical phenotype and with the highest risk of morbidity and mortality. However, distinguishing TS subtypes, in any form, are not supported by our data. Systematic review registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42020184737].

Visualizable vs. standard, non-visualizable steerable sheath for pulmonary vein isolation procedures: Randomized, single-centre trial.

Introduction: Steerable sheaths (SSs) are frequently used to improve catheter contact during pulmonary vein isolation (PVI) procedures. A new type of visualizable (by electroanatomical mapping system) SS has become available in clinical treatment. Purpose: We aimed to compare procedural data of visualizable vs. non-visualizable steerable sheath assisted PVI procedures in patients with atrial fibrillation (AF). Methods: In this single-centre randomized study, we enrolled a total of 100 consecutive patients who underwent PVI due to AF. Results: A total of 100 patients were randomized into 2 groups (visualizable SS group: 50; non-visualizable SS group: 50). Acute ablation success was 100% and the rate of the first pass isolation were similar (92% vs. 89%; p = 0.88). Using visualizable SS, left atrial (LA) procedure time (53.1 [41.3; 73.1] min vs. 59.5 [47.6; 74.1] min.; p = 0.04), LA fluoroscopy time (0 [0; 0] s vs. 17.5 [5.5; 69.25] s; p < 0.01) and LA fluoroscopy dose (0 [0; 0.27] mGy vs. 0.74 [0.16; 2.34] mGy; p < 0.01) was significantly less, however, there was no difference in the total procedural time (90 ± 35.2 min vs. 99.5 ± 31.8 min; p = 0.13), total fluoroscopy time (184 ± 89 s vs. 193 ± 44 s; p = 0.79), and total fluoroscopy dose (9.12 ± 1.98 mGy vs. 9.97 ± 2.27 mGy; p = 0.76). Compared to standard, non-visualizable SS group, the number of radiofrequency ablations was fewer (69 [58; 80] vs. 79 [73; 86); p < 0.01) as well as total ablation time was reduced (1049 sec. [853; 1175] vs. 1265 sec. [1085; 1441]; p < 0.01) in the visualizable SS cohort. No major complications occurred in either group. Conclusion: Compared to the standard, non-visualizable SS, visualizable SS significantly reduces the left atrial procedure time, RF delivery and fluoroscopy exposure without compromising its safety or effectiveness in patients undergoing PVI procedures for AF.

Cardiovascular outcomes in patients treated with sodium-glucose transport protein 2 inhibitors, a network meta-analysis of randomized trials.

Background: Gliflozins altering the sodium-glucose transport protein 2 (SGLT2) in the nephron, represent alone or in combination a promising treatment option for patients with type II diabetes mellitus. In addition to glucose control, these drugs provide benefits including reduced risk of long-term cardiovascular (CV) and renal complications. Several trials evaluated gliflozins in patients with various degrees of cardiac dysfunction with heterogeneous results. Objectives: We aimed to perform a comprehensive analysis of the effect of gliflozins on CV outcomes. Methods: Systematic searches of electronic databases were conducted until September 2022. Multiple treatment network meta-analysis was performed in R. Random-effects model was used to combine risk estimates across trials calculating risk ratio (RR) with 95% confidence intervals as summary statistics. The primary endpoint of interest was the rate of heart failure-related hospitalization (HHF) and the composite of HHF with CV mortality (HHF + CVD). Secondary outcomes included major adverse cardiac events (MACE), CV- and overall mortality, myocardial infarction (MI), and stroke. Results: Twenty-nine studies randomizing 88,418 patients were identified. Gliflozins reduced the risk of HHF (RR: 0.72 [0.69; 0.76]) and HHF + CVD (RR: 0.78 [0.75; 0.82]). The risk of MACE and its component also improved significantly except for stroke. The network analyses did not explore major differences among the individual substances. The only exception was sotagliflozin which appeared to be more effective regarding HHF + CVD, stroke, and MI compared to ertugliflozin, in HHF + CVD and stroke compared to dapagliflozin, and in stroke endpoint compared to empagliflozin. Conclusion: Our meta-analysis supports a group effect of gliflozins beneficial in a wide spectrum of patients with a risk of heart failure (HF) development. In addition to the improvement of HF-related outcomes, the risk of major adverse events is also reduced with SGLT2 inhibition. Systematic review registration: [www.ClinicalTrials.gov], identifier [CRD42022358078].

