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Vedage NA, Cronin EM. Effect of pacing site on P wave parameters: Within-patient comparison of right atrial appendage and Bachmann's bundle. J Electrocardiol 2024; 84:9-14. [PMID: 38432160 DOI: 10.1016/j.jelectrocard.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Conventional right atrial appendage pacing (RAAp) is associated with adverse clinical outcomes mediated in part by electromechanical atrial delays. Bachmann's bundle pacing (BBp) offers more physiologic atrial activation; however, detailed analysis of pacing site on paced P wave parameters is lacking. METHODS Intraprocedural electrocardiograms of 21 consecutive patients undergoing atrial lead implantation were retrospectively analyzed and within-patient comparisons of 7 P wave parameters (P wave duration, P wave voltage, P wave area, PR interval, PR segment, PTFV1 and P wave axis) during sinus rhythm, RAAp and BBp performed. RESULTS The median basal P wave duration was prolonged at 134.5 ms (Q1,Q3: 120.5, 150.5) and similarly prolonged during RAAp at 144.0 ms (127.0, 176.0) but was significantly reduced with BBp at 98.0 ms (93.0, 116.0; p = 0.005 and p < 0.001, respectively). The median basal P wave voltage in lead II was normal at 0.11 mV (0.08, 0.15) but significantly reduced during RAAp at 0.08 mV (0.04, 0.11) and greatest during BBp at 0.16 mV (0.09, 0.19; p < 0.001 and p = 0.003, respectively). The median basal PR interval was top normal at 185.0 ms (163.0, 213.0) and similarly prolonged during RAAp at 204.0 ms (166.5, 221.0) but was significantly shortened during BBp at 163.0 ms (142.0, 208.0; p = 0.03 and p = 0.001, respectively). CONCLUSIONS BBp has favorable effects on the paced P wave parameters including marked shortening in P wave duration, increase in P wave voltage in lead II and increase in PR segment which may offer significant hemodynamic advantages over conventional RAAp.
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Affiliation(s)
- Natasha A Vedage
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Edmond M Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America.
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2
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Invers-Rubio E, Hernández-Romero I, Reventos-Presmanes J, Ferro E, Guichard JB, Regany-Closa M, Pellicer-Sendra B, Borras R, Prat-Gonzalez S, Tolosana JM, Porta-Sanchez A, Arbelo E, Guasch E, Sitges M, Brugada J, Guillem MS, Roca-Luque I, Climent AM, Mont L, Althoff TF. Regional conduction velocities determined by noninvasive mapping are associated with arrhythmia-free survival after atrial fibrillation ablation. Heart Rhythm 2024:S1547-5271(24)02390-7. [PMID: 38636930 DOI: 10.1016/j.hrthm.2024.04.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/24/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Atrial arrhythmogenic substrate is a key determinant of atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI), and reduced conduction velocities have been linked to adverse outcome. However, a noninvasive method to assess such electrophysiologic substrate is not available to date. OBJECTIVE This study aimed to noninvasively assess regional conduction velocities and their association with arrhythmia-free survival after PVI. METHODS A consecutive 52 patients scheduled for AF ablation (PVI only) and 19 healthy controls were prospectively included and received electrocardiographic imaging (ECGi) to noninvasively determine regional atrial conduction velocities in sinus rhythm. A novel ECGi technology obviating the need of additional computed tomography or cardiac magnetic resonance imaging was applied and validated by invasive mapping. RESULTS Mean ECGi-determined atrial conduction velocities were significantly lower in AF patients than in healthy controls (1.45 ± 0.15 m/s vs 1.64 ± 0.15 m/s; P < .0001). Differences were particularly pronounced in a regional analysis considering only the segment with the lowest average conduction velocity in each patient (0.8 ± 0.22 m/s vs 1.08 ± 0.26 m/s; P < .0001). This average conduction velocity of the "slowest" segment was independently associated with arrhythmia recurrence and better discriminated between PVI responders and nonresponders than previously proposed predictors, including left atrial size and late gadolinium enhancement (magnetic resonance imaging). Patients without slow-conduction areas (mean conduction velocity <0.78 m/s) showed significantly higher 12-month arrhythmia-free survival than those with 1 or more slow-conduction areas (88.9% vs 48.0%; P = .002). CONCLUSION This is the first study to investigate regional atrial conduction velocities noninvasively. The absence of ECGi-determined slow-conduction areas well discriminates PVI responders from nonresponders. Such noninvasive assessment of electrical arrhythmogenic substrate may guide treatment strategies and be a step toward personalized AF therapy.
