Citations

Abstract Chronic overlapping pain conditions (COPCs) affect a wide population and incur a substantial disease burden including comorbid mental disorders. Although these comorbidities have been extensively documented, the longitudinal trajectories of their onset, particularly for those with three or more conditions, have been rarely studied. We conducted retrospective cohort studies to identify statistically significant COPCs and mental health trajectories in the All of Us Research Program (AoU v8, 338,170 persons) and the Mayo Data Warehouse (3,957,444 individuals). For each trajectory, cases were matched with controls by demographic factors. Logistic regression was then applied to assess the increased likelihood of the final condition given the prior conditions in that sequence. The significant trajectories were visualized as a “pain forest.” More than 88% of trajectories identified from AoU (Male: 78, Female: 361) were reproducible in the Mayo Data Warehouse data (Male: 361, Female: 1286), with female trajectories encompassing more than 96% of the male trajectories. The findings indicate that chronic low back pain generally occurs earlier than other conditions, while fibromyalgia tends to follow other COPCs. Endometriosis seems to be associated with an increased prevalence of COPCs in women. In addition, longer trajectories are associated with a greater risk of developing additional COPC or mental condition. The results offer new insights into the progression of COPCs and associated mental conditions, which may inform healthcare providers and patients in managing and preventing exacerbation of these conditions.

Purpose: Chronic dizziness and imbalance is often difficult to rehabilitate based on the complex set of systems involved. Recently, transcutaneous vagus nerve stimulation (tVNS) has been investigated as a noninvasive means to reduce symptoms associated with vestibular impairment, chronic dizziness, and neurological conditions affecting balance control. The purpose of this integrative review is to examine available data describing therapeutic efficacy and proposed mechanisms of tVNS in adult patients with dizziness and imbalance. Method: PubMed, Europe PMC, and Google Scholar searches were conducted using the following search terms from 1987 to 2024: “vagal nerve stimulat*” OR “vagus nerve stimulat*” OR “transcutaneous vagus nerve stimulat*” OR “tVNS” AND “dizziness,” “vertigo.” Articles were imported for screening and review through Rayyan. Articles discussing the use of tVNS to study metrics related to vestibular and balance function in adult humans were selected for full-text review. Results: Eleven articles were identified as meeting the inclusion criteria and are classified according to the neurotological class studied and level of evidence provided. Available data show that tVNS may benefit patients with dizziness and imbalance based on subjective metrics including quality of life and reduction in dizziness handicap. Less-controlled case study evidence suggests that additional benefit from tVNS may manifest in changes to vestibulo-ocular reflex function. Conclusion: Although tVNS exposure has provided variable degrees of benefit in both subjective (e.g., quality of life) and objective (e.g., changes in vestibulo-ocular reflex function and gait) contexts, the degree to which distinct mechanisms can explain these benefits is unclear.

Abstract Background Patients with atrial fibrillation (AF) are at increased risk of stroke, often arising from a thrombus in the left atrial appendage (LAA). In selected cases, left atrial appendage occlusion or closure is an alternative for stroke prevention with oral anticoagulation. To assess the risk of stroke and the benefit of LAA closure and to select the appropriate device, it is crucial to quantify the morphology and dynamics of the left atrial appendage (LAA). To date, much about LAA dynamics in this setting is unknown, and subsequently the risk of embolic stroke and inappropriate device positioning is insufficiently explored. Purpose We describe the morphological and dynamic differences of the left atrium (LA) and LAA in high risk AF patients compared to controls undergoing trans catheter aortic valve implantation (TAVI). Methods Our study population consists of 14 patients, seven with AF and seven without AF, undergoing TAVI, since dynamic computed tomography (CT) angiography scans are performed in the standard of care in these patients. The scans were acquired every 5% of the cardiac cycle (i.e., R-R interval on the ECG) (Figure 1a). The LA and LAA were semi-automatically segmented (Figure 1b) to determine the following parameters across the entire cardiac cycle: LA volume; LAA volume, depth, height, and length; and ostium area, eccentricity, and diameter. Results AF patients had a significantly larger LA volume (108 mL vs 68 mL, p=0.03), while the LA volume change throughout the cardiac cycle was similar in AF patients and controls. Both groups had an LA volume change of 35mL on average. Figure 1cd shows the LA and LAA volume curves of a patient with and without AF. The LAA ostium size and volume of AF patients exhibited larger dynamic variations than those from non-AF patients, while the ostium eccentricity in AF patients showed less variation and the ostium shape was rounder. Conclusions We found differences in morphologic and dynamic parameters of the LA and LAA between AF and non-AF patients. The morphology and dynamics of the LAA can increase the understanding of LAA thrombus formation. Moreover, it may have implications for the risk of embolic stroke and may assist in the selection of the optimal LAA closure device type and size.

