Futela, Pragyat

Background: Nonpharmacologic interventions have known benefits for managing chronic pain, particularly for conditions such as fibromyalgia, and are included in clinical guidelines. However, eye movement desensitization and reprocessing (EMDR) has not been established as a routine clinical practice for pain management. Objective: To systematically review the efficacy of EMDR for managing chronic pain. Methods: A search was conducted to identify randomized clinical trials (RCTs) and observational studies by using the keywords “EMDR” and “chronic pain.” Information was collected on the study population, EMDR protocol, methods for pain assessment, and outcomes. Risk of bias was evaluated, and intervention effect sizes were determined by calculating Hedges g values for long-term follow-up data in RCTs. Results: A total of nine studies, including seven RCTs, were reviewed. The studies used various diverse pain measurement tools and EMDR protocols. All reported significant improvements in pain symptoms with EMDR. Most of the studies reported statistically significant improvements in associated mental health issues, notably in psychological distress (four out of four studies), anxiety (three out of three studies), and depression (three out of four studies). Effect sizes varied among the studies, with three RCTs reporting large effects, two RCTs reporting moderate effects, and one RCT reporting small or nonsignificant effects. Conclusion: EMDR shows promise for managing chronic pain and addressing associated mental health symptoms. Despite study differences and limitations, the findings of this systematic review support the potential use of EMDR for chronic pain management.

Abstract Background Thrombotic Thrombocytopenic Purpura (TTP) is a rare, typically acquired disorder due to an immune-mediated deficiency of ADAMTS13, a metalloprotease responsible for cleaving large multimers of von Willebrand Factor (vWF). In the absence of ADAMTS13 activity, ultra-large vWF multimers accumulate, promoting widespread platelet aggregation and microvascular thrombosis. This consumptive cascade leads to thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological symptoms, and rarely renal dysfunction. Although therapeutic plasma exchange (TPE) has long been the cornerstone of TTP treatment, the FDA approved Caplacizumab as a first-line treatment for TTP in 2019. This drug is a bivalent single-domain antibody that binds to the A1 domain of vWF and prevents its interaction with platelets, thus effectively interrupting the pathogenic cascade, which is associated with a risk of bleeding. Methods We conducted a retrospective cohort study using the TriNetX Global Collaborative Network, comprising data from 152 healthcare organizations. Adults (≥18 years) with a diagnosis of TTP who received Caplacizumab plus TPE were compared to patients with TTP who received TPE alone. 1:1 propensity score matching (PSM) was performed to balance characteristics between cohorts. The primary outcomes assessed were all-cause mortality and major bleeding events over a period of 1 month. Results A total of 4084 patients with TTP were identified, of whom 356 received caplacizumab with TPE and 3728 received TPE. After PSM, 2 balanced cohorts were created: C+P (Caplacizumab + TPE), P only (TPE), each comprising 356 patients. The average age in C+P and P only, after PSM, was 50.4 +/- 16.2 and 50.8 +/- 16.2 years, respectively. Females formed 65.7% of both C+P and P only, and males accounted for 28.4% and 28.7% of C+P and P only, respectively. 2.8% patients in C+P and 7.06% patients in P only had all-cause mortality at the end of 1 month. One-month all-cause mortality was significantly lower in C+P (2.8%) compared to P only (7.06%), with an odds ratio (OR) of 0.385 (95% CI 0.182 to 0.814, p=0.010). Upon assessment of bleeding outcomes, no statistically significant risk difference was noted between the 2 groups, with the odds ratio being 0.974 (95% CI 0.399 to 2.379, p=0.954). Conclusion Our large database study suggests that the addition of caplacizumab to standard TPE therapy is associated with a reduction in one-month all-cause mortality in patients with TTP, without a corresponding increase in major bleeding. However, given the lack of granular clinical data, such as contraindications to caplacizumab use, it is possible that patients who received TPE alone were inherently at a higher risk. As such, while these findings support the potential benefit of early caplacizumab use, they should be interpreted with caution and warrant prospective validation to confirm causality and assess long-term outcomes.