Combination of antiplatelet and anticoagulant therapy, component network meta-analysis of randomized controlled trials.

Background: Despite numerous randomized clinical trials (RCT), data regarding the efficacy of antiplatelet and anticoagulant combinations are still conflicting. We aimed to analyze treatment options tested in various fields of cardiovascular prevention, regarding their efficacy and bleeding risk. Methods: Systematic searches of electronic databases were conducted until June 2022. A component network meta-analysis was performed in R. Risk estimates across trials were pooled using random-effects model selecting risk ratio (RR) with 95% confidence intervals (95% CIs) as summary statistics. The primary endpoint of interest was the rate of major cardiac adverse events (MACE). Major bleeding events were assessed as main safety endpoint. Secondary outcomes included cardiovascular- and overall mortality, myocardial infarction (MI), stent thrombosis, and stroke. Results: Fifteen studies randomizing 73,536 patients were identified. The MACE risk reflected heterogeneity among the anticoagulants with dabigatran and apixaban significantly reducing the risk of MACE (RR 0.56; 95% CI 0.39-0.80 and RR 0.75; 95% CI 0.58-0.98, respectively). Vitamin K antagonist (VKA), rivaroxaban, or edoxaban did not reduced of MACE while it was associated with a significant increase of bleeding risk (RR 1.66; 3.66, and 5.47, respectively). The direct anticoagulant (DOAC) dose reduction resulted in tendencies of fewer bleeding but higher MACE risk, while combination with aspirin was followed with increased risk for bleeding, however, remained non-significant in these cases. Conclusion: Our meta-analysis supports that the ischemic-bleeding balance is different among direct-acting oral anticoagulants (DOACs) while this is not significantly affected by the dose reduction approaches. Long-term aspirin treatment as part of the anticoagulant and dual antiplatelet regimen provides no ischemic benefit but may increase bleeding risk. Systematic review registration: [https://www.crd.york.ac.uk/prospero/], identifier [259703].

Antithrombotic therapy for secondary prevention in patients with stroke or transient ischemic attack: A multiple treatment network meta-analysis of randomized controlled trials.

OBJECTIVE: As stroke represents one of the leading causes of mortality and disability worldwide, we aimed to determine the preventive effect of different antiplatelet therapies after an ischemic stroke or transient ischemic attack. METHODS: Network meta-analysis evaluating antiplatelet regimes after an ischemic stroke or transient ischemic attack. Searches were conducted in MEDLINE, EMBASE, and Cochrane Library databases until Nov. 23, 2021, for randomized controlled trials. Direct comparisons within trials were combined with indirect evidence from other trials by using a frequentist model. An additive network meta-analysis model was used to evaluate the influence of individual components. The primary efficacy endpoint was a recurrent stroke, the main safety outcomes were the risk of major bleeding and mortality at the longest available follow-up. RESULTS: 58 randomized controlled trials (175,730 patients) were analyzed. The analysis involved 20 antithrombotic strategies including different antiplatelet agents, combinations with aspirin, and anticoagulant therapies. Cilostazol proved to be the most efficacious in reducing stroke recurrence and the risk of bleeding (RR = 0.66, 95%CI = 0.55-0.80 and RR = 0.39, 95%CI = 0.08-2.01) compared to aspirin, respectively. Intensification with combinations of aspirin with ticagrelor or clopidogrel resulted in a lower risk of stroke recurrence (RR = 0.79, 95%CI = 0.67-0.93 and RR = 0.79, 95%CI = 0.72-0.87) but carried a higher bleeding risk (RR = 3.01, 95%CI = 1.65-5.49 and RR = 1.78 95%CI = 1.49-2.13). CONCLUSION: The prognosis of patients with an ischemic stroke or transient ischemic attack is improved with antiplatelets. Cilostazol showed the best risk-benefit characteristics without trade-off with the risk of major bleeding. Improved stroke recurrence with intensified antiplatelet regimens is counterbalanced with higher bleeding risk, and consequently, mortality remains unaffected. Treatment decisions in stroke survivals should integrate the assessment of bleeding risk for better identification of patients with the highest benefit of treatment intensification. SYSTEMATIC REVIEW REGISTRATION: Prospero registration number: CRD42020197143, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197143.

