HeartRhythm主编—陈鹏生教授语音速递（六月刊 英文版）

The featured article is titled “Racial Differences in Incidence of Atrial Fibrillation after Cryptogenic Stroke”. The authors retrospectively analyzed 416 consecutive patients undergoing insertable cardiac monitor implantation and follow-up for 1.5 years. They found that the incidence of newly detected AF is approximately double in whites compared with both blacks and Hispanics. This has important implications for the investigation and treatment of nonwhites with cryptogenic stroke.

The next article is “Blood biomarkers to detect new-onset atrial fibrillation and cardioembolism in ischemic stroke patients.”The authors prospectively collected from ischemic stroke patients multiple blood biomarkers, including NT-proBNP, d-dimer, S100β, neuron-specific enolase, vitamin D, cortisol, interleukin-6, insulin, uric acid, and albumin. Of the 515 ischemic stroke patients (mean age 61 years; 71% men), 44 (8.5%) were diagnosed with new-onset AF, and 75 (14.5%) had cardioembolism. The combination of 2 laboratory parameters and 2 or 3 biomarkers could identify patients with increased likelihood of new onset of AF and cardioembolism. Adding clinical predictors did not improve the performance of these models.

Next ups is “An Individualized Ablation Strategy to Treat Persistent Atrial Fibrillation: Core-to-Boundary Approach Guided by Charge-Density Mapping.”The authors used noncontact charge-density mapping for rapid real-time global mapping of atrial fibrillation (AF). They then compared the 2-year outcome of an individualized strategy consisting of pulmonary vein isolation plus core-to-boundary ablation (targeting the conduction pattern core with an extension to the nearest nonconducting boundary) guided by charge-density mapping, with an empirical PVI plus posterior wall electrical isolation strategy. The authors found that an individualized ablation strategy consisting of PVI plus core-to-boundary ablation guided by noncontact charge-density mapping is a feasible and effective strategy for treating persistent AF, with a favorable 24-month outcome.

Coming up next is “Oral Anticoagulants in Extremely High Risk Very Elderly (>90 years) Patients with Atrial Fibrillation.” The authors used the Taiwan National Health Insurance Research Database to identify high-risk, very elderly subjects taking oral anticoagulants (OAC) and compared them to non-OAC users for the composite net clinical endpoint of ischemic stroke, intracranial hemorrhage, major bleeding, or mortality. They found that warfarin was associated with a similar or even higher risk of composite clinical outcomes compared to non-OACs. Non-vitamin K OACs were associated with a lower risk of composite endpoint compared to warfarin or non-OACs, and their use should be considered in these high-risk, very elderly AF patients.

The following article is “Does Pulsed Field Ablation Regress Over Time? A Quantitative Temporal Analysis of Pulmonary Vein Isolation.” Pulsed field ablation (PFA) is an attractive energy source for PV isolation. However, beyond each PFA lesion's zone of irreversible electroporation and cell death, there may be a surrounding zone of reversible electroporation and cell injury that could potentially normalize with time. In a clinical trial using biphasic PFA waveform, detailed voltage maps were created using a multispline diagnostic catheter immediately after PFA and again ∼3 months later. There was no significant difference in either the left- and right-sided PV antral isolation areas or nonablated posterior wall area. The distances between low-voltage edges on the posterior wall were also not significantly different between the 2 time points. This study demonstrates that the level of PV antral isolation after PFA with a multielectrode PFA catheter persists without regression.

Next up is “Catheter Ablation of Ventricular Tachycardia in Ischemic Cardiomyopathy: Impact of Concomitant Amiodarone Therapy on Short and Long-Term Clinical Outcomes.” A total of 134 consecutive patients were included in the study. In 84 patients (63%), the ablation was performed on amiodarone; the remaining 50 patients (37%) were off amiodarone. During mean follow-up of 24 months, recurrence of any ventricular arrhythmias off antiarrhythmic drugs was 44% (37/84) in the on-amiodarone group vs 22% (11/50) in the off-amiodarone group. Although patients on amiodarone required less radiofrequency time and less need for epicardial ablation, these patients had significantly higher VT recurrence at long-term follow-up when amiodarone was discontinued.

The following article is “Ventricular tachycardia burden reduction after substrate ablation: predictors of recurrence.” The purpose of this study was to assess VT burden reduction during long-term follow-up after substrate ablation and identify predictors of VT recurrence. The authors analyzed 234 consecutive VT ablation procedures in 207 patients. After follow-up of 3.14 years, the VT recurrence rate was 41.4%. Overall, a 99.6% reduction in VT burden and a 96.3% decrease in ICD shocks were observed. Lower ejection fraction and persistence of late potentials are predictors of recurrence.

