Expanding the clinical spectrum of biglycan-related Meester-Loeys syndrome

Pathogenic loss-of-function variants in BGN, an X-linked gene encoding biglycan, are associated with Meester-Loeys syndrome (MRLS), a thoracic aortic aneurysm/dissection syndrome. Since the initial publication of five probands in 2017, we have considerably expanded our MRLS cohort to a total of 18 probands (16 males and 2 females). Segregation analyses identified 36 additional BGN variant-harboring family members (9 males and 27 females). The identified BGN variants were shown to lead to loss-of-function by cDNA and Western Blot analyses of skin fibroblasts or were strongly predicted to lead to loss-of-function based on the nature of the variant. No (likely) pathogenic missense variants without additional (predicted) splice effects were identified. Interestingly, a male proband with a deletion spanning the coding sequence of BGN and the 5' untranslated region of the downstream gene (ATP2B3) presented with a more severe skeletal phenotype. This may possibly be explained by expressional activation of the downstream ATPase ATP2B3 (normally repressed in skin fibroblasts) driven by the remnant BGN promotor. This study highlights that aneurysms and dissections in MRLS extend beyond the thoracic aorta, affecting the entire arterial tree, and cardiovascular symptoms may coincide with non-specific connective tissue features. Furthermore, the clinical presentation is more severe and penetrant in males compared to females. Extensive analysis at RNA, cDNA, and/or protein level is recommended to prove a loss-of-function effect before determining the pathogenicity of identified BGN missense and non-canonical splice variants. In conclusion, distinct mechanisms may underlie the wide phenotypic spectrum of MRLS patients carrying loss-of-function variants in BGN.

Impact of Left Atrial Posterior Wall Ablation During Pulsed-Field Ablation for Persistent Atrial Fibrillation

BACKGROUND

Pulmonary vein isolation (PVI) alone is insufficient to treat many patients with persistent atrial fibrillation (PersAF). Adjunctive left atrial posterior wall (LAPW) ablation with thermal technologies has revealed lack of efficacy, perhaps limited by the difficulty in achieving lesion durability amid concerns of esophageal injury.

OBJECTIVES

This study aims to compare the safety and effectiveness of PVI + LAPW ablation vs PVI in patients with PersAF using pulsed-field ablation (PFA).

METHODS

In a retrospective analysis of the MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-approval Clinical Use of Pulsed Field Ablation) registry, we studied consecutive PersAF patients undergoing post-approval treatment with a pentaspline PFA catheter. The primary effectiveness outcome was freedom from any atrial arrhythmia of ≥30 seconds. Safety outcomes included the composite of acute and chronic major adverse events.

RESULTS

Of the 547 patients with PersAF who underwent PFA, 131 (24%) received adjunctive LAPW ablation. Compared to PVI-alone, patients receiving adjunctive LAPW ablation were younger (65 vs 67 years of age, P = 0.08), had a lower CHA2DS2-VASc score (2.3 ± 1.6 vs 2.6 ± 1.6, P = 0.08), and were more likely to receive electroanatomical mapping (48.1% vs 39.0%, P = 0.07) and intracardiac echocardiography imaging (46.1% vs 17.1%, P < 0.001). The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmias was not statistically different between groups in the full (PVI + LAPW: 66.4%; 95% CI: 57.6%-74.4% vs PVI: 73.1%; 95% CI: 68.5%-77.2%; P = 0.68) and propensity-matched cohorts (PVI + LAPW: 71.7% vs PVI: 68.5%; P = 0.34). There was also no significant difference in major adverse events between the groups (2.2% vs 1.4%, respectively, P = 0.51).

CONCLUSIONS

In patients with PersAF undergoing PFA, as compared to PVI-alone, adjunctive LAPW ablation did not improve freedom from atrial arrhythmia at 12 months.

Pulmonary vein isolation by visually guided laser balloon ablation: single-center 5-year follow-up results

BACKGROUND

Visually guided laser balloon (VGLB) ablation is a balloon-based treatment for atrial fibrillation (AF) that uses a titratable laser energy source to perform pulmonary vein isolation (PVI), allowing for real-time visualization of target tissue and ablation lesions through an endoscopic camera. Few long-term data on this technique are currently available. This report presents acute efficacy, procedural data, complication rates, and long-term AF-free survival up to 5 years post-ablation.

METHODS

In this single-center, retrospective, observational report, 152 patients (72.4% male, mean age 60.6 ± 9.7 years, 62.5% paroxysmal AF, 598 pulmonary veins in total) treated with the first-generation VGLB system between 2014 and 2016 were included for analysis. AF ablation consisted of PVI only.

RESULTS

Acute PVI was achieved in 98.2% of veins, with first-pass isolation in 92.5%. Procedure duration of 129 min [IQR 113-150], fluoroscopy time of 15 min [IQR 11-20], and dose area product of 5016 mGy·cm2 [IQR 3603-8711] were recorded. During a median follow-up of 51 months [IQR 45-57], 74.3% of patients remained free of AF (78.8% for paroxysmal and 65.3% for persistent AF, p = 0.108). Freedom of AF at 1, 2, 3, and 4 years follow-up was 88.2%, 82.2%, 78.9%, and 74.8%, respectively. PV reconnections were identified in only 46.9% of redo procedures. The median number of PV reconnections during redo procedures was 0 [IQR 0-2]. Anti-arrhythmic drug use was significantly reduced after ablation (p < 0.001). The most commonly reported complications were minor vascular complications (4.6%) and transient phrenic nerve paralysis (3.3%).

CONCLUSIONS

First-generation VGLB ablation demonstrated high acute isolation rates, reasonable procedure times and low complication rates. Long-term freedom from AF was 78.8% for paroxysmal AF and 65.3% for persistent AF, performing PVI only.