Abstract Introduction Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disorder with a pathogenic mutation identified in approximately 50% of cases. The MYH7 and MYBPC3 genes account for over half of these cases, while dozens of other genes can be pathogenic(1). Genetic test results are not independently used to determine which people with HCM benefit from implanted cardiac defibrillators (ICDs)(2, 3). Little is known about the additive role of genetic testing results to existing indications for ICD insertion. Purpose This study aims to examine the interaction between genetic testing results and existing ICD indications and imaging results on defibrillator discharge rates in HCM. Methods Patients who underwent an ICD for HCM, who underwent a cardiac magnetic resonance (CMR) study and who underwent genetic testing were included across 3 sites. The outcome was the incidence rate of appropriate ICD discharges, calculated using cox regression controlling for current age and primary vs secondary prevention. Interaction analysis between genetic risk factors and existing ICD indications, and with CMR quantification of LGE and septal thickness, was performed, and stratum specific estimates calculated using linear computation. Results 177 patients were included in the study, of whom 70 (39.55%) had a pathogenic mutation, 5 (2.82%) had a variant likely pathogenic (VLP), 44 (24.86%) had a variant of undetermined significance (VUS) and 58 (39.55%) had no identifiable mutation. The event rate was 3.32 {2.28 to 4.84) per 100 person years. There was no association between genetic variables and ICD discharge rate. There was an 80% reduction in ICD discharge rate in people who underwent ICD insertion exclusively for family history of sudden cardiac death or for syncope who had no pathogenic or likely pathogenic mutation, however this change was not statistically significant (table 2). Conclusion There is no strong association between genetic characteristics and ICD discharge rates among people with hypertrophic cardiomyopathy with an existing ICD indication. There is a nonsignificant trend towards fewer ICD discharges among people who underwent ICD insertion for family history alone or for a history of syncope and did not have a pathologic variant.Table 1 Table 2

Abstract Background Cardiac sarcoidosis (CS) is an infiltrative cardiomyopathy characterized by myocardial granulomatous inflammation, leading to conduction system abnormalities and ventricular arrhythmias. Cardiac resynchronization therapy (CRT) outcomes in CS patients are controversial. The efficacy of CRT with left bundle branch area pacing (LBBAP) in these patients has not yet been elucidated. Objective To evaluate electrocardiographic, echocardiographic and long-term clinical outcomes after CRT with LBBAP in CS patients. Methods In this retrospective multicenter study, conducted between June 2020 and March 2024, patients with a histopathologically confirmed diagnosis of CS with an indication for CRT were included in the analysis. The primary outcome was a composite of all-cause mortality, heart failure related hospitalizations, implantable cardioverter defibrillator shocks and requirement of left ventricular assist device/heart transplant. The primary safety outcome was procedure-related complications. Secondary outcomes included pre- and post-procedural electrocardiographic and echocardiographic parameters and change in NYHA functional class. Results A total of 16 patients were included in the analysis (mean age 66.2 ± 9.4 years; 62.5% female; body mass index 30.4 ± 8.5 kg/m2). Four patients (25%) had isolated CS. The median follow-up was 579 [Q1: 295.5 – Q3: 797.5] days. Five patients (31.25%) experienced the composite outcome. Among these, two patients (12.5%) had acute heart failure related hospitalizations, two patients (12.5%) died due to severe pulmonary hypertension and sepsis complicated by cardiorenal syndrome, respectively; and one patient (6.25%) presented an episode of ventricular tachycardia that was successfully terminated with an implantable cardioverter defibrillator shock. No patients required advanced heart failure therapies. There were no procedure-related complications. There was a significant improvement in paced QRS duration (Pre 156.8 ± 36.2 vs. Post 128.3 ± 22.3 milliseconds, p=0.003), left ventricular ejection fraction (Pre 36.5 ± 10.6% vs. Post 50.4 ± 12.2%, p<0.001), left ventricular end systolic diameter (Pre 52 [39.5 – 84.3] vs. Post 41 [29 – 72] millimeters, p=0.011) and left ventricular end diastolic diameter (Pre 66.7 [48 – 159] vs. Post 61 [44 – 135] millimeters, p=0.023). Ten (62.5%) patients exhibited an improvement ≥ I in NYHA functional class post procedure. Conclusion In CS patients, CRT with LBBAP was associated with significant improvements in electrocardiographic and echocardiographic parameters, as well as NYHA functional class, alongside favorable long-term clinical outcomes by optimizing interventricular dyssynchrony.Graphical abstract ECG and Echo parameters