Background: Tricuspid regurgitation (TR) can lead to right ventricular failure (RVF) and poor clinical outcomes. The TriClip™ G4 transcatheter edge-to-edge repair (TEER) system has shown improved outcomes in TR patients and received FDA approval on April 2, 2024. The FDA’s Manufacturer and User Facility Device Experience (MAUDE) database collects mandatory manufacturer reports and voluntary provider reports on device-related complications. Methods: We retrieved all TriClip™-related adverse events from the MAUDE database post-FDA approval, excluding duplicate entries and literature reviews. After removing 47 literature reviews and 36 duplicate reports, 443 unique adverse event reports from 407 procedures (some with multiple events) were analyzed between April 2, 2024, and January 31, 2025. Results: SLDA (Single Leaflet Device Attachment) was the most frequent complication, occurring in 204 cases (Figure 1). Detached leaflets included septal (105 cases), anterior (46), posterior (27), lateral (3), multiple (2), and unreported. Contributing factors included poor imaging, tethered leaflet, clip-clip interaction, dense chordae, large right atrium (RA) or gap size, pacer lead, or prior valve intervention. Persistent TR was a common consequence. SLDA was addressed with additional clips in 77 cases (18 requiring multiple clips), no intervention in 55 cases (13 with significant residual TR), repeat TriClip procedures in 16 cases, and surgical repair in 4 cases. Other complications included partial SLDA (23 cases), clip deployment or gripper malfunctions (68), chordal entanglement (41), leaflet entanglement (3), and clip migration/embolization (6). Migrated clips were found in the RA, right atrial appendage, cardiac vein, or pulmonary artery; three required snare retrieval, and three were left in place. Triclip Steerable Guide Catheter (TSGC) malfunctions, such as leaks, loss of column support, and blockages, were reported in 29 cases, with 27 requiring replacement. Miscellaneous events included residual TR, leaflet grasping issues, F-knob malfunction, lock line jams, and TSGC entanglement. Clip opening during Establishing Final Arm Angle (EFAA) occurred in 25 cases, and leaflet puncture in 15 cases, with one requiring surgical intervention. Conclusion: SLDA was the most frequently reported complication following TriClip™ approval, with some cases leading to severe outcomes. Continued surveillance is crucial to assess long-term safety and optimize procedural strategies.

Background: Papillary Muscle (PM) related ventricular arrhythmia ablation is associated with lower acute success and suboptimal long-term outcomes due to complex anatomy, variable arrhythmogenic sites and dynamic exit points. Objective: To evaluate clinical and procedural outcomes of patients undergoing PM vs non-PM ablation. Methods: A retrospective analysis of adults (≥18 years) undergoing PVC ablation at Mayo Clinic (2019–2024) matched PM PVC ablations to controls (1:2) using propensity scoring based on age, sex, comorbidities and baseline LVEF. Chi-square and t-tests compared baseline and procedural characteristics. Logistic regression estimated odds ratios for immediate procedural success, PVC burden reduction and LVEF improvement at 3 months. Results: Of the 720 ablations, 392 cases were included after propensity matching: 132 PM and 260 non-PM. Patients in the PM group exhibited higher rates of complicated diabetes (9.8% vs 4.6%, p =0.045) and prior MI (18.2% vs 9.2%, p =0.011). Preprocedural ECG PVCs in the PM group showed a shorter intrinsicoid deflection (89.1 ± 35.0 msec vs 100.7 ± 24.3 msec, p <0.001) and longer coupling intervals (532.7 ± 100.3 vs 512.2 ± 81.4 msec, p =0.048).Moderate-to-severe MR was more prevalent in the PM group (17.4% vs 10.0%, p =0.036). Intraoperatively, the PM group had higher total energy delivery times (1939 ± 1336 sec vs 1227 ± 1033 sec, p <0.001) and more frequent cryoablation use (46.2% vs 7.3%, p <0.001). During post-ablation testing, non-clinical PVC was inducible in 39.5% of the cases in PM group compared to 25.7% in non-PM group ( p =0.005). More patients in the PM group were discharged on atleast one antiarrhythmic drug (AAD)(35.9% vs 18.5%, p <0.001) and AAD use persisted at 3 months (31.3% vs 18.4%, p =0.004). Outcomes were similar between groups, with no significant differences observed in immediate ablation success (aOR 0.64, p = 0.063, CI = 0.40-1.03), or >5% improvement in LVEF (aOR 0.76, p = 0.29) and PVC burden reduction (aOR 0.93, p = 0.81) at 3 months follow up. Conclusion: Patients undergoing PM ablation exhibited higher baseline rates of comorbidities. Intraoperatively they required greater energy delivery times, and an increased use of cryoablation. Postoperatively, a larger proportion of PM ablation patients required antiarrhythmic drug therapy. Despite these complexities, PM ablation showed no significant differences in PVC burden reduction, LVEF improvement, or procedural success compared to non-PM ablation.