Clinical Outcomes by Sex After Pulsed Field Ablation of Atrial Fibrillation

Importance

Previous studies evaluating the association of patient sex with clinical outcomes using conventional thermal ablative modalities for atrial fibrillation (AF) such as radiofrequency or cryoablation are controversial due to mixed results. Pulsed field ablation (PFA) is a novel AF ablation energy modality that has demonstrated preferential myocardial tissue ablation with a unique safety profile.

Objective

To compare sex differences in patients undergoing PFA for AF in the Multinational Survey on the Methods, Efficacy, and Safety on the Postapproval Clinical Use of Pulsed Field Ablation (MANIFEST-PF) registry.

Design, Setting, and Participants

This was a retrospective cohort study of MANIFEST-PF registry data, which included consecutive patients undergoing postregulatory approval treatment with PFA to treat AF between March 2021 and May 2022 with a median follow-up of 1 year. MANIFEST-PF is a multinational, retrospectively analyzed, prospectively enrolled patient-level registry including 24 European centers. The study included all consecutive registry patients (age ≥18 years) who underwent first-ever PFA for paroxysmal or persistent AF.

Exposure

PFA was performed on patients with AF. All patients underwent pulmonary vein isolation and additional ablation, which was performed at the discretion of the operator.

Main Outcomes and Measures

The primary effectiveness outcome was freedom from clinically documented atrial arrhythmia for 30 seconds or longer after a 3-month blanking period. The primary safety outcome was the composite of acute (<7 days postprocedure) and chronic (>7 days) major adverse events (MAEs).

Results

Of 1568 patients (mean [SD] age, 64.5 [11.5] years; 1015 male [64.7%]) with AF who underwent PFA, female patients, as compared with male patients, were older (mean [SD] age, 68 [10] years vs 62 [12] years; P < .001), had more paroxysmal AF (70.2% [388 of 553] vs 62.4% [633 of 1015]; P = .002) but had fewer comorbidities such as coronary disease (9% [38 of 553] vs 15.9% [129 of 1015]; P < .001), heart failure (10.5% [58 of 553] vs 16.6% [168 of 1015]; P = .001), and sleep apnea (4.7% [18 of 553] vs 11.7% [84 of 1015]; P < .001). Pulmonary vein isolation was performed in 99.8% of female (552 of 553) and 98.9% of male (1004 of 1015; P = .90) patients. Additional ablation was performed in 22.4% of female (124 of 553) and 23.1% of male (235 of 1015; P = .79) patients. The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was similar in male and female patients (79.0%; 95% CI, 76.3%-81.5% vs 76.3%; 95% CI, 72.5%-79.8%; P = .28). There was also no significant difference in acute major AEs between groups (male, 1.5% [16 of 1015] vs female, 2.5% [14 of 553]; P = .19).

Conclusion and Relevance

Results of this cohort study suggest that after PFA for AF, there were no significant sex differences in clinical effectiveness or safety events.

Pulsed field ablation using focal contact force-sensing catheters for treatment of atrial fibrillation: acute and 90-day invasive remapping results

AIMS

Pulsed field ablation (PFA) has emerged as a promising alternative to thermal ablation for treatment of atrial fibrillation (AF). We report performance and safety using the CENTAURI™ System (Galvanize Therapeutics) with three commercial, focal ablation catheters.

METHODS AND RESULTS

ECLIPSE AF (NCT04523545) was a prospective, single-arm, multi-centre study evaluating safety and acute and chronic pulmonary vein isolation (PVI) durability using the CENTAURI System in conjunction with the TactiCath SE, StablePoint, and ThermoCool ST ablation catheters. Patients with paroxysmal or persistent AF were treated at two centres. Patients were analysed in five cohorts based upon ablation settings, catheter, and mapping system. Pulsed field ablation was performed in 82 patients (74% male, 42 paroxysmal AF). Pulmonary vein isolation was achieved in 100% of pulmonary veins (322/322) with first-pass isolation in 92.2% (297/322). There were four serious adverse events of interest (three vascular access complications and one lacunar stroke). Eighty patients (98%) underwent invasive remapping. Pulsed field ablation development Cohorts 1 and 2 showed a per-patient isolation rate of 38% and 26% and a per-PV isolation rate of 47% and 53%, respectively. Optimized PFA Cohorts 3-5 showed a per-patient isolation rate of 60%, 73%, and 81% and a per-PV isolation rate of 84%, 90%, and 92%, respectively.

CONCLUSION

ECLIPSE AF demonstrated that optimized PFA using the CENTAURI System with three commercial, contact force-sensing, solid-tip focal ablation catheters resulted in transmural lesion formation and high proportion of durable PVI with a favourable safety profile, thus providing a viable treatment option for AF that integrates with contemporary focal ablation workflows.

Safety and Effectiveness of Pulsed Field Ablation to Treat Atrial Fibrillation: One-Year Outcomes From the MANIFEST-PF Registry

BACKGROUND

Pulsed field ablation is a novel nonthermal cardiac ablation modality using ultra-rapid electrical pulses to cause cell death by a mechanism of irreversible electroporation. Unlike the traditional ablation energy sources, pulsed field ablation has demonstrated significant preferentiality to myocardial tissue ablation, and thus avoids certain thermally mediated complications. However, its safety and effectiveness remain unknown in usual clinical care.

METHODS

MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-Approval Clinical Use of Pulsed Field Ablation) is a retrospective, multinational, patient-level registry wherein patients at each center were prospectively included in their respective center registries. The registry included all patients undergoing postapproval treatment with a multielectrode 5-spline pulsed field ablation catheter to treat atrial fibrillation (AF) between March 1, 2021, and May 30, 2022. The primary effectiveness outcome was freedom from clinical documented atrial arrhythmia (AF/atrial flutter/atrial tachycardia) of ≥30 seconds on the basis of electrocardiographic data after a 3-month blanking period (on or off antiarrhythmic drugs). Safety outcomes included the composite of acute (<7 days postprocedure) and latent (>7 days) major adverse events.