Abstract Background Epicardial access for ventricular arrhythmia (VA) ablation has become integral, particularly in non-ischemic and arrhythmogenic right ventricular cardiomyopathy. General anesthesia (GA) or conscious sedation (CS) is typically employed to minimize patient discomfort and movement during epicardial access. This study aimed to identify key differences in baseline characteristics and procedural outcomes between patients undergoing GA or CS. Purpose This study seeks to compare baseline characteristics, procedural details, and outcomes between patients receiving GA versus CS during epicardial access for VA ablation. Understanding these differences may inform procedural planning and patient selection to optimize outcomes. Methods Patients who underwent epicardial access for VA ablation from 2004 to 2024 were included. Baseline characteristics, procedural details, and outcomes were collected and compared using t-tests between GA and CS patients. Additionally, Kaplan-Meier survival analysis was conducted to compare survival in GA and CS groups, stratified by VA type (Ventricular Tachycardia (VT) and Premature Ventricular Complexes (PVC)). Results The study included 265 patients, with 148 receiving GA and 117 receiving CS. Significant differences in baseline characteristics were observed between the groups. CS patients had a higher ejection fraction (48.71% vs. 40.97%, p < 0.01) and a greater proportion of structurally normal hearts (35% vs. 8%, p < 0.01). GA patients had a higher comorbidity burden, including a greater prevalence of diabetes (21% vs. 10%, p = 0.02), heart failure (70% vs. 41%, p < 0.01), hypertension (48% vs. 33%, p = 0.01), device in-situ (80% vs. 50%, p < 0.01), and ischemic heart disease (25% vs. 12%, p = 0.01). PVC ablation was more common in CS patients (37% vs. 18%, p < 0.01). Fluoroscopy time was longer in CS patients (74.94 vs. 60.42 mins, p < 0.01), and GA patients required more ablation lesions (34.13 vs. 24.06, p < 0.01). Kaplan-Meier survival analysis showed no significant differences in survival between GA and CS groups for either VT or PVC. Complication rates and the combined endpoint of recurrence, heart transplant, or death also did not differ significantly between groups. Conclusions Patients undergoing epicardial access with GA had a higher burden of comorbidities and required more ablation lesions, while those with CS generally had better baseline cardiac function and were more frequently treated for PVCs. Although fluoroscopy time was longer in CS patients, complication rates and the combined outcome of recurrence, heart transplant, or death did not significantly differ between groups. Kaplan-Meier analysis further demonstrated similar survival outcomes between GA and CS groups for both VT and PVC. These findings suggest that both GA and CS can be safely used for epicardial access in VA ablation, with each approach tailored to the patient’s clinical profile and procedural needs.Table 1 Figure 1