Zero and Minimal Fluoroscopic Approaches During Ablation of Supraventricular Tachycardias: A Systematic Review and Meta-Analysis.

Introduction: Catheter ablations for cardiac arrhythmias are conventionally performed under fluoroscopic guidance. To guide these procedures, zero/minimal fluoroscopy (Z/MF) approaches have become available, using three-dimensional electroanatomical mapping systems. Our aim was to conduct a meta-analysis comparing these two different methods for the treatment of paroxysmal supraventricular tachycardia (SVT). Methods: Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of conventional, fluoroscopy-guided vs. Z/MF approaches in patients undergoing electrophysiology (EP) procedures for SVTs. The random-effects model was used to derive mean difference (MD) and risk ratios (RRs) with 95% confidence interval (CI). Results: Twenty-four studies involving 9,074 patients met our inclusion criteria. There was no difference between the groups in terms of acute success rate (RR = 1.00, 95% CI, 0.99-1.01; p = 0.97) and long-term success rate (RR: 1.01, 95% CI, 1.00-1.03; p = 0.13). Compared to the conventional method, zero-and-minimal fluoroscopy (Z/MF) ablation significantly reduced fluoroscopic time [MD: -1.58 min (95% CI, -2.21 to -0.96 min; p < 0.01)] and ablation time [MD: -25.23 s (95% CI: -42.04 to -8.43 s; p < 0.01)]. No difference could be detected between the two groups in terms of the procedure time [MD: 3.06 min (95% CI: -0.97 to 7.08; p = 0.14)] and the number of ablation applications [MD: 0.13 (95% CI: -0.86 to 1.11; p = 0.80)]. The complication rate was 1.59% in the entire study population and did not differ among the groups (RR: 0.68, 95% CI: 0.45-1.05; p = 0.08). Conclusions: The Z/MF approach for the catheter ablation of SVTs is a feasible method that reduces radiation exposure and ablation time without compromising the acute and long-term success or complication rates.

Is prophylactic ablation of the cavotricuspid and peri-incisional isthmus justified in patients with postoperative atrial flutter after right atriotomy?

BACKGROUND: The two most common postoperative atrial flutter (AFL) circuits after right atriotomy are the cavotricuspid isthmus (CTI) dependent and the lateral, peri-incisional. We investigated whether radiofrequency ablation (RFA) of both circuits results in more favorable long-term outcomes. METHODS: Single-center retrospective cohort study of consecutive patients who underwent RFA of AFL after open-heart surgery. The effect of surgery type and RFA strategy on AFL recurrence was evaluated. RESULTS: One hundred and forty-two patients (mean age 64.5 ± 12.7 years, 65.% male) were enrolled. Patients with right atrial (RA) flutter (n = 124) were divided into two groups based on the index RFA procedure: only one RA circuit was ablated (Group 1, n = 84, 67.7%) or both the CTI and the peri-incisional circuit ablated (Group 2, n = 40, 32.3%). The previous open-heart surgery was categorized based on the extension of the RA incision: limited (Type A) or extended (Type B) atriotomy. After a mean follow-up of 36 ± 28 months, flutter recurrence was not different among patients with limited RA atriotomy (25% vs. 22% in Groups 1A and 2A, respectively, p = 1.0). However, after type B surgery, ablation of both AFL circuits was associated with a reduced recurrence rate (63% vs. 26% in Groups 1B and 2B, respectively, p = .002). CONCLUSIONS: In patients with postoperative RA flutter after extended right atriotomy, ablation of both the CTI and the peri-incisional isthmus significantly reduces the AFL recurrence rate. Prophylactic ablation of both isthmi, even if not proven to support reentry, is reasonable in this population.