RESULTS

At 24 European centers (77 operators) pulsed field ablation was performed in 1568 patients with AF: age 64.5±11.5 years, female 35%, paroxysmal/persistent AF 65%/32%, CHA₂DS₂-VASc 2.2±1.6, median left ventricular ejection fraction 60%, and left atrial diameter 42 mm. Pulmonary vein isolation was achieved in 99.2% of patients. After a median (interquartile range) follow-up of 367 (289-421) days, the 1-year Kaplan-Meier estimate for freedom from atrial arrhythmia was 78.1% (95% CI, 76.0%-80.0%); clinical effectiveness was more common in patients with paroxysmal AF versus persistent AF (81.6% versus 71.5%; P=0.001). Acute major adverse events occurred in 1.9% of patients.

CONCLUSIONS

In this large observational registry of the postapproval clinical use of pulsed field technology to treat AF, catheter ablation using pulsed field energy was clinically effective in 78% of patients with AF.

Damage to the left descending coronary artery due to radiofrequency ablation in the right ventricular outflow tract: Clinical case series and anatomical considerations

The purpose of this paper was to highlight the importance of the anatomy of the right ventricular outflow tract (RVOT) and the proximity of the mid segment of the left anterior descending coronary artery (LAD) to the RVOT in the setting of ablation of ventricular arrhythmias in the RVOT. During the period from 2014 till 2017, five patients with injury to the LAD during ablation within RVOT were identified in three centers, in Belgium, Germany and Israel. The clinical characteristics, procedural data and follow up data, where available, are reported. The literature review over coronary artery damage during radiofrequency ablation procedures is provided and the anatomy of the RVOT and the neighboring vascular structures is discussed. We present five patients who underwent radiofrequency ablation of ventricular arrhythmias mapped to the inferior and anterior part of the RVOT, at the insertion of the right ventricular wall to the septum, whereby ablation resulted in occlusion in four and severe stenosis in one, of the mid segment of the LAD coronary artery. All patients underwent percutaneous coronary intervention and stenting, four of them immediately during the same procedure and one 3 days later because of lack of signs and symptoms of acute coronary occlusion. In conclusion, the mid segment of the LAD at the level of the second septal perforator/second diagonal branch runs in very close proximity to the endocardial aspect of the lower part of the RVOT and care should be taken during ablation of ventricular arrhythmias in this region. Additional imaging such as intracardiac echocardiography and coronary angiography may be helpful in avoiding complications.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Multi-national survey on the methods, efficacy, and safety on the post-approval clinical use of pulsed field ablation (MANIFEST-PF)

AIMS

Pulsed field ablation (PFA) is a novel atrial fibrillation (AF) ablation modality that has demonstrated preferential tissue ablation, including no oesophageal damage, in first-in-human clinical trials. In the MANIFEST-PF survey, we investigated the 'real world' performance of the only approved PFA catheter, including acute effectiveness and safety-in particular, rare oesophageal effects and other unforeseen PFA-related complications.

METHODS AND RESULTS

This retrospective survey included all 24 clinical centres using the pentaspline PFA catheter after regulatory approval. Institution-level data were obtained on patient characteristics, procedure parameters, acute efficacy, and adverse events. With an average of 73 patients treated per centre (range 7-291), full cohort included 1758 patients: mean age 61.6 years (range 19-92), female 34%, first-time ablation 94%, paroxysmal/persistent AF 58/35%. Most procedures employed deep sedation without intubation (82.1%), and 15.1% were discharged same day. Pulmonary vein isolation (PVI) was successful in 99.9% (range 98.9-100%). Procedure time was 65 min (38-215). There were no oesophageal complications or phrenic nerve injuries persisting past hospital discharge. Major complications (1.6%) were pericardial tamponade (0.97%) and stroke (0.4%); one stroke resulted in death (0.06%). Minor complications (3.9%) were primarily vascular (3.3%), but also included transient phrenic nerve paresis (0.46%), and TIA (0.11%). Rare complications included coronary artery spasm, haemoptysis, and dry cough persistent for 6 weeks (0.06% each).

CONCLUSION

In a large cohort of unselected patients, PFA was efficacious for PVI, and expressed a safety profile consistent with preferential tissue ablation. However, the frequency of 'generic' catheter complications (tamponade, stroke) underscores the need for improvement.

Comparison of de novo versus upgrade cardiac resynchronisation therapy on clinical effect and long-term outcome

BACKGROUND

The benefit of de novo cardiac resynchronisation therapy (CRT) implantation in selected patients with heart failure is well known. The number of upgrade procedures is increasing but data on clinical response and outcome are less well documented as compared to de novo implantation.

OBJECTIVES

To investigate the efficacy and outcome of CRT upgrade procedures in patients with existing cardiac implantable electronic devices (CIEDs).

METHODS

Baseline characteristics, change in New York Heart Association (NYHA) functional class, echocardiographic parameters, life-threatening ventricular tachyarrhythmias, all-cause mortality and mode of death were evaluated in CRT patients with the comparison between de novo and upgrade CRT procedures.

