Jose Maria Tolosana

Background: Sinus node dysfunction (SND) is rare in the paediatric population. Leadless atrial pacing represents a novel therapeutic option. To our knowledge, this case represents the youngest reported patient to receive an atrial leadless pacemaker (AVEIR AR). While ventricular leadless pacing has been described in children, atrial leadless pacing experience in this population remains extremely limited. Case Summary: An 11-year-old boy with lifelong bradycardia documented since fetal life presented with exertional dyspnoea and recurrent syncopal episodes. Electrocardiography revealed nodal rhythm without sinus activity. Electrophysiological evaluation demonstrated a corrected sinus node recovery time (cSNRT) of 4800 ms and absence of chronotropic response to intravenous atropine (0.04 mg/kg IV). The patient met Class I criteria for permanent pacemaker implantation according to current paediatric pacing consensus recommendations, given symptomatic sinus node dysfunction with chronotropic incompetence. An AVEIR AR leadless pacemaker was successfully implanted at the base of the right atrial appendage with optimal electrical parameters. No procedural or 18-month follow-up complications were observed. Discussion: This case demonstrates procedural feasibility of atrial leadless pacing in a carefully selected paediatric patient, with encouraging mid-term follow-up. Larger studies are required to establish long-term safety and clinical outcomes.

Background: Optimization of biventricular pacing for cardiac resynchronization therapy (CRT) with fusion (fusion‐optimized intervals method) has been shown to improve left ventricular remodeling. However, information on programming the atrioventricular (AV) interval during left bundle branch pacing (LBBP) is scarce. Objective: Assess with electrocardiographic imaging (ECGI) the electrical benefit of optimization of the AV interval during LBBP. Methods: Retrospective analysis of prospectively collected data. Pilot study including patients who received LBBP with CRT indication, normal AV conduction, sinus rhythm, and left bundle branch block. ECGI was used to obtain non‐invasive activation maps, ventricular activation times, and QRS widths during the optimization of the AV interval. Results: A total of 10 patients who received LBBP were included. Median age was 62 years (57–74 years), 40% were women, 20% had ischemic cardiomyopathy, and baseline LVEF was 29% (23%–36%). The baseline median QRS duration was 178 ms (168–187 ms), with a left ventricular activation time (LVAT) of 99 ms (90–109 ms), a right ventricular activation time (RVAT) of 42 ms (34–71 ms), and a total ventricular activation time (TAT) of 111 ms (105–131 ms). A non‐tailored AV programming showed a QRS measured from intrinsic deflection of 142 ms (137–149 ms); when a tailored AV was programmed, the median QRS decreased to 124 ms (116–130 ms). Ventricular activation times showed shortening with a tailored approach. Conclusion: AV interval adjustment during left bundle branch pacing may result in better resynchronization.

Introduction: Electrogram peak‐to‐peak voltage depends on atrial wall structure and mapping configuration. We evaluated the relationship between computed tomography–derived atrial wall thickness, intramyocardial fat, myocardial muscle thickness, and electrogram voltage obtained with omnipolar, bipolar, and unipolar mapping. Methods: Consecutive patients undergoing left atrial mapping during atrial fibrillation or atypical atrial flutter ablation were retrospectively included. Pre‐procedural contrast‐enhanced CT was processed with ADAS 3D to quantify left atrial wall thickness and intramyocardial fat infiltration, from which myocardial muscle thickness was derived. High‐density electroanatomical maps were spatially co‐registered with CT. Associations between anatomical parameters and peak‐to‐peak voltage were assessed, stratifying by rhythm stability. Results: Twenty patients were included. In stable rhythms, left atrial wall thickness correlated positively with voltage for all configurations, strongest for unipolar ( β = 0.38) and omnipolar ( β = 0.23) vs. bipolar mapping ( β = 0.13) (BP–UP p < 0.0001; BP–OT p < 0.01). Intramyocardial fat showed the strongest inverse association with omnipolar ( β = –0.39), compared with bipolar ( β = –0.14) and unipolar ( β = –0.01; p ≤ 0.02). After excluding fat, muscle thickness correlated positively with OT ( β = 0.30) and UP ( β = 0.30), exceeding BP ( β = 0.14; p < 0.0001). In unstable rhythms, associations were attenuated but OT remained most responsive to fat ( β = –0.20) and muscle thickness ( β = 0.11) (both p < 0.01). Conclusions: Myocardial muscle thickness is the main determinant of local atrial voltage, while intramyocardial fat contributes to voltage attenuation. OT provides the most consistent assessment of atrial wall composition, particularly under rhythm instability.