Background: Catheter ablation of frequent premature ventricular complexes (PVCs) has been demonstrated to improve left ventricular ejection fraction (LVEF) in patients with PVC-induced cardiomyopathy. However, this improvement is not uniformly observed across all patients. Objective: To identify predictors of LVEF improvement following catheter ablation. Methods: This retrospective analysis included adult patients (≥18 years) who underwent PVC catheter ablation at Mayo Clinic, Rochester, between 2021 and 2024. Patients were grouped based on whether they experienced an LVEF improvement of ≥5%. Data on baseline comorbidities,, ECG characteristics, baseline transthoracic echocardiography (TTE), procedural details, and follow-up outcomes at 3-6 months (via Holter monitoring and TTE) were collected. Propensity matching (1:1) was performed using age(caliper=5), sex, and baseline LVEF(caliper=5). Comparative analyses used chi-square and t-tests. Variables with a p-value <0.1 were included in multivariate regression analysis. Results: After propensity matching, 98 patients with LVEF improvement and 98 controls were included. Table 1 summarizes baseline and procedural characteristics, and outcomes. Immediate PVC suppression was more common in the EF improvement group (74.2% vs. 60.4%, p=0.04), and fewer patients in this group were placed on long-term anti-arrhythmic medications (11.2% vs. 27.8%, p<0.01). Multivariate analysis showed that patients without PVC-related symptoms (OR=3.16, p=0.038) had higher odds of LVEF improvement, while those with CKD (OR=0.36, p=0.007) or a coupling interval ≥500 ms (OR=0.38, p=0.002) had lower odds of improvement.

Background: Patients with adult congenital heart disease (ACHD) form a unique subset of patients with complex ventricular tachycardia (VT). Objective: To evaluate the clinical and procedural characteristics and outcomes of patients with congenital heart disease who present for VT ablation. Methods: A single-center, retrospective study of patients undergoing VT ablation was conducted. The primary composite outcome was recurrent monomorphic VT, and repeat ablation. Results: Out of 508 procedures for ventricular tachycardia ablation, 37 were performed in ACHD patients. These patients were younger compared to the non-ACHD subtype.(Table 1). Out of 26 patients with congenital heart disease, a majority had a diagnosis of tetralogy of Fallot (57.6%) and 69% had 2-3 prior open-heart surgeries, including ventriculotomy (53.8%), ventricular septal defect repair (65.3%), and pulmonary valve replacement (57.6%) (Table2). They had a higher mean LVEF,and lower burden of comorbidities including hypertension, chronic kidney disease, and myocardial infarction compared to their non-ACHD counterparts and had been on fewer antiarrhythmics at baseline. ACHD patients were less likely to require epicardial access, but the requirement for induction meds was higher, and energy delivery times were longer. There were no significant differences in the VT characteristics and mapping techniques between the two groups. There were no significant differences in outcomes including complications, and time to recurrence, and a Kaplan-Meier analysis showed no significant difference in VT free survival when ACHD patients were compared to patients without ACHD (Figure 3). After adjusting for age, sex and comorbidities, ACHD was not a predictor of having VT recurrence or repeat ablation (aHR =1.1 (0.7-1.9), p=0.6) Conclusion: VT ablation in patients with ACHD is safe, and as effective as ablation in non-ACHD patients. Procedure times tend to be longer owing to a more challenging substrate.

Background: PAINESD score was established as a predictor of periprocedural acute hemodynamic instability, long-term mortality and heart failure among patients undergoing catheter ablation for ventricular tachycardia (VT-CA). Objective: To assess the validity of PAINESD score and compare outcomes of high-risk patients undergoing catheter ablation for ventricular tachycardia (VT) with and without mechanical circulatory support (MCS) use during procedure. Methods: We conducted an observational dual-center study of consecutive patients with SHD undergoing VT-CA over a decade (2012-2022). The PAINESD score, based on 7 variables (COPD, age >60 years, general anesthesia, ischemic cardiomyopathy, NYHA class III or IV, ejection fraction <25%, VT storm, and diabetes mellitus), was calculated and categorized into low risk (<10), intermediate risk (10-16), and high risk (>16) as previously reported. Two survival analyses were performed to compare outcomes between different groups: one using all-cause mortality or heart transplant as the event, and another using recurrent or repeat ablation as the event. Multivariable Cox proportional hazards regression models were used to calculate hazard ratios for each PAINESD category and to determine the hazard ratio for the use of MCS among high-risk patients. Results: We found that between 2012 to 2022, 559 ablations were performed on 441 patients. There were 296 (53%), 182 (32.6%) and 81(14.5%) patients in low, medium, and high risk. Using low risk as reference, aHR for medium risk was 2.1 (1.24-3.7; p=0.006) and for high risk was 4.6(2.54-8.3; p <0.001). Among patients with high PAINESD score (n=81), 5 patients (6.2%) required MCS (Intra-arterial balloon pump (IABP)=1, ECMO only=1, ECMO+IABP=1, bypass=2). 4/5 (80%) patients on MCS stayed on them post procedure, except one patient on IABP. In this cohort, there was no difference between patients with and without MCS in primary outcome [aHR= 1.6 (0.48-5.4); p=0.43] and in secondary OUTCOME [1.29 (0.3-5.5; p=0.735)]. Conclusion: PAINESD was a significant predictor of mortality or heart failure, but it did not help in prediction of recurrence of VT, or repeat VT-CA.