RESULTS

About 410 patients (CRT upgrade/de novo CRT, n = 97/313) were followed for 63.5 ± 38.1 months. Upgrade patients were older (75.5 ± 8.1 vs 69.9 ± 10.7 years; p < 0.001), had more often an ischaemic cause of heart failure (58.8% vs 45.4%; p = 0.021), a higher NYHA functional class (p = 0.004) and a higher comorbidity burden. Improvement in left ventricular ejection fraction (LVEF) was higher in the de novo CRT group (8.4 ± 9.9 vs 11.0 ± 10.3%; p = 0.035). Clinical response was similar between both groups (60.5 vs 62.5%; p = 0.793), as was mortality at 1 year (8.2 vs 5.8%; p = 0.351) and at last follow-up (33.0 vs 28.8%; p = 0.447). The proportion of cardiovascular related deaths was similar between both groups (46.9% vs 38.9%; p = 0.531).

CONCLUSIONS

Patients with CRT upgrade procedures have similar symptomatic improvements, as well as 1 year and long-term outcome as compared to patients with de novo CRT implantation.

Clinical characterization of the first Belgian SCN5A founder mutation cohort

AIMS

We identified the first Belgian SCN5A founder mutation, c.4813 + 3_4813 + 6dupGGGT. To describe the clinical spectrum and disease severity associated with this mutation, clinical data of 101 SCN5A founder mutation carriers and 46 non-mutation carrying family members from 25 Belgian families were collected.

METHODS AND RESULTS

The SCN5A founder mutation was confirmed by haplotype analysis. The clinical history and electrocardiographic parameters of the mutation carriers and their family members were gathered and compared. A cardiac electrical abnormality was observed in the majority (82%) of the mutation carriers. Cardiac conduction defects, defined as PR or QRS prolongation on electrocardiogram (ECG), were most frequent, occurring in 65% of the mutation carriers. Brugada syndrome (BrS) was the second most prevalent phenotype identified in 52%, followed by atrial dysrythmia in 11%. Overall, 33% of tested mutation carriers had a normal sodium channel blocker test. Negative tests were more common in family members distantly related to the proband. Overall, 23% of the mutation carriers were symptomatic, with 8% displaying major adverse events. As many as 13% of the patients tested with a sodium blocker developed ventricular arrhythmia. One family member who did not carry the founder mutation was diagnosed with BrS.

CONCLUSION

The high prevalence of symptoms and sensitivity to sodium channel blockers in our founder population highlights the adverse effect of the founder mutation on cardiac conduction. The large phenotypical heterogeneity, variable penetrance, and even non-segregation suggest that other genetic (and environmental) factors modify the disease expression, severity, and outcome in these families.

Dynamic Takotsubo Syndrome: When SCAD Hides in a Pot

Both Takotsubo cardiomyopathy and spontaneous coronary artery dissection (SCAD) of the distal portion of the left anterior descending artery affect the apical myocardium. It is important to distinguish between both diseases, because therapy and follow-up differ. Revascularization may be lifesaving in SCAD, whereas heart failure management is vital in Takotsubo cardiomyopathy. (Level of Difficulty: Intermediate.)

47CRT-D versus CRT-P: are we on the right track?

Introduction

Implantable cardioverter defibrillators (ICD) and cardiac resynchronisation therapy (CRT) have both proven to reduce mortality in patients with heart failure (HF). However, randomised trials comparing CRT-pacemaker (CRT-P) vs CRT-defibrillator (CRT-D) are lacking. Understanding a patient’s primary mode of death is therefore important as this may guide the proper use of CRT systems and avoid risks that are associated with under -or overtreatment with an ICD. 

Purpose 

This study aims to analyse the mode of death and the occurrence of life-threatening ventricular arrhythmias (VAs) in patients who received a CRT-P or CRT-D. This may help in the future selection for an appropriate cardiac device in patients with HF. 

Methods 

Patients with HF undergoing CRT-P or CRT-D implantation in a tertiary hospital between January 2008 and December 2018 were retrospectively evaluated. CRT indications were in compliance with the ESC guidelines. The decision to implant CRT-D or CRT-P in primary prevention was left at the discretion of the treating physician but was based on ESC clinical guidance. Life threatening VAs (sustained ventricular tachycardia &gt; 30s not requiring therapy or appropriate therapy for VAs) and mode of death were analysed. 

Results 

511 patients were implanted with a CRT (CRT-D/CRT-P; n = 311/200) of which 410 (CRT-D/CRT-P; n= 245/165) were followed in our centre for 63,5 ± 38,1 months. Patients with CRT-P were older (77,6 ± 8,1 vs 66,8 ± 9,5 years; p &lt;0,001), more often female (39,4 vs 26,9%; p 0,006), had more a non-ischaemic cause (61,2 vs 44,9%; p 0,001) and a significant higher comorbidity burden. They also received less treatment with neurohumoral blockers. Baseline LVEF was higher in the CRT-P group (33,1 ± 8,9 vs 28,0 ± 7,6%, p &lt;0,001). 6 months follow-up showed a similar increase in LVEF in the CRT-P vs CRT-D group (+10,3 ± 9,6 vs +11,4 ± 10,8%, p 0,38).

Main reasons to choose for CRT-P were RV-pacing induced cardiomyopathy (CMP) (26,1%), multiple comorbidities (18,8%), HF complicated by high degree AV block or AV junction ablation (18,2%), non-ischaemic CMP with suspected good CRT response (10,3%), age (7,3%), other (19,3%).

6/165 patients with CRT-P (3,6%), of which 5 were detected by remoted telemonitoring, vs 51/245 with CRT-D (20,8%) experienced episodes of life-threatening arrhythmias (p &lt;0,001). All-cause mortality was higher in the CRT-P vs CRT-D group (36,4 vs 25,3%, p 0,005). However, the CRT-P group had a predominant non-cardiac mode of death (70,9 vs 43,3%, p &lt;0,001). Death secondary to a tachyarrhythmic event was present in only 1 patient (1,7%) in the CRT-P group. 

Conclusions

Guided by clinical parameters and presence of competitive non-cardiac causes of death, adequate decision between CRT-P or CRT-D implantation can be made. In our cohort, sudden cardiac death in the CRT-P group occurred only once. Remote monitoring is able to identify a subgroup of patients potentially benefiting from an upgrade from CRT-P to CRT-D.