Randomized trial of intracardiac echocardiography-guided slow pathway ablation.

PURPOSE: Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS: In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS: Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS: ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.

Limitations of ventricular pacing maneuvers to differentiate orthodromic reciprocating tachycardia from atrioventricular nodal reentry tachycardia.

PURPOSE: Various ventricular pacing maneuvers have been developed to differentiate orthodromic reciprocating tachycardia (ORT) from atrioventricular nodal reentry tachycardia (AVNRT). We aimed to evaluate the diagnostic value of ventricular pacing maneuvers in patients undergoing catheter ablation for AVNRT/ORT. METHODS: Sixty patients with supraventricular tachycardia (SVT) undergoing invasive EP study were included (ORT: 31, typical AVNRT: 18, atypical AVNRT: 11). Ventricular overdrive pacing (VOP) and resetting by premature ventricular stimulation (PVS) during SVT were analyzed by 3 independent observers blinded to the ultimate diagnosis. We determined intraclass correlation coefficient (ICC) for interobserver agreement and the diagnostic accuracy of consensual results. RESULTS: Although specificity of all parameters was high (96-100%) for ORT, semi-quantitative parameters of VOP (requiring the recognition of specific ECG patterns) had lower interobserver reliability (ICC: 0.32-0.66) and sensitivity (16.1-77.4%). In contrast, most quantitative measurements of VOP and PVS showed good reproducibility (ICC: 0.93-0.95) and sensitivity (74.2-89.3%), but post-pacing interval after VOP needed correction with AV nodal conduction slowing. False negative results for diagnosing ORT were more common with left free wall vs. right free wall or septal, and slowly vs. fast-conducting septal APs. False positivity was only seen with a bystander, concealed nodo-fascicular/nodo-ventricular (NF/NV) AP in a case of AVNRT. CONCLUSIONS: No single maneuver is 100% sensitive for ORT. Semi-quantitative features have limited reproducibility and all parameters can be misleading in the case of rate-dependent delay during VOP/PVS, ORT circuits remote from the pacing site, or a bystander, concealed NF/NV AP.

Successful termination of ventricular arrhythmias with implantable cardioverter defibrillator in a patient with myotonic dystrophy / Implantálható kardioverter-defibrillátor által sikeresen megszüntetett malignus kamrai ritmuszavar dystrophia myotonicában szenvedo betegben.

