Félix, Iuri Ferreira

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.

ABSTRACT Background The efficacy and safety of PolarX cryoballoon for pulmonary vein isolation (PVI) among patients with atrial fibrillation (AF) is unclear. Methods PubMed, Embase, Cochrane Central, and ClinicalTrials.gov were systematically searched for studies comparing the PolarX vs. standard cryoballoon (CB‐2/CB‐4). Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (95% CIs) were computed for binary and continuous outcomes, respectively. Results This systematic review and meta‐analysis included 2 randomized controlled trials and 18 observational studies with a total of 7107 patients, of whom 3.188 (44.8%) underwent ablation with PolarX. When compared to standard cryoablation, PolarX had similar incidence of atrial arrhythmias recurrence (OR 1.04; 95% CI 0.82–1.32; p = 0.73), acute PVI success (OR 0.91; 95% CI 0.31–2.68; p = 0.98), and procedural duration (MD 3.41; 95% CI ‐2.89 to 9.71; p = 0.29). However, PolarX was associated with higher persistent phrenic nerve palsy (OR 2.17; 95% CI 1.26–3.74; p = 0.005) and a lower nadir temperature in all veins. Additionally, in a subgroup analysis of randomized trials and propensity score matching studies, similar findings were noted for recurrence of atrial arrhythmias. Conclusion In patients with AF undergoing PVI, PolarX had similar acute PVI success, procedural duration, and recurrence of atrial arrhythmias as compared with standard cryoballoon technology, however, was associated with a lower nadir temperature, and higher rates of persistent nerve palsy.

Summary Introduction Postoperative delirium is a common complication following cardiac surgery. Despite its known impact on patient outcomes, effective preventative strategies remain elusive. We aimed to perform a comprehensive Bayesian network meta‐analysis of randomised controlled trials assessing the effect of pharmacological interventions on the incidence of postoperative delirium. Methods Databases were searched from inception to September 2024. Our search was updated in January 2025. Eligible studies included randomised controlled trials reporting the incidence of postoperative delirium in patients having cardiac surgery treated with pharmacological interventions. Bayesian models were used to estimate risk ratios (RR) and mean differences with 95%CrI through Markov chain Monte Carlo. Interventions were ranked using the surface under the cumulative ranking curve. Sensitivity analyses and grading of recommendations, assessment, development and evaluation assessment were conducted to evaluate the robustness and certainty of evidence. Results Seventy‐nine randomised controlled trials comprising 24,827 patients were included, with 29 pharmacological interventions compared. Dexmedetomidine combined with melatonin was the most effective intervention, reducing the incidence of postoperative delirium compared with placebo (risk ratio 0.31, 95%CrI 0.13–0.69; low certainty). Dexmedetomidine with melatonin also significantly decreased intensive care unit stay (2.4 days, 95%CrI ‐3.50–1.10) and hospital stay (1.32 days, 95%CrI ‐2.09 to ‐0.57). Other interventions, including ketamine and risperidone, showed potential efficacy but with low or very low certainty of evidence. Discussion We identified dexmedetomidine with melatonin as the most effective pharmacological strategy for preventing postoperative delirium following cardiac surgery. Whilst these findings highlight potential benefits, the low certainty of evidence underscores the need for more high‐quality primary evidence.