Background/Objectives: Frailty and congestion are highly prevalent in patients with heart failure (HF) and are independently associated with adverse outcomes. However, their interrelationship and combined prognostic significance remain incompletely understood. We aimed to investigate the association between frailty and congestion phenotypes in older patients with HF and to evaluate their combined impact on clinical outcomes. Methods: We prospectively included 308 ambulatory patients aged ≥65 years with chronic HF from a specialized HF clinic between 2022 and 2024. Frailty was assessed using the Fried phenotype. Congestion was defined by clinical signs and/or elevated NT-proBNP (≥1000 pg/mL) and CA125 (≥35 U/mL). Associations between congestion and frailty were evaluated using logistic regression and restricted cubic spline analyses. The primary endpoint was a composite of all-cause mortality or HF hospitalization at 1 year. Results: Frailty was present in 49.7% of patients and congestion in 79.9%. Frailty prevalence increased progressively across congestion phenotypes, from 21.0% in patients without congestion to 70.8% in those with combined clinical and biochemical congestion (p < 0.001). Congestion was also associated with worse nutritional status and reduced muscle strength. In multivariable analyses, frailty and congestion remained independently associated with adverse outcomes. Their coexistence identified the subgroup with the highest risk of death or HF hospitalization (HR 25.54, 95% CI 3.46–188.26; p = 0.001). Conclusions: In older ambulatory patients with HF, frailty and congestion frequently coexisted and identified patients at increased risk of adverse outcomes, particularly when clinical and biochemical congestion were present. These findings support combining frailty evaluation with congestion assessment for prognostic stratification.

Background: Sinus node dysfunction (SND) is a well-recognized complication after orthotopic heart transplantation (OHT), particularly in recipients of biatrial anastomosis. In this setting, conventional transvenous pacing may be technically challenging due to complex post-surgical anatomy and increased infection risk. Case summary: A 36-year-old woman with restrictive cardiomyopathy underwent successful biatrial OHT. Eleven months later, she presented with persistent junctional rhythm and exertional fatigue. Electrophysiological study confirmed electrical dissociation between the donor and recipient atria with preserved atrioventricular conduction but absent sinus activity. Considering her immunosuppressed status and challenging anatomy, a leadless atrial pacemaker (Aveir AR, Abbott) was implanted under three-dimensional computed tomography (CT)–fluoroscopy fusion guidance. The device was positioned at the base of the donor right atrial appendage, achieving optimal electrical parameters. The procedure was completed without complications, and at follow-up, the patient showed complete symptom resolution and improved chronotropic response. Conclusion: This case demonstrates the feasibility and safety of CT–fluoroscopy–guided leadless atrial pacing in a post-transplant recipient with persistent SND, highlighting the value of advanced imaging for accurate spatial orientation and device deployment in complex post-surgical anatomy.

BACKGROUND: Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is useful for identifying ventricular tachycardia (VT) substrate in patients with structural heart disease. While preprocedural LGE-CMR is widely used for planning, the role of postprocedural LGE-CMR in evaluating VT ablation success and long-term scar evolution has been less explored. This study aimed to prospectively and systematically assess the long-term evolution of scar and ablation lesions using serial postablation LGE-CMR with long-term follow-up. METHODS: This prospective study included 51 patients (mean age, 65.2±9.8 years; men, 95.8%; ischemic heart disease, 83%; left ventricular ejection fraction, 34.5±10.4%) undergoing their first substrate-based VT ablation between March 2019 and July 2020. Preprocedural LGE-CMR and 2 postprocedural scans at 3 to 6 months (CMR-1) and 18 to 24 months (CMR-2) were performed. Scar characteristics, including core scar, border zone, and conducting channels, were analyzed. VT recurrence was monitored, and factors associated with recurrence were evaluated using a Cox proportional hazards model. A Kaplan-Meier curve was used to represent the VT-free survival function. RESULTS: Core scar mass increased significantly from baseline to CMR-1 (12.2±1.5 to 19.8±1.6 g, P P P P =0.012). Evidence of favorable left ventricular remodeling was observed, with a significant reduction in left ventricular volume at CMR-2 (131.8±8.6 mL; CMR-1, 156.7±8.1 mL and 160.8±7.6 mL at baseline <0.01). CONCLUSIONS: Postablation LGE-CMR reveals durable changes in scar characteristics, with early scar evaluation at 3 to 6 months strongly associated with long-term VT recurrence. The reduction in scar heterogeneity and conducting channels is sustained over time, underscoring the usefulness of LGE-CMR for assessing ablation success. Additionally, VT ablation appeared to be associated with favorable reverse remodeling, highlighting potential benefits beyond arrhythmia control. These findings support the use of LGE-CMR for personalized management following VT ablation.

