Ligang Ding

Impact of Alcohol Consumption on Substrate Remodeling and Ablation Outcome of Paroxysmal Atrial Fibrillation

Background The effect of alcohol consumption on substrate remodeling and ablation outcome of paroxysmal atrial fibrillation (PAF) remains unknown. Methods and Results We performed circumferential pulmonary vein isolation (CPVI) and voltage mapping of left atrium (LA) during sinus rhythm in 122 consecutive patients with symptomatic PAF (age, 55.4±9.4 years; 73.8% men). Low‐voltage zones (LVZs) were semiquantitatively estimated and presented as low‐voltage index (LVI). Each patients daily alcohol consumption history was recorded at baseline and classified into alcohol abstainers, moderate drinkers, and heavy drinkers based on the National Institute on Alcohol Abuse and Alcoholism definition. Follow‐up was ≥12 months for AF recurrence. Alcohol abstainers and moderate and heavy drinkers were 70 (57.4%), 13 (10.6%), and 39 (32.0%), respectively. In total, LVZs were observed in 44 patients (36.1%). Daily alcohol consumption independently predicted presence of LVZs (odds ratio [OR], 1.097; 95% confidence interval [CI], 1.001–1.203; P=0.047). During mean follow‐up of 20.9±5.9 months, 40 patients (35.1%) experienced AF recurrence. Success rate was 81.3%, 69.2%, and 35.1% in alcohol abstainers, moderate drinkers, and heavy drinkers, respectively (overall log rank, P<0.001). Multivariate analysis showed that both alcohol consumption and LVI were independent predictors of AF recurrence (hazard ratio [HR], 1.579; 95% CI, 1.085–2.298; P=0.017; HR, 2.188; 95% CI, 1.582–3.026; P<0.001, respectively). Furthermore, mediation analysis revealed that LVZs acted as a partial mediator in effect of alcohol consumption on AF ablation outcomes. Conclusions Daily alcohol consumption was associated with atrial remodelling, and heavy drinkers have substantial risk for AF recurrence after CPVI.

Comparison of Radiofrequency Catheter Ablation Between Asymptomatic and Symptomatic Persistent Atrial Fibrillation: A Propensity Score Matched Analysis

Whether patients with asymptomatic atrial fibrillation (AF) could benefit from radiofrequency catheter ablation (RFCA) remains unclear. This study aimed to compare the outcomes of RFCA between asymptomatic and symptomatic AF.

Incidence and predictors of sudden cardiac death in patients with reduced left ventricular ejection fraction after myocardial infarction in an era of revascularisation

Objective To determine the incidence and predictors of sudden cardiac death (SCD) in the current era of revascularisation of myocardial infarction (MI) survivors with reduced LVEF. Methods A prospective observational study was conducted in FuWai Hospital from 2004 to 2009. A total of 1018 consecutive patients who had an LVEF ≤35% and New York Heart Association Class II/III heart failure at least 40 days after MI were enrolled if they were not available for implantation of an implantable cardioverter defibrillator. The degree of coronary artery disease and revascularisation were analysed. The primary outcome was SCD and secondary outcome was all-cause death. Results During a mean follow-up of 2.8 years, the SCD rate was 5% and all-cause mortality was 7.4%. The annual incidence of SCD was 1.8%. Kaplan–Meier analysis showed that the cumulative rate of SCD was significantly increased in patients with triple-vessel disease (6.7% vs 0.6%), left main coronary disease (10.3% vs 4.1%), EF ≤25% (8.3% vs 3.9%) and non-revascularisation therapy (9.6% vs 2.7%) (all log-rank, p<0.05). After multivariable Cox regression analysis, the risk of SCD was predicted by age (HR 1.05, 95% CI 1.02 to 1.09), EF ≤25% (HR 1.82, 95% CI 1.04 to 3.21) and non-revascularisation (HR 3.97, 95% CI 2.15 to 7.31). Conclusions Revascularisation may reduce the risk of SCD in post-MI patients with an LVEF ≤35% on the basis of medical therapy, and the increased risk for SCD may be predicted by age, LVEF ≤25% and non-revascularisation.

Regression of Fragmented QRS Complex: A Marker of Electrical Reverse Remodeling in Cardiac Resynchronization Therapy

Fragmented QRS (fQRS) marks inhomogeneous activation and asynchronous cardiac contraction. It has been proved that cardiac resynchronization therapy (CRT) could reverse geometrical remodeling as well as correct electrical dyssynchrony. We aimed to investigate whether fQRS changed corresponding to the therapeutic response to CRT.