ABSTRACT Background High‐power short‐duration (HPSD) ablation has emerged as a promising alternative to conventional power delivery (CPD) for pulmonary vein isolation (PVI) among patients with atrial fibrillation (AF), though its efficacy, procedural efficiency, and safety profile remain uncertain. Aims To evaluate and compare the efficacy, procedural efficiency, and safety of HPSD versus CPD ablation strategies for PVI in patients with AF through a systematic review and meta‐analysis of randomized controlled trials (RCTs). Materials and Methods PubMed, Embase, Cochrane Library, and ClinicalTrials.Gov databases were systematically searched for RCTs comparing HPSD with CPD ablation for PVI in patients with AF. Random‐effects models were used to pool hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals (CI). R version 4.4.2 was used for statistical analysis. Results Eight RCTs with 1094 patients (558 undergoing HPSD and 536 undergoing CPD ablation) were included. No significant differences were found in freedom from arrhythmia during the follow‐up period (HR: 0.77; 95% CI: 0.41–1.45; p = 0.424). AF recurrence did not differ (RR: 0.83; 95% CI: 0.59–1.16; p = 0.268) between groups. HPSD had a significantly shorter procedural (mean difference [MD]: −21.93 min; 95% CI: −31.34, −12.53; p < 0.001) and RF ablation times (MD: −13.87 min; 95% CI: −19.46, −8.27; p < 0.001). No differences were observed in fluoroscopy time and first‐pass isolation for right and left pulmonary veins. There was no difference in esophageal lesion rates, pericardial, or neurological complications, but there was a higher incidence of steam pops in HPSD (RR: 3.42; 95% CI: 1.45–8.09; p = 0.005). Discussion Although HPSD ablation did not significantly improve freedom from arrhythmia or reduce AF recurrence compared to CPD, it demonstrated enhanced procedural efficiency, with shorter procedure and RF ablation times. Despite the higher rate of steam pops, the overall safety profile was similar between both groups. Conclusion High‐power short‐duration ablation for pulmonary vein isolation in atrial fibrillation demonstrated comparable efficacy and safety to conventional power delivery, with the added benefit of shorter procedure and RF ablation times. However, HPSD ablation was associated with increased occurrence of steam pops.

Background: Ventricular tachycardia (VT) is a life-threatening arrhythmia frequently observed in structural heart diseases, including LMNA-related cardiomyopathy, a genetic disorder associated with high risk of sudden cardiac death and progressive systolic dysfunction. While catheter ablation is an established therapeutic option for VT, its efficacy in cardiac laminopathy remains poorly defined. Objectives: To synthesize available evidence on the role and outcomes of VT ablation in patients with cardiac laminopathy. Methods: A systematic review and single-arm meta-analysis was performed in accordance with PRISMA guidelines. PubMed, Embase, and Cochrane databases were searched for studies reporting VT ablation outcomes in LMNA-related cardiomyopathy. An inverse variance random-effects model was applied for meta-analysis of proportions. Results: Seven studies (six cohorts, one abstract) comprising 62 patients (mean age 53.2 ± 9.7 years; 85% male; 88% with implantable cardioverter-defibrillator) were included. An endocardial/endo-epicardial approach was used in 93% of cases. Acute procedural success was achieved in 37% (95% CI: 14–63%; I 2 = 27.4%), and 28% required multiple procedures. Over a median follow-up of 26 (9–35) months, VT recurrence occurred in 91% (95% CI: 76–100%; I 2 = 37.2%). All-cause mortality was 54% (95% CI: 39–70%; I 2 = 28%), predominantly from cardiac causes (51%, 95% CI: 25–76%; I 2 = 53%), and 14% (95% CI: 1–34%; I 2 = 42%) underwent heart transplantation. Conclusions: In LMNA-related cardiomyopathy, catheter ablation is associated with high VT recurrence, limited long-term success, and substantial cardiovascular mortality and transplantation rates, underscoring the importance of ICD implantation and the need for alternative strategies, including variant-specific and molecularly targeted therapies.

Background. The Fontan procedure has transformed the management of congenital heart defects characterized by single ventricle physiology, yet it predisposes individuals to Fontan-associated liver disease. Combined heart and liver transplantation (CHLT) emerges as a therapeutic option, but evidence of its efficacy and safety remains limited. This study aimed to comprehensively evaluate CHLT in Fontan patients, focusing on patient characteristics, perioperative outcomes, and posttransplant morbidity and mortality. Methods. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted. Studies meeting the intervention of CHLT in Fontan patients were included, and data were collected and synthesized using proportion meta-analysis techniques. Statistical analysis was carried out using R software. Results. Four studies met inclusion criteria, comprising 67 Fontan patients undergoing CHLT. All included studies were observational retrospective cohorts performed in the United States. The 1-y survival rate post-CHLT was 88% (95% confidence interval [CI], 70%-98%). Liver graft rejection rates were low, 4% (95% CI, 0%-22%), and no heart graft rejection greater than mild was reported. Postoperative complications included acute kidney injury 75% (95% CI, 50%-93%), temporary dialysis 27% (95% CI, 9%-51%), neurologic events 7% (95% CI, 0%-26%), infection 23% (95% CI, 3%-55%), and unplanned medical procedures 40% (95% CI, 23%-59%). Conclusions. CHLT in Fontan patients demonstrates promising survival rates, but graft rejection and postoperative complications pose challenges. The rate of renal complications is particularly notable and requires further evaluation. Future research should prioritize comparative different management strategies and long-term follow-up to refine protocols and optimize outcomes.