Background: Patients undergoing epicardial access for ventricular tachycardia (VT) have a higher rate of complications and VT recurrence post-procedure. Data regarding electrophysiological factors driving the outcomes are scant. Objective: To compare the factors and outcomes associated with epicardial vs endocardial VT ablation. Methods: A single-center, retrospective study of patients undergoing catheter ablation for scar-related VT was conducted. Data collected included demographics, comorbidities, medications, relevant laboratory abnormalities, electrocardiograms, echocardiograms, detailed procedural characteristics, and outcomes. Results: Our cohort of 554 patients had 89 (16.1%) epicardial and 465 (83.9%) endocardial VT ablations. Patients undergoing epicardial ablation had a greater frequency of NICM, and more patients had undergone sympathetic modulation for VT (p < 0.05) but had lesser frequency of valve surgery, and CABG. Epicardial ablation was associated with greater use of both short-term (<3 months) and long-term (>6 months) anti-arrhythmic drugs (AAD) (p<0.01). Epicardial access was obtained by micropuncture or needle-in-needle technique for 22.5% (n=20) of patients. Except for more use of general anesthesia and the lesser usage of drugs for VT induction during epicardial procedures, there were no significant differences. Epicardial ablation had a higher risk of acute complications (<30 days) after the procedure (driven by pericarditis) (25% vs 7.8%, p<0.01). On survival analysis, epicardial access was associated with an increase in VT recurrence and repeat ablation (p<0.01) during a mean follow-up of 1072 days. On multivariate analysis, after adjusting for age, sex and comorbidities, epicardial access was an independent predictor of VT recurrence or repeat ablation [aHR 1.61 (CI: 1.18- 2.2)] Conclusion: Patients undergoing epicardial ablations with fewer comorbidities demonstrated increased AAD usage prior to and after the procedure, and a higher risk of acute complications after the procedure. Epicardial access was an independent predictor of VT recurrence or repeat ablation.

Background: In recent years, catheter ablation has emerged as a sustainable, first-line therapy for the management of ventricular tachycardia (VT). Given the rise of the “obesity paradox” theory in atrial ablation outcomes, we sought to study the effect of BMI on patients undergoing structural VT ablation. Purpose: To assess the outcomes of VT ablation, specifically VT recurrence, in patients with elevated vs. normal BMI. Methods: Clinical characteristics and demographic data were collected for VT patients who underwent ablation at Mayo Clinic Rochester from 2012-2022. Patient BMI was classified as non-obese (<30 kg/m2), obese (30-40 kg/m2), and morbidly obese (≥40 kg/m2). The endpoint was a composite of initial monomorphic VT recurrence and repeat ablation after adjusting for age, sex, and comorbidities. Results: A total of 399 patients underwent 508 ablations. 51.4% of ablations had a BMI <30, 39.2% were between 30-40, and 9.4% were ≥40. There was a greater prevalence of hypertension and type 2 diabetes mellitus in morbidly obese patients (p <0.01). Morbidly obese individuals also had a significantly increased rate of general anesthesia during ablation and long VT cycle lengths. The Kaplan-Meier curve demonstrates no statistically significant differences in time to VT recurrence among the three BMI groups (p = 0.324). Neither morbid-obesity (aHR= 1.20; CI = 0.94-1.56, p = 0.14) nor nonmorbid-obesity (aHR = 0.92; CI = 0.76-1.10, p = 0.4), compared to non-obesity was a significant independent predictor of VT recurrence or repeat ablation on multivariate regression after adjusting for age, sex and comorbidities. Conclusion: There was no significant association between BMI groups and VT recurrence or repeat ablation, and no difference in complications. We did not find the obesity paradox to be relevant for VT ablation in our patient population. Further study would be needed with larger samples to corroborate these findings.