Abstract Background Cardiac sarcoidosis (CS) is a rare condition associated with electrical conduction disturbances. Ventricular tachycardia (VT) may be a life-threatening manifestation of CS. Immunosuppressants and antiarrhythmic drugs (AADs) are considered first-line management, but for refractory cases, an implantable cardioverter-defibrillator (ICD) and VT ablation may be required. Purpose This study aims to document predictors for complete acute success after VT ablation in patients with CS. Methods This was a post hoc analysis from an observational study that included patients who underwent VT ablation for cardiac sarcoidosis at our institution from 2007 to 2024. Patients with suspected, clinically diagnosed, or histologically diagnosed CS, according to the JCS 2016 guidelines, were included. The cohort was divided into two groups: patients with complete acute success, defined as no VT induced at the end of the procedure, and patients with no acute success, which included patients with partial success, unsuccessful procedures, and no inducibility test at the end of the procedure. After univariate analysis, variables with an uneven distribution between the two groups (p < 0.1) were included in a multivariate logistic regression analysis. Results A total of 95 patients were enrolled. Complete acute success was achieved in 40 patients (42%). The mean age was 56.7 ± 10.1 years, and 14 (15%) patients were female. Extracardiac sarcoidosis involvement was reported in 38 (40%) patients. Only one patient in the complete acute success group did not have an ICD. Before VT ablation admission, 40 (42%) patients were on immunomodulators, and 78 (82%) on AADs. The mean ejection fraction in the complete acute success group was 44.5% ± 11.9, compared to 41.7 ± 12.0 in the no-complete success group. Among the 53 patients who underwent a PET scan in the 6 months before ablation, 17 (32%) showed active inflammation based on 18FDG uptake, with no significant difference between the two groups. LGE was present in 57 of 58 patients with a cardiac MR before ablation. Septal involvement was more common in the complete success group (86% versus 58%; OR, 4.41; 95% CI, 1.02-27.5; P = 0.039). A multifocal distribution was also more common in the complete success group (95% versus 67%; OR, 10.17; 95% CI, 1.3-468; P = 0.011). Fluoroscopy and total procedure time were comparable between both groups. The presence of clinical VT with an RBBB morphology was more common in the no-complete success group (54% versus 79%; OR, 0.31; 95% CI, 0.09-1.02; P = 0.03). In the multivariate analysis, epicardial LGE was associated with lower odds of complete acute success (adjusted OR, 0.087; 95% CI, 0.008-0.944; P = 0.04). Conclusions In our population, the presence of epicardial LGE on cardiac MR prior to VT ablation was an independent predictor of no complete acute success.

Abstract Background/Introduction Multielectrode mapping catheters enhance the speed and accuracy of 3-dimensional data collection. However, with variable catheter configurations, data acquisition and efficiency may differ. We sought to compare the HD Grid X mapping catheter to a multi linear 8-spline catheter (spline catheter) with respect to chamber modeling speed and accuracy in in-vivo and bench setups. Methods In-vivo: In 6 pigs, 4 physicians used each catheter in a randomized order to create unedited models of the left atrium and ventricle (LA and LV) during coronary sinus atrial pacing. A sensor-enabled ablation catheter marked five locations per chamber while applying 10-15g of force. These markers, which denoted the ‘true’ location of the endocardial surface, were compared to the nearest surface location defined by each mapping catheter. Bench: In a tank setup designed to emulate an LA to pulmonary vein (PV) transition, chamber models were created during robotic manipulation of each mapping catheter. Resulting models were compared to a "gold-standard" model generated using robotic manipulation of sensor-enabled ablation catheters. Additionally, a static shape analysis was performed with each catheter held by a fixture in a deformed (HD Grid X catheter-bent 90o degrees; spline catheter-3 splines bunched) and undeformed state. Images of the physical catheters were captured to determine the true catheter shape and were compared to the renderings from the respective electroanatomical mapping systems (EnSite X v3.1 and Carto v7.2). Results In-Vivo: The mean error between the ablation catheter generated points and the models for HD Grid X trended lower than for the spline catheter by 11.7% (p=0.63; 2.57mm, 2.91mm) in the LA. In the LV, the mean error for HD Grid X was 34.4% (p=0.04; 2.04 mm, 3.67mm) less than for the spline catheter. In the LA, time for model creation for HD Grid X trended higher than for the spline catheter by 14.0% (p=0.34; 524s, 451s). However, in the LV, modeling time for HD Grid X was 22.9% (p=0.05; 368s, 478s) less than for the spline catheter. Bench: Compared to the ablation catheter created models, HD Grid X had a median bloat of 1.70mm (5.91mm max) while the spline catheter had 2.53mm (11.45mm max). The RMS error (mm) for the static shape analysis of electrode positions in an undeformed state was 0.60 for HD Grid X and 2.26 for the spline catheter. In a deformed state, the error was 0.82 for HD Grid X and 2.07 for the spline catheter. Conclusion In this translational model, the HD Grid X catheter created faster and more accurate unedited LV model geometry than the spline catheter, with no statistically significant difference noted in the LA. Bench data further supports the enhanced geometry accuracy seen in-vivo with HD Grid X, which may result in superior anatomical delineation, and faster mapping data acquisition times.