The next article is “Assessment of patients presenting with life-threatening ventricular tachyarrhythmias and suspected myocarditis: the key role of endomyocardial biopsy.” The authors enrolled 54 consecutive patients with normal ventricular function. In 31 patients, the histological diagnosis was myocarditis, while in 14 patients, focal replacement myocardial fibrosis and in 9 patients, specimens were inadequate. At a follow-up of 21 months, histological diagnosis of myocarditis and RV endocardial scar were independent predictors of sustained ventricular arrhythmias. These data highlight the need for 3D-electroanatomic mapping-guided endomyocardial biopsy in apparently healthy young patients with suspected myocarditis and ventricular arrhythmias.

Next ups is “Spatial and Transmural Properties of the Reentrant Ventricular Tachycardia Circuit in Arrhythmogenic Right Ventricular Cardiomyopathy: Simultaneous Epicardial and Endocardial Recordings”. The purpose of this study was to delineate the reentrant VT circuit with simultaneous epicardial and endocardial mapping in 23 consecutive ARVC patients. Of the 30 VT circuits, 24 were delineated. There is a consistent predominance of epicardial participation during reentry in ARVC. Only the perivalvular inflow region of the "triangle of dysplasia" had a strong propensity to harbor VT circuits, with the greatest proportion located in the inferior wall. Localized epicardial reentry may be a manifestation of earlier stage disease with a relative paucity of endocardial substrate.

The following article is “Temperature Monitoring and Temperature-driven irrigated Radiofrequency Energy Titration do not prevent thermally-induced Esophageal Lesions in Pulmonary vein isolation: A randomized study controlled by esophagoscopy before and after catheter ablation”. The purpose of this study was to study (1) the benefit of luminal esophageal temperature monitoring and (2) the impact of esophagogastroduodenoscopy. The primary endpoint was the number of ablation-induced lesions. Eight of 86 patients developed esophageal lesions. Temperature overshooting ≥42°C was associated with a higher risk for new lesions. The authors conclude that monitoring of luminal esophageal temperature does not prevent ablation-induced esophageal lesions. Patients without temperature surveillance were not at higher risk, but temperatures ≥42°C were associated with increased likelihood of mucosal lesions.

Coming up next is “Physiology-Based Electrocardiographic Criteria for Left Bundle Branch Capture”. The authors hypothesized that because LBB pacing results in physiological depolarization of the LV, then the native QRS can serve as a reference for diagnosis of LBB capture in the same patient. A total of 357 ECGs from 124 patients were analyzed: 118 with native rhythm, 124 with nonselective LBB capture, 69 with selective LBB capture, and 46 with LV septal capture. The authors compared the paced and native V6 R-wave peak time. They showed equivalency of LV activation times on ECG during native and paced LBB conduction. Therefore, if V6 R-wave peak time is longer during pacing, this finding is indicative of lack of LBB capture.

The next paper is also about LBB pacing, titled “The Relationship of Paced Left Bundle Branch Pacing Morphology with Anatomic Location and Physiologic Outcomes”. The purpose of this study was to explore pacing and physiological characteristics associated with different LBB pacing locations. The study included 68 consecutive patients with normal unpaced QRS duration and successful LBBP implantation. Patients were divided into 3 groups according to the paced QRS complex as left bundle branch trunk pacing, left posterior fascicular pacing, or left anterior fascicular pacing. Fluoroscopic imaging indicated that the lead tip was located most commonly in the basal-middle region of the septum independent of paced QRS morphology group. These data show that pacing at different sites of the LBB resulted in similar intraventricular and interventricular electrical synchrony in patients with an intact conduction system. Fluoroscopic imaging alone could not predict specific LBBP paced ECG morphology.

Next up is “Extent of peri-infarct scar on late gadolinium enhancement cardiac magnetic resonance imaging and outcome in patients with ischemic cardiomyopathy.” The authors studied 216 patients with ischemic cardiomyopathy underwent CMR imaging before primary or secondary ICD implantation and prospectively followed up the patients for 1497 days. They found that scar extent of peri-infarct border zone was significantly associated with appropriate ICD therapy. Thus, LGE-CMR parameters can identify a subgroup of patients with ischemic cardiomyopathy and an increased risk of life-threatening ventricular tachyarrhythmias.