Összefoglaló. A dystrophia myotonica (DM) multiszisztémás, autoszomális domináns módon öröklodo, többségében felnottkori izombetegség, melynek incidenciája 1 : 8000. A betegség kapcsán fellépo izomszöveti degeneráció a harántcsíkolt izomszövet átépülése mellett a szívizomszövetet is érinti, ami fontos oki szerepet játszik az érintett betegek csökkent várható élettartamában. A DM-ben szenvedok halálozásának közel egyharmadáért a cardiovascularis okok tehetok felelossé. Esetriportunkban egy 52 éves, korábban kritikus bradycardia és I. fokú atrioventricularis blokk miatt pacemakerimplantáción átesett, DM-mel diagnosztizált nobeteg kardiológiai utánkövetését mutatjuk be. A hirtelen szívhalál rizikóstratifikációja céljából elvégzett invazív elektrofiziológiai vizsgálat során kamrafibrilláció lépett fel, így a korábban implantált pacemakerelektródák mellé sokkelektróda került beültetésre, a pacemakerkészüléket implantálható kardioverter-defibrillátorra (ICD) cseréltük. Az 1 éves ICD-kontrollvizsgálat során azt találtuk, hogy a beültetés óta 22, tartós kamrai tachycardiával járó epizód lépett fel, melyek közül a készülék valamennyit sikeresen terminálta. Az eset bemutatásával szeretnénk rámutatni arra, hogy a magas cardiovascularis rizikócsoportba tartozó DM-betegek azonosítása kiemelkedo fontosságú lehet a hirtelen szívhalál megelozése érdekében. Orv Hetil. 2021; 162(46): 1856-1858. Summary. Myotonic dystrophy (DM) is one of the most frequent adulthood diseases of the skeletal muscles, which develops multisystemic features and shows autosomal dominant trait. In DM, tissue degeneration affects not only the skeletal, but the cardiac muscle, too. In one third of the patients, the cause of death is of cardiac origin. We report on our patient's case, who was diagnosed with DM at the age of 52, in whom episodes of critical bradycardia with first-degree atrioventricular block was detected, resulting in a pacemaker implantation. Invasive cardiac electrophysiological study was performed, during which ventricular fibrillation was registered. A shock electrode was added to the previously implanted pacemaker, enabling defibrillation in case of detection of a sustained ventricular arrhythmia. During the 1-year follow-up, 22 episodes of sustained ventricular tachycardia were identified, with the device successfully terminating the malignant arrhythmias. Our case shows that electrophysiological study and the succeeding implantation of an implantable cardiac defibrillator is highly important in identifying and terminating ventricular arrhythmias in high-risk DM patients. Orv Hetil. 2021; 162(46): 1856-1858.

Network Meta-Analysis of Ticagrelor for Stroke Prevention in Patients at High Risk for Cardiovascular or Cerebrovascular Events.

Background and Purpose: Preventive antiplatelet therapy is recommended for patients with cardiac or cerebrovascular atherosclerosis. Ticagrelor has an improved safety and efficacy profile in patients with acute coronary syndrome; however, data regarding stroke prevention remain controversial. We conducted a network meta-analysis to compare ticagrelor with other receptor antagonists (P2Y12) inhibitors and aspirin in monotherapy or combination in the treatment of patients with high risk for cardiovascular or cerebrovascular disease, defined as coronary artery disease, acute coronary syndrome, stroke or transient ischemic attack, or peripheral artery disease.Systematic searches of MEDLINE, EMBASE, and the Cochrane Library were conducted until August 1, 2020. Search terms included ticagrelor, AZD 6140, and stroke. The risk of bias was assessed using the Cochrane Collaboration assessment tool. Random-effects model was used to combine risk estimates across trials and risk ratio with 95% CIs served as summary statistics. The influence of individual components was evaluated in an additive network meta-analysis model. The primary efficacy end point was the occurrence of stroke. The safety end points included bleeding and all-cause mortality.Twenty-six randomized clinical trials comprising 124 495 patients were analyzed. When compared with controls, ticagrelor plus aspirin significantly reduced the risk of ischemic stroke by 20% (risk ratio, 0.80 [95% CI, 0.71­0.89]). Treatment with ticagrelor monotherapy did not significantly affect ischemic stroke (risk ratio, 0.88 [95% CI, 0.77­1.00]; P=0.05). Compared with aspirin alone, major bleeding was in similar ranges with antiplatelet monotherapies while the relative risk was twice higher with combined antiplatelet therapies. There was no considerable difference in the risk of mortality with ticagrelor plus aspirin (risk ratio, 0.99 [95% CI, 0.91­1.07]).Ticagrelor on top of aspirin may provide more favorable outcomes on secondary stroke prevention in patients with vascular risk factors; however, this benefit may come with the price of increased bleeding risk including intracranial bleeding.