Intracardiac thrombosis in patients with arrhythmogenic right ventricular cardiomyopathy.

Intracardiac thrombus has been reported in anecdotal cases of arrhythmogenic right ventricular cardiomyopathy (ARVC). This prospective study aimed to determine the prevalence, risk factors, and prognosis of intracardiac thrombosis in patients with ARVC.

OptiVol fluid index predicts acute decompensation of heart failure with a high rate of unexplained events.

Background Intrathoracic impedance monitoring has emerged as a promising new technique for the detection of impending heart failure (HF). Although false positive episodes have been reported in case reports and clinical trials, the efficacy and false positive rate in real-world practice remain unclear. Objective The aim of this study is to investigate the utility and reliability of the OptiVol alert feature in clinical practice. Methods We continuously recruited patients who underwent implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with defibrillator (CRT-D) implantation with feature of intrathoracic impedance monitoring system in our center from Sep. 2010 to Oct. 2012. Regular in-office follow-up were required of all patients and the following information was collected at each visit: medical history, device interrogation, N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement and an echocardiogram. Worsening HF was defined as hospitalization or the presentation of signs or symptoms of HF. Results Forty three patients (male: 76.7%, mean age: 57 ± 15 years, left ventricular ejection fraction (LVEF): 33% ± 14%) were included in this observational study. Fifty four alert events and 14 adjudicated worsening HF were detected within 288 ±163 days follow-up. Eleven (20.4%) alert episodes were associated with acute cardiac decompensation in 9 patients with a positive predictive value of 78.6%. Forty three audible alerts showed no connection to worsening HF. The unexplained alerts rate was 79.6% and 1.27 per person-year. Thirty seven alarm alerts were detected in patients with EF < 45%, among which 9 accompanied with HF, 17 alerts detected in patients with LVEF ≥ 45% and 2 associated with HF. There was no significant difference between the two groups (9/37 vs. 2/17; P = 0.47). Conclusions Patients with normal or nearly normal left ventricular systolic function also exhibited considerable alert events. The OptiVol fluid index predicted worsening cardiac events with a high unexplained detection rate, and any alert must therefore be analyzed with great caution. Efforts to improve the specificity of this monitoring system represent a significant aspect of future studies.

The training and learning process of transseptal puncture using a modified technique

AIMS As the transseptal (TS) puncture has become an integral part of many types of cardiac interventional procedures, its technique that was initial reported for measurement of left atrial pressure in 1950s, continue to evolve. Our laboratory adopted a modified technique which uses only coronary sinus catheter as the landmark to accomplishing TS punctures under fluoroscopy. The aim of this study is prospectively to evaluate the training and learning process for TS puncture guided by this modified technique. METHODS AND RESULTS Guided by the training protocol, TS puncture was performed in 120 consecutive patients by three trainees without previous personal experience in TS catheterization and one experienced trainer as a controller. We analysed the following parameters: one puncture success rate, total procedure time, fluoroscopic time, and radiation dose. The learning curve was analysed using curve-fitting methodology. The first attempt at TS crossing was successful in 74 (82%), a second attempt was successful in 11 (12%), and 5 patients failed to puncture the interatrial septal finally. The average starting process time was 4.1 ± 0.8 min, and the estimated mean learning plateau was 1.2 ± 0.2 min. The estimated mean learning rate for process time was 25 ± 3 cases. Important aspects of learning curve can be estimated by fitting inverse curves for TS puncture. CONCLUSIONS The study demonstrated that this technique was a simple, safe, economic, and effective approach for learning of TS puncture. Base on the statistical analysis, approximately 29 TS punctures will be needed for trainee to pass the steepest area of learning curve.

High sensitivity C-reactive protein and cardfiac resynchronization therapy in patients with advanced heart failure.