P356Effect of catheter ablation on left and right ventricular function in patients with frequent premature ventricular contractions and preserved ejection fraction

INTRODUCTION

Improvement of left ventricular ejection fraction (LVEF) after catheter ablation (CA) in patients with left ventricular (LV) dysfunction and frequent premature ventricular contractions (PVCs) of the outflow tract (OT) has been reported. However, many patients with PVCs of the OT have a normal LVEF. The effect of CA on the left and right ventricular function in these patients is not well established.  

PURPOSE 

This study aims to evaluate the effect of CA on improvement of left and right ventricular function in patients with a preserved LVEF (EF &gt; 50%) and frequent PVCs originating from the OT. 

METHODS 

We retrospectively examined clinical, electrophysiological and echocardiographic measurements in 95 patients with a preserved LVEF and frequent PVCs from the OT who underwent CA, dating from January 2014 till December 2018. Two dimensional TTE was performed at baseline and follow up. LV volumes and LVEF were calculated using the Simpson’s method. LV global longitudinal strain (GLS) and RV free wall longitudinal strain were calculated by 2D speckle tracking.  The Shapiro-Wilk test was used to determine the normal distribution of all variables. The Wilcoxon Signed Rank test was used to compare the evolution of the categorical and continuous variables between the TTE at baseline and follow-up. 

RESULTS 

Mean age of our study population was 52.8 ± 16.6 years, 49% was female. Mean burden of PVC before ablation was 18423 (2496-54000)/24h; 23.2% had a burden of less than 10.000 PVCs/24h. Mean burden of PVC after ablation was 1403 (0-27349)/24h. Median time between ablation and follow-up TTE was 117,8 days. There was a significant amelioration of LVEF (54.0 ± 4.0 vs 58.0 ± 3.8%, p &lt;0.001) and LV GLS (18.4 ± 2.2 vs 20.4 ± 2.0 %, p &lt; 0.001) as well as TAPSE (24.8 ± 3.5 vs 25.2 ± 3.1mm, p 0.013) and RV strain (25.4 ± 3.9 vs 27.6 ± 3.7%, p &lt;0.001). There was no significant difference in LV end diastolic diameter (50.1 ± 5.6 vs 49.6 ± 5.3mm, p 0.06) or LV end diastolic volume (109.7 ± 27.8 vs 107.2 ± 24.9mm, p 0.25), but there was a significant reduction in LV end systolic volume  (50.7 ± 13.9 vs 44.7 ± 11.1mm, p &lt; 0.001). RV basal diameter was not different (33.8 ± 4.5mm vs 33.6 ± 4.2mm, p 0.30).In the patient group with VES &lt;10000/24h, there was no significant difference in LVEF (55,2 ± 4,6 vs 55,9 ± 4,6%, p 0,12), but there was a significant amelioration of GLS (18.4 ± 2.2 vs 19.9 ± 2.1%, p &lt; 0.001) and RV strain (24.1 ± 4.3 vs 25.9 ±3.3%, p0.003). In the patient group with VES &gt;10000/24h, beneficial effects were noticed in LVEF (53.6 ± 3.8 vs 58.7 ±3.2%, p &lt; 0.001), GLS (18.4 ± 2.2 vs 20.5 ± 2.0%, p &lt; 0.001) and RV strain (25.8 ± 3.7 vs 28.1 ± 3.7%, p &lt; 0.001).

CONCLUSION

Frequent PVCs from the OT can induce subtle cardiac dysfunction in patients without apparent cardiomyopathy. CA can improve left and right ventricular function in these patients, which can be detected by conventional TTE parameters but also in an earlier stage by 2D speckle tracking.

P365Does papillary muscle ablation affect mitral valve function: a single centre experience

Introduction

Ventricular arrhythmias from papillary muscles (PMs) often require extensive catheter ablation (CA). Not much is known about the mitral valve (MV) function after these extensive catheter ablations.

Purpose

The goal of this study was to determine the impact of papillary muscle CA on MV function. 

Methods

We retrospectively examined echocardiographic measurements in 21 patients with frequent premature ventricular contractions (PVCs) originating from the mitral PMs who underwent CA, dating from October 2012 till November 2018. We assessed MV function at baseline, 6 month and last follow-up. Degree of mitral regurgitation (MR) was graded as mild (ERO &lt;0,2 cm2, regurgitation volume (RV) &lt;30ml), moderate (ERO 0,2-0,4cm2, RV 30-59ml) or severe (ERO ≥0,4cm2, RV  ≥60ml). Significant MR was defined as a 2+ change.

Results

Mean age of the study population was 59,7 (27-80)years, 52,4% was female.

2 patients were known with ischemic heart disease. There was a family history of sudden cardiac death in 3 patients. Main symptoms at presentation were palpitations (66,7%), fatigue (33,3%), dyspnea (33,3%, all NYHA 2), dizziness (28,6%), angina pectoris (14,3%) and syncope (4,8%). Beta blocker (71,4%), flecaïnide (23,8%), amiodarone (9,5%), sotalol (4,8%) and propafenon (4,8%) were the most frequent medical therapies before CA.

Mean burden of PVC before ablation was 15 574 (2000-39700)/24h. In 28,6% non sustained VT was documented, 1 patient suffered a sustained episode of VT.  After ablation, mean burden of PVC was reduced to 1331 (0-14200)/24h. Redo ablation was necessary in 28,6% of patients. PVCs orginated from the anterolateral PM in 33,3% and from the posteromedial PM in 66,7%. Mean troponin release was 9.4 ± 5.3 µg/l, mean troponin hs (since 2016) was 1591.0 ±658.6ng/ml. CMR was done in 14/21 (66,7%) patients before CA. In 5 out of 14 patients (35,7%), delayed enhancement at the papillary muscles was noticed. In 5 patients without delayed enhancement, CMR was repeated after CA. In all these 5 patients, delayed enhancement was noticed at the level of the papillary muscles. 