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Affiliation(s)
- Eric Invers-Rubio
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Jana Reventos-Presmanes
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Elisenda Ferro
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Jean-Baptiste Guichard
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Cardiology, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Mariona Regany-Closa
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Berta Pellicer-Sendra
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Roger Borras
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Susanna Prat-Gonzalez
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Jose Maria Tolosana
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Andreu Porta-Sanchez
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Elena Arbelo
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Eduard Guasch
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Marta Sitges
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Josep Brugada
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Maria S Guillem
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Ivo Roca-Luque
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Lluís Mont
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Till F Althoff
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
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Tubeeckx MRL, De Keulenaer GW, Heidbuchel H, Segers VFM. Pathophysiology and clinical relevance of atrial myopathy. Basic Res Cardiol 2024; 119:215-242. [PMID: 38472506 DOI: 10.1007/s00395-024-01038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
Atrial myopathy is a condition that consists of electrical, structural, contractile, and autonomic remodeling of the atria and is the substrate for development of atrial fibrillation, the most common arrhythmia. Pathophysiologic mechanisms driving atrial myopathy are inflammation, oxidative stress, atrial stretch, and neurohormonal signals, e.g., angiotensin-II and aldosterone. These mechanisms initiate the structural and functional remodeling of the atrial myocardium. Novel therapeutic strategies are being developed that target the pathophysiologic mechanisms of atrial myopathy. In this review, we will discuss the pathophysiology of atrial myopathy, as well as diagnostic and therapeutic strategies.
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Affiliation(s)
- Michiel R L Tubeeckx
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium.
| | - Gilles W De Keulenaer
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium
- Department of Cardiology, ZNA Middelheim Hospital Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Vincent F M Segers
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
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4
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Qiu Y, Sun J, Wang Y, Jin C, Ju W, Yang G, Gu K, Liu H, Wang Z, Jiang X, Li M, Chen H, Chen M. Association between P-wave terminal force in lead V 1 and extent of left atrial low-voltage substrate in older patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01710-w. [PMID: 38030935 DOI: 10.1007/s10840-023-01710-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The P-wave terminal force in lead V1 (PTFV1) is a marker of cardiomyopathy and risk of atrial fibrillation (AF). Low-voltage area (LVA) in the left atrium (LA), which indicates underlying atrial fibrosis, could predict AF recurrence. This study aimed to investigate the correlation between PTFV1 and LVA in older patients with paroxysmal AF. METHODS From May 1, 2020, to October 31, 2021, a total of 162 patients aged 65-80 years with paroxysmal AF who underwent index ablation procedures were enrolled. PTFV1 was measured in sinus rhythm (SR) using 12-lead electrocardiograms prior to the ablation. Abnormal PTFV1 was defined as a ≥ 4 mVms depression. Additional LVA ablation beyond circumferential pulmonary vein isolation (CPVI) was performed if LVAs were found. RESULTS Among the 162 patients, 88 had a normal PTFV1 and 74 had an abnormal PTFV1 prior to ablation. There was a significant difference in LVA in patients with and without an abnormal PTFV1 (LVA, 11.0 vs. 5.1 cm2, P < 0.001; LVA burden, 8.9% vs. 4.5%, P < 0.001). PTFV1 and PTAV1 were highest in the upper tertile with extensive LVAs (P < 0.001). Multivariate analysis revealed that abnormal PTFV1 was an independent predictor of LVAs (β = 4.961; 95% CI, 2.135-7.788; P < 0.001). After a median follow-up of 23 months, the AF-free survival rate was similar between the normal PTFV1 group and the abnormal PTFV1 group (13/88 vs. 12/74, hazard ratio [HR], 0.933 [95% CI, 0.425-2.047]; P = 0.861). CONCLUSIONS Abnormal PTFV1 at baseline was independently associated with the extent of LVA in older patients with paroxysmal AF.
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Affiliation(s)
- Yue Qiu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Jinyu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yuxuan Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Caiyi Jin
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Hailei Liu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Zidun Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Xiaohong Jiang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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Cronin EM, Vedage N, Israel CW. Alternative atrial pacing site to improve cardiac function: focus on Bachmann's bundle pacing. Eur Heart J Suppl 2023; 25:G44-G55. [PMID: 37970517 PMCID: PMC10637835 DOI: 10.1093/eurheartjsupp/suad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Pacing from the right atrial appendage (RAA) prolongs the P wave duration and can induce interatrial and especially left-sided atrio-ventricular dyssynchrony. Pacing from Bachmann's bundle closely reproduces normal physiology and has the potential to avoid the electromechanical dysfunction associated with conventional RAA pacing. Interatrial conduction delay is associated with an increased risk of stroke, heart failure, and death. In addition to a reduction in atrial fibrillation, Bachmann's bundle pacing has emerging applications as a hemodynamic pacing modality. This review outlines the pathophysiology of atrial conduction disturbances and their potential remedies and provides the reader with a practical guide to implementing Bachmann's bundle pacing with an emphasis on the recapitulation of normal electrical and mechanical function.
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Affiliation(s)
- Edmond M Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Natasha Vedage
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Carsten W Israel
- Department of Medicine—Cardiology, Diabetology, and Nephrology, Bethel-Clinic, Bielefeld, Germany
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