Introduction: High-power short-duration (HPSD) ablation has emerged as a promising alternative to conventional power delivery (CPD) for pulmonary vein isolation (PVI) among patients with atrial fibrillation (AF). However, its efficacy, procedural efficiency, and safety profile remain uncertain. Methods: PubMed, Embase, Cochrane Library and ClinicalTrials.Gov databases were systematically searched for randomized controlled trials (RCTs) comparing HPSD with CPD ablation for PVI in patients with AF. Random-effects models were used to pool hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals (CI). R version 4.4.2 was used for statistical analysis. Results: Seven RCTs with 1,006 patients (514 HPSD, 489 CPD) were included. No significant differences were found in freedom from arrhythmia during the follow-up period (HR 0.77; 95% CI 0.41–1.45; p=0.424). AF recurrence did not differ (RR 0.94; 95% CI 0.65–1.36; p=0.733) between groups. HPSD had a significantly shorter procedural (MD -22.61 min; 95% CI -33.18, -12.04; p<0.001) and RF ablation times (MD -15.70 min; 95% CI -20.86, -10.55; p<0.001). No differences were observed in fluoroscopy time and first-pass isolation for right and left pulmonary veins. There was no difference in esophageal lesion rates, pericardial, or neurological complications, but there was a higher incidence of steam pops in HPSD (RR 3.42; 95% CI 1.45–8.09; p=0.005). Conclusion: In patients with AF undergoing PVI, HPSD did not increase freedom from arrhythmia as compared with CPD ablation, however it was associated with shorter procedure and RF ablation times with a similar safety profile.

Background: The Fontan procedure has transformed the management of congenital heart defects (CHD) characterized by single ventricle physiology, yet it predisposes individuals to Fontan-associated liver disease (FALD), potentially leading to end-stage liver disease (ESLD). Combined heart and liver transplantation (CHLT) emerges as a therapeutic option, but evidence on its efficacy, safety, and outcomes remains limited. Objectives: This systematic review and single-arm meta-analysis aims to comprehensively evaluate the literature on CHLT in Fontan patients, focusing on patient characteristics, perioperative outcomes, and post-transplant morbidity and mortality. Methods: A systematic search of PubMed, Embase, and Cochrane Central Register of Controlled Trials was conducted following PRISMA guidelines. Studies meeting the intervention of CHLT in Fontan patients were included and data were collected and synthesized using proportion meta-analysis techniques. Statistical analysis was carried out using R software. Results: Four studies met inclusion criteria, comprising 67 Fontan patients undergoing CHLT. All included studies were observational retrospective cohorts performed in the United States. One-year survival rate post-CHLT was 84% (95% CI 66%-94%), Figure 1A. Rates of liver and heart graft rejection were low 10% (95% CI 3%-33%) and 8% (95% CI 2%-31%), respectively, Figure 1B. Postoperative complications included acute kidney injury 72% (95% CI 46%-88%), temporary dialysis 31% (95% CI 14%-55%), neurologic events 14% (95% CI 5%-34%), infection 24% (95% CI 6%-63%), and unplanned medical procedures 41% (95% CI 24%-60%), Figure 1C. Conclusion: CHLT in Fontan patients demonstrates promising survival rates, but graft rejection and postoperative complications pose challenges. The rate of renal complications is particularly notable and requires further evaluation. Future research should prioritize comparative different management strategies and long-term follow-up to refine protocols and optimize outcomes.