At baseline, 15/21 had mild, 5/21 moderate and  1/21 severe MR. There was no significant chance in MR at 6m follow-up with 15/21 having mild and  6/21 moderate MR (p 0.58) with 1 patient having a significant MR 2+ change. At last follow-up (23.7 ± 22.6 months) there was also no significant chance in MR with 15/21 having mild and 6/21 moderate MR (p 0.58) without a significant MR 2+ change. 

Complications occurred in 1 patient (transient AV blok). No patients died during follow up. 

Conclusions

Although PM ablation was associated with time extensive ablation, significant troponine release and documented delayed enhancement on post ablation MRI, there was no risk of additional valvular dysfunction after CA in this study. Larger studies will be necessary to confirm these findings.

A mutation update for the FLNC gene in myopathies and cardiomyopathies

Filamin C (FLNC) variants are associated with cardiac and muscular phenotypes. Originally, FLNC variants were described in myofibrillar myopathy (MFM) patients. Later, high‐throughput screening in cardiomyopathy cohorts determined a prominent role for FLNC in isolated hypertrophic and dilated cardiomyopathies (HCM and DCM). FLNC variants are now among the more prevalent causes of genetic DCM. FLNC‐associated DCM is associated with a malignant clinical course and a high risk of sudden cardiac death. The clinical spectrum of FLNC suggests different pathomechanisms related to variant types and their location in the gene. The appropriate functioning of FLNC is crucial for structural integrity and cell signaling of the sarcomere. The secondary protein structure of FLNC is critical to ensure this function. Truncating variants with subsequent haploinsufficiency are associated with DCM and cardiac arrhythmias. Interference with the dimerization and folding of the protein leads to aggregate formation detrimental for muscle function, as found in HCM and MFM. Variants associated with HCM are predominantly missense variants, which cluster in the ROD2 domain. This domain is important for binding to the sarcomere and to ensure appropriate cell signaling. We here review FLNC genotype–phenotype correlations based on available evidence.

Innovation in dental education: The "On-the-Fly" approach to simultaneous development, implementation and evidence collection

INTRODUCTION

This study outlines an approach for education innovation and addresses the ambivalence between evidence-based and non-evidence-based conditions. The "on-the-fly" approach was described as involving implementation during the development of an innovation for dental education.

MATERIALS AND METHODS

The process of designing and implementing cutting-edge technology of the MOOG Simodont Dental Trainer (DT) whilst systematically collecting evidence illustrates the "on-the-fly" approach.

RESULTS

Using the "on-the-fly" approach for developing, implementing and collecting evidence simultaneously in an academic environment appears feasible in serving both the professionals, users and developers and system designers. During the implementation of the new technology, growing evidence stepwise strengthened its position; therefore, showing stakeholders that evidence was used to improve the technology seemed to support and increase acceptance of the new technology.

CONCLUSIONS

When pioneering an innovative technology in a specialty field, the development stage often precedes evidence for its effectiveness. Consciously choosing the "on-the-fly" approach clarifies to stakeholders in advance about the lack of evidence in an innovation and the need of their support to collect such evidence for improvement and in order to facilitate implementation.

Effect of reinforced, targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire in patients with atrial fibrillation: A randomized controlled trial

BACKGROUND

The knowledge level of atrial fibrillation patients about their arrhythmia, its consequences and treatment is poor. The best strategy to provide education is unknown.

AIM

To investigate the effect of reinforced targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ).

METHODS

Sixty-seven atrial fibrillation patients were randomized to standard care (including brochures) or targeted education. Follow-up visits were scheduled after one, three, six and 12 months. Targeted education during each visit focused on the knowledge gaps revealed by the JAKQ. Patients completed two questionnaires to assess their quality of life and symptom profile. Adherence to non-vitamin K antagonist oral anticoagulants was measured using electronic monitoring.

RESULTS

Sixty-two patients (31 education; 31 standard care) completed follow-up. Median baseline score on the JAKQ was similar in education (62.5%) and standard care group (56.3%; p=0.815). The intervention group scored significantly better over time (one month: 75.0%, 12 months: 87.5%; p<0.001) whereas there was no significant improvement in the control group (one month: 62.5%, 12 months: 62.5%; p=0.085). Providing targeted education after completion of the JAKQ required on average 6.9±4.6 min. Some improvements in quality of life, symptom burden and adherence were shown, without significant differences between the two groups ( p-values between 0.282 and 0.677).

CONCLUSION

The JAKQ is an effective tool for providing individualized education. A first targeted educational session significantly improved patients' knowledge level. Additional educational sessions maintained and strengthened this effect. A larger scale study is warranted to evaluate the impact on adherence and outcome measures.

The Health Buddies App as a Novel Tool to Improve Adherence and Knowledge in Atrial Fibrillation Patients: A Pilot Study

BACKGROUND

Atrial fibrillation (AF) constitutes an important risk for stroke, especially in an ageing population. A new app (Health Buddies) was developed as a tool to improve adherence to non-vitamin K antagonist oral anticoagulants (NOACs) in an elderly AF population by providing a virtual contract with their grandchildren, spelling out daily challenges for both.

OBJECTIVE

The aim of this pilot study was to assess the feasibility and usability of the Health Buddies app in AF patients.