Jana Reventos-Presmanes, MSc, Andrea Cano, MSc, Eric Invers-Rubio, MSc, Berta Pellicer-Sendra, B.Eng, Jaume Serrano, B.Eng, Ernesto Zacur, PhD, Till F Alth

BACKGROUND: Atrial fibrillation (AF) is associated with reduced quality of life and frequent hospitalizations. Integrated nurse-led care (NLC) has proven beneficial in unselected AF patients, but evidence specific to patients undergoing catheter ablation is limited. We aimed to assess the impact of a structured nurse-led intervention in patients undergoing first-time AF ablation. METHODS: NURSECAT-AF was a single-center prospective randomized clinical trial comparing usual care with NLC, which incorporated an AF educational program, peri-procedural support, and risk factor management. Consecutive patients without heart failure referred for first-time AF ablation were randomized to NLC or usual care. NLC visits were scheduled at 15 days preablation, 15 days, and 6 months postablation. The primary end point was quality of life at 12 months postablation using the arrhythmia-specific scale in tachycardia and arrhythmia. Secondary outcomes included arrhythmia recurrence, readmissions and emergency visits, and symptom burden at 1 year and AF knowledge and satisfaction at 3 months. RESULTS: Of 116 patients screened, 66 were randomized (33 per group; mean age 63±10 years; 67% male). At 12 months, the NLC group showed statistically significant better quality of life (baseline-adjusted arrhythmia-specific scale in tachycardia and arrhythmia difference +4 points [95% CI, 1.8–6.3]; P =0.0007) than usual care, and presented with less arrhythmia recurrences (odds ratio, 0.2 [95% CI, 0.05–0.78]) and emergency visits (odds ratio, 0.2 [95% CI, 0.06–0.66]). Patients assigned to NLC also presented with a lower symptom burden, higher satisfaction, and greater disease knowledge. Risk factor profile was improved in the NLC group, with higher rates of smoking cessation, engagement in regular physical activity, and weight optimization. Nurse-led management enabled more frequently diagnosing obstructive sleep apnea. CONCLUSIONS: Nurse-led, integrated care for patients undergoing AF ablation improves the quality of life, clinical outcomes, and risk factor management at 1 year postprocedure. These findings support the incorporation of structured nurse-led interventions in the peri-ablation care pathway. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05333445.

Background: Positron emission tomography (PET) is a valuable tool in the diagnosis of cardiovascular infections. However, increased radiotracer uptake can also be observed in non-infectious inflammatory processes, leading to potential false positives. This study analyzed the uptake related to left atrial appendage closure devices (LAACD—AtriClip^®) to determine its association with infectious or inflammatory processes. Methods: We retrospectively analyzed 28 PET/CT scans from 20 patients with implanted LAACDs: 24 using ¹⁸F-fluorodeoxyglucose (FDG) and 4 using ¹⁸F-Choline (CHO). Clinical, laboratory, and imaging data were reviewed, and PET uptake was measured semi-quantitatively. All patients had at least 12 months of follow-up after PET imaging to assess for evidence of device-related infection. Results: Homogeneous PET uptake in the LAACD was observed in 93% (26/28) of the PET studies, regardless of the radiotracer used, clinical indication, or time since implantation. Clinical follow-up and laboratory findings revealed no signs of infection related to the LAACD in any case. SUV ratios did not differ significantly between the three PET indication groups (infection, neoplasia, or other; p = 0.46), nor between scans performed in patients with and without other confirmed infections unrelated to the LAACD (p = 0.37). Conclusions: FDG and CHO uptake in LAACDs appears to be a consistent and reproducible finding, most likely reflecting a sterile inflammatory response postoperative inflammatory uptake rather than true infection. Clear recognition of this uptake pattern is important to prevent misinterpretation and reduce the risk of false-positive PET/CT results in patients evaluated for suspected cardiovascular infections.