Background: LQTS is a genetic heart disease associated with an increased risk of sudden death. Despite advances in genetic testing, a small subset of patients still lacks identifiable genetic markers. Consequently, the true prevalence and clinical phenotype of genotype negative remains to be determined. Objective: To determine the prevalence and clinical characteristics of patients with a clinical diagnosis of LQTS but a negative genetic test. Methods: A retrospective review was conducted on patients evaluated and treated at a tertiary hospital between 2000 and 2024, focusing on those with a clinical diagnosis of LQTS, but a negative genetic test for all LQTS-associated genes, with available follow-up of at least 1 year. Results: After exclusion for follow-up and lack of genetic testing, the study cohort consisted of 1834 patients with LQTS including 1708 (93%) with a (likely) pathogenic (LP/P), LQTS-causative variant. Also, in 95 patients (5%), their variant of uncertain significance was clinically upgraded to a LP/P-variant, leaving only 31 patients classified as phenotype positive but genotype negative (1.6%). Of these, 16/31 underwent next-generation genetic sequencing, revealing the genetic cause in 6/16 cases (37%; 0.3% of all patients). For the remaining 25 genotype negative LQTS patients (1.3%), the mean age at diagnosis was 26 ± 15 years, with 19 (76%) being female, and an average initial QTc of 497 ± 41 ms. In total, 11 patients (44%) experienced a cardiac event before diagnosis [1 sudden cardiac arrest (SCA), 1 Torsades, 1 VT, 8 syncopes] and 1 patient had his first cardiac event during follow-up; 7/12 patients had more than one subsequent event. Twenty patients were proband (80%) and 6 had a family history of SCA. Eleven patients received an ICD (44%), left cardiac sympathetic denervation was performed in 4 (16%), and 2 patients experienced arrhythmia-related deaths (8%). The mean follow-up since diagnosis was 7 ± 5 years. Conclusion: With a prevalence of genotype-negative LQTS of 2%, the number of these patients is much lower than previously suggested, underscoring the advancements in identifying new genetic markers and the role of phenotype-enhanced variant adjudication and next-generation sequencing. Additionally, significant disease severity was observed in the remaining patients, emphasizing the pivotal role of genotype-phenotype correlations and risk stratification in managing and counseling patients lacking identified LQTS-causing mutations.

Introduction: Long QT syndrome (LQTS) is a potentially life-threatening genetic heart disease. Patients with LQTS may also have co-existent mental health illnesses that may benefit from psychiatric medications. However, because many of these medications have QT-prolonging potential (www.crediblemeds.org), many of these patients receive suboptimal mental health care. Objective: To evaluate the frequency, management, and incidence of breakthrough cardiac events (BCEs) in patients with LQTS and concomitant mental health issues treated with psychiatric medications. Methods: A retrospective review was conducted on patients cared for in Mayo Clinic's Windland Smith Rice Genetic Heart Rhythm Clinic between 2000 and 2024 focusing on patients with LQTS and a concomitant psychiatric diagnosis requiring medication with known, possible or conditional risk of torsades de pointes (TdP). Electronic medical records were reviewed for data. BCEs were defined as LQTS-triggered syncope, seizures, appropriate ICD therapy, sudden cardiac arrest (SCA), or sudden cardiac death (SCD). Patients with missing information were excluded. Results: Overall, 195 /1899 LQTS patients [10%, 86 (43%) with LQT1, 83 (42%) with LQT2, and 16 (8%) with LQT3] had a concomitant psychiatric diagnosis requiring medication [150 female (76%), mean age at diagnosis 27 ± 18 years, median follow-up time 6.6 years (IQR 2.9-13)]. The most common psychiatric conditions were depression (71%), anxiety (62%), and ADHD (9%). The mean duration of therapy was 3.36 +/- 3.48 years and the most common medications used were fluoxetine (26%), sertraline (14%), and escitalopram (11%). There was no significant difference in QTc after starting the first psychiatric medication when compared to baseline (473 ± 33 vs 474 ± 35 ms, p=0.6). Prior to their LQTS diagnosis and while therefore untreated, 61/195 (31%) had at least 1 LQTS-associated cardiac event. This occurred in the setting of a psychiatric drug in 7 patients (11%). Following LQTS diagnosis and treatment, 14/195 patients (7%) have experienced a non-lethal BCE of which only 3/14 (21%) while on psychiatric medications. Conclusions: Although avoidance of medications with known QT-prolonging potential is prudent, attention to patient’s overall well-being besides just their LQTS must be given. After correct diagnosis and treatment, LQTS patients with concomitant mental health issues may be safely and effectively treated with medications known to prolong QTc.