METHODS

Two workshops were conducted to steer app development and to test a first prototype. The feasibility of the finalized app was investigated by assessing the number of eligible AF patients (based on current prescription of NOACs, the presence of grandchildren between 5 and 15 years old, availability of a mobile phone, computer, or tablet), and the proportion of those who were willing to participate. Participants had to use the app for 3 months. The motivation of the patients to use the app was assessed based on the number of logins to the app. Their perception of its usefulness was examined by specific questionnaires. Additionally, the effects on knowledge level about AF and its treatment, and adherence to NOAC intake were investigated.

RESULTS

Out of 830 screened AF patients, 410 were taking NOACs and 114 were eligible for inclusion. However, only 3.7% (15/410) of the total NOAC population or 13.2% of the eligible patients (15/114) were willing to participate. The main reasons for not participating were no interest to participate in general or in the concept in particular (29/99, 29%), not feeling comfortable using technology (22/99, 22%), no interest by the grandchildren or their parents (20/99, 20%), or too busy a lifestyle (12/99, 12%). App use significantly decreased towards the end of the study period in both patients (P=.009) and grandchildren (P<.001). NOAC adherence showed a taking adherence and regimen adherence of 88.6% (SD 15.4) and 81.8% (SD 18.7), respectively. Knowledge level increased from 64.6% (SD 14.7) to 70.4% (SD 10.4) after 3 months (P=.09). The app scored positively on clarity, novelty, stimulation, and attractiveness as measured with the user experience questionnaire. Patients evaluated the educational aspect of this app as a capital gain.

CONCLUSIONS

Only a small proportion of the current AF population seems eligible for the innovative Health Buddies app in its current form. Although the app was positively rated by its users, a large subset of patients was not willing to participate in this study or to use the app. Efforts have to be made to expand the target group in the future.

Performance of handheld electrocardiogram devices to detect atrial fibrillation in a cardiology and geriatric ward setting

AIMS

To determine the usability, accuracy, and cost-effectiveness of two handheld single-lead electrocardiogram (ECG) devices for atrial fibrillation (AF) screening in a hospital population with an increased risk for AF.

METHODS AND RESULTS

Hospitalized patients (n = 445) at cardiological or geriatric wards were screened for AF by two handheld ECG devices (MyDiagnostick and AliveCor). The performance of the automated algorithm of each device was evaluated against a full 12-lead or 6-lead ECG recording. All ECGs and monitor tracings were also independently reviewed in a blinded fashion by two electrophysiologists. Time investments by nurses and physicians were tracked and used to estimate cost-effectiveness of different screening strategies. Handheld recordings were not possible in 7 and 21.4% of cardiology and geriatric patients, respectively, because they were not able to hold the devices properly. Even after the exclusion of patients with an implanted device, sensitivity and specificity of the automated algorithms were suboptimal (Cardiology: 81.8 and 94.2%, respectively, for MyDiagnostick; 54.5 and 97.5%, respectively, for AliveCor; Geriatrics: 89.5 and 95.7%, respectively, for MyDiagnostick; 78.9 and 97.9%, respectively, for AliveCor). A scenario based on automated AliveCor evaluation in patients without AF history and without an implanted device proved to be the most cost-effective method, with a provider cost to identify one new AF patient of €193 and €82 at cardiology and geriatrics, respectively. The cost to detect one preventable stroke per year would be €7535 and €1916, respectively (based on average CHA₂DS₂-VASc of 3.9 ± 2.0 and 5.0 ± 1.5, respectively). Manual interpretation increases sensitivity, but decreases specificity, doubling the cost per detected patient, but remains cheaper than sole 12-lead ECG screening.

CONCLUSION

Using AliveCor or MyDiagnostick handheld recorders requires a structured screening strategy to be effective and cost-effective in a hospital setting. It must exclude patients with implanted devices and known AF, and requires targeted additional 12-lead ECGs to optimize specificity. Under these circumstances, the expenses per diagnosed new AF patient and preventable stroke are reasonable.

Transvenous extraction of pacing and defibrillator leads--a single-centre experience

PURPOSE

Worldwide, the number of transvenous extractions of chronically implanted endocardial leads rapidly increases. Despite great technical progress, lead extraction remains a challenging procedure with possible life-threatening complications. We present the success and complication rate of lead extractions in the University Hospitals Leuven, and investigated a possible relationship between the use of powered sheaths and lead type, fixation, location and implantation time.

METHODS

We present an observational retrospective cohort study of 157 patients admitted to the University Hospitals Leuven between January 2005 and December 2010, for the transvenous removal of a total of 259 endocardial leads.

RESULTS

Complete procedural success was achieved in 92% of patients (n = 144). Of all leads, 94% (n = 243) were completely extracted. Only in 5 patients (3%), lead extraction failed. Leads that could not be removed were significantly older (134.1 +/- 90.7 months vs. 73.1 +/- 61.9 months; P = 0.02). In the other 8 patients the leads were partially removed with a remaining major retained lead fragment in 2 and a minor fragment in 6 patients. Major procedural complication rate was 2.5% (n = 4). There were no procedure-related deaths. Powered sheaths were used significantly more for the extraction of defibrillator leads (51%) (vs. pacing leads (33%; P = 0.015)) and right ventricular located leads (43%) (vs. other location (28%; P = 0.011)). However, when comparing the need of powered sheaths for the extraction of right ventricular defibrillator leads vs. right ventricular pacing leads, only a trend to higher use was noticed (51 vs. 39%; P = 0.146). Powered sheath use was not related to fixation type. Leads that required the use of a powered sheath were implanted significantly longer (112 +/- 69.5 months vs. 41.7 +/- 33.7 months; P = 0.001).

CONCLUSIONS

Chronically implanted endocardial leads can be transvenously extracted in a high number of cases and with a low risk of procedural complications. Powered sheaths proved to be a helpful tool to extract leads that could not be removed by manual traction. Powered sheaths are necessary for leads with longer implantation duration and are more often used for the extraction of defibrillator leads.