Background The data on the prognostic values of high sensitivity C-reactive protein (hsCRP) levels in patients with advanced symptomatic heart failure (HF) receiving cardiac resynchronization therapy (CRT) are scarce. The aim of present study was to investigate the association of serum hsCRP levels with left ventricle reverse remodeling after six months of CRT as well as long-term outcome. Methods A total of 232 CRT patients were included. The assessment of hsCRP values, clinical status and echocardiographic data were performed at baseline and after six months of CRT. Long-term follow-up included all-cause mortality and hospitalizations for HF. Results During the mean follow-up periods of 31.3 ± 31.5 months, elevated hsCRP (> 3 mg/L) prior to CRT was associated with a significant 2.39-fold increase (P = 0.006) in the risk of death or HF hospitalizations. At 6-month follow-up, patients who responded to CRT showed significant reductions or maintained low in hsCRP levels (–0.5 ± 4.1 mg/L reduction) compared with non-responders (1.7 ± 6.1 mg/L increase, P = 0.018). Compared with patients in whom 6-month hsCRP levels were reduced or remained low, patients in whom 6-month hsCRP levels were increased or maintained high experienced a significantly higher risk of subsequent death or HF hospitalizations (Log-rank P < 0.001). The echocardiographic improvement was also better among patients in whom 6-month hsCRP levels were reduced or remained low compared to those in whom 6-month hsCRP levels were raised or maintained high. Conclusions Our findings demonstrated that measurement of baseline and follow-up hsCRP levels may be useful as prognostic markers for timely potential risk stratification and subsequent appropriate treatment strategies in patients with advanced HF undergoing CRT.

Repetitive optimizing left ventricular pacing configurations with quadripolar leads improves response to cardiac resynchronization therapy: A single-center randomized clinical trial

Background: This study aimed to investigate whether repetitive optimizing left ventricular pacing configurations (LVPCs) with quadripolar leads (QUAD) can improve response to cardiac resynchronization therapy (CRT). Methods: Fifty-two eligible patients were enrolled and 1:1 randomized to either the quadripolar LV leads (QUAD) group or the conventional bipolar leads (CONV) group. In the QUAD group, optimization of LVPC was performed for all patients before discharge and for nonresponders at 3 months follow-up. Clinical evaluations and transthoracic echocardiograms were performed before, 3, and 6 months after CRT implantation. Results: At 3 months follow-up, 16 of 25 (64%) patients in the CONV group (1 patient was lost to follow-up) and 18 of 26 (69%) patients in the QUAD group were classified as responders. After optimizing the LVPCs in 3-month nonresponders in the QUAD group, 21 of 26 (80.8%) patients in the QUAD group were classified as responders at 6 months as compared with 17 of 25 (68%) patients in the CONV group. Left ventricular end-systolic volume (LVESV) reduction, left ventricular ejection fraction (LVEF) increase, and New York Heart Association (NYHA) functional class reduction at 6 months were significantly greater in the QUAD group than in the CONV group (LVESV: −26.9 ± 13.8 vs −17.2 ± 13.3%; P = .013; LVEF: +12.7 ± 8.0 vs +7.8 ± 6.3 percentage points; P = .017; NYHA: −1.27 ± 0.67 vs −0.72 ± 0.54 functional classes; P = .002). Conclusions: Compared with conventional bipolar leads, CRT using quadripolar leads with repetitive optimized LVPCs resulted in an additional increase in LVEF and reduction in LVESV and NYHA functional class at 6-month follow-up.

Delayed efficacy of radiofrequency catheter ablation on ventricular arrhythmias originating from the left ventricular anterobasal wall

BACKGROUND Ventricular arrhythmias (VAs) originating from the left ventricular anterobasal wall (LV-ABW) may represent a therapeutic challenge. OBJECTIVE The purpose of this study was to investigate the delayed efficacy of radiofrequency catheter (RFCA) ablation without an epicardial approach on VAs originating from the LV-ABW. METHODS Eighty patients (mean age 46.9 ± 14.9 years; 47 male) with VAs originating from the LV-ABW were enrolled. After systematic mapping of the right ventricular outflow tract, aortic root, adjacent LV endocardium, and coronary venous system, 3-4 ablation attempts were made at the earliest activation sites and/or best pace-mapping sites. Delayed efficacy was evaluated in patients with acute failure. RESULTS During mean follow-up of 23.8 ± 21.9 months (range 3-72 months), complete elimination of all VAs was achieved in 47 patients (59%) and partial success in 19 (24%), for an overall success rate of 83%. In 25 of 37 patients (68%) with acute failure, VAs were eliminated or significantly reduced (>80% VA burden) by the delayed effect of RFCA during follow-up. Logistic regression analysis revealed that response time to ablation was a predictor of occurrence of delayed efficacy. No complications occurred during follow-up. CONCLUSION Instead of extensive ablation, waiting for delayed efficacy of RFCA may be a reasonable choice for patients with VAs arising from the LV-ABW.