Redd1 is a novel marker of testis development but is not required for normal male reproduction

In an effort to identify novel candidate genes involved in testis determination, we previously used suppression subtraction hybridisation PCR on male and female whole embryonic (12.0-12.5 days post coitum) mouse gonads. One gene to emerge from our screen was Redd1. In the current study, we demonstrate by whole-mount in situ hybridisation that Redd1 is differentially expressed in the developing mouse gonad at the time of sex determination, with higher expression in testis than ovary. Furthermore, Redd1 expression was first detected as Sry expression peaks, immediately prior to morphological sex determination, suggesting a potential role for Redd1 during testis development. To determine the functional importance of this gene during testis development, we generated Redd1-deficient mice. Morphologically, Redd1-deficient mice were indistinguishable from control littermates and showed normal fertility. Our results show that Redd1 alone is not required for testis development or fertility in mice. The lack of a male reproductive phenotype in Redd1 mice may be due to functional compensation by the related gene Redd2.

Expression and functional analysis of Dkk1 during early gonadal development

WNT signalling plays a central role in mammalian sex determination by promoting ovarian development and repressing aspects of testis development in the early gonad. Dickkopf homolog 1 (DKK1) is a WNT signalling antagonist that plays critical roles in multiple developmental systems by modulating WNT activity. Here, we examined the role of DKK1 in mouse sex determination and early gonadal development. Dkk1 mRNA was upregulated sex-specifically during testis differentiation, suggesting that DKK1 could repress WNT signalling in the developing testis. However, we observed overtly normal testis development in Dkk1-null XY gonads, and found no significant upregulation of Axin2 or Sp5 that would indicate increased canonical WNT signalling. Nor did we find significant differences in expression of key markers of testis and ovarian development. We propose that DKK1 may play a protective role that is not unmasked by loss-of-function in the absence of other stressors.

Long-term endurance sport is a risk factor for development of lone atrial flutter

OBJECTIVE

To evaluate whether in a population of patients with 'lone atrial flutter', the proportion of those engaged in long-term endurance sports is higher than that observed in the general population.

DESIGN

An age and sex-matched retrospective case-control study.

SETTING

A database with 638 consecutive patients who underwent ablation for atrial flutter at the University of Leuven. Sixty-one patients (55 men, 90%) fitted the inclusion criteria of 'lone atrial flutter', ie, aged 65 years or less, without documented atrial fibrillation and without identifiable underlying disease (including hypertension). Sex, age and inclusion criteria-matched controls, two for each flutter patient, were selected in a general practice in the same geographical region.

METHODS

Sports activity was evaluated by detailed questionnaires, which were available in 58 flutter patients (95%). A transthoracic echocardiogram was performed in all lone flutter patients.

MAIN OUTCOME MEASURES

Types of sports, number of years of participation and average number of hours per week.

RESULTS

The proportion of regular sportsmen (≥3 h of sports practice per week) among patients with lone atrial flutter was significantly higher than that observed in the general population (50% vs 17%; p<0.0001). The proportion of sportsmen engaged in long-term endurance sports (participation in cycling, running or swimming for ≥3 h/week) was also significantly higher in lone flutter patients than in controls (31% vs 8%; p=0.0003). Those flutter patients performing endurance sports had a larger left atrium than non-sportsmen (p=0.04, by one-way analysis of variance).

CONCLUSION

A history of endurance sports and subsequent left atrial remodelling may be a risk factor for the development of atrial flutter.

Light chain deposition disease as a rare cause of restrictive cardiomyopathy

We report an unusual case of a 47-year-old Caucasian woman who presented with severe dyspnoea as a manifestation of restrictive cardiomyopathy, found to be due to myocardial deposition of kappa light chains. Non-routine specific immunofluorescence stainings of endomyocardial biopsy specimens were key for the diagnosis of myocardial light chain deposition disease. We discuss non-amyloidotic cardiac immunoglobulin deposition disease in contrast to cardiac amyloidosis.

The delicate balance between male and female sex determining pathways: potential for disruption of early steps in sexual development

Testes and ovaries develop from the same primordial structures, the genital ridges, in the mammalian foetus. Male development depends critically on the correct functioning of the Y-linked testis-determining gene, Sry. However, Sry is highly vulnerable to mutation, and so does not provide a very robust sex-determining mechanism. Both in testes and in ovaries, proper gonadal development involves co-ordinated regulation of the bipotential fates of a number of different cell lineages, and is dependent on intercellular signalling mechanisms. If either the testicular or ovarian pathway stalls in the early stages, mechanisms operate to engage the alternative pathway. For these reasons, the early steps in mammalian sexual development are vulnerable to genetic and environmental perturbation, and represent possible points of action of endocrine disrupting compounds.

Identification of suitable normalizing genes for quantitative real-time RT-PCR analysis of gene expression in fetal mouse gonads

In biological research, quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) assays are commonly employed to study mRNA abundance in cells and tissues. This type of assay usually relies on assessing transcript abundance relative to constitutively expressed endogenous reference genes. Therefore, it is important that the reference genes themselves are stably expressed in the cells or tissues analyzed, independent of factors such as age, sex, disease or experimental manipulations. Since no gene is expressed at the same level in all cells at all times, suitable reference genes must be identified for the specific cellular system or tissue being investigated. Here, we sought to identify stably expressed endogenous reference genes during embryonic gonad development in the mouse. We measured the transcript abundance of 10 frequently employed normalizing genes, of which 4 were stably expressed in fetal gonads from 11.5 to 14.5 dpc irrespective of sex. Based on our analysis, we suggest that Rn18s, Rps29, Tbp and Sdha are suitable reference genes for qRT-PCR expression studies during early gonad differentiation in the mouse.