The edition · Cardiology
Left bundle branch area pacing matched biventricular pacing after AV node ablation
CONDUCT-AF found the same ejection fraction gain with a narrower QRS and a shorter procedure. Also: an AHA statement on antiplatelet stewardship, disease-specific mitral regurgitation thresholds in ATTR cardiomyopathy, and which vulnerable plaques may benefit from preventive PCI.
The edition in brief
Today's cardiology edition closes on CONDUCT-AF. In 82 patients with refractory atrial fibrillation, heart failure with LVEF below 50% and a narrow QRS, left bundle branch area pacing after atrioventricular node ablation was non-inferior to biventricular pacing: LVEF rose from 36% to 46% and from 34% to 46% respectively, a between-group difference of 0.4 percentage points (95% CI −3.1 to 3.8). Paced QRS was 14 ms shorter and procedures were quicker with conduction system pacing. An AHA scientific statement sets out the case for multidisciplinary antiplatelet stewardship in acute and chronic coronary disease, focusing on transitions of care and adherence. In 1,101 patients with transthyretin amyloid cardiomyopathy, mitral regurgitation thresholds associated with worse outcomes were well below guideline cut-offs, and a composite grading scheme classed 21% as severe against about 12–13% with guideline criteria. A post hoc analysis of the PREVENT trial found that preventive PCI of non-flow-limiting lesions was associated with fewer events only where near-infrared spectroscopy showed a lipid-rich plaque (adjusted HR 0.23), not in other high-burden lesions; this is hypothesis-generating. The pearl covers pacing rate after AV node ablation.
AHA statement: antiplatelet therapy needs a team, not a single prescriber
Put the planned duration and de-escalation date of antiplatelet therapy in writing at discharge, and check adherence at the first visit.
Mitral regurgitation in ATTR cardiomyopathy carries risk at lower thresholds
In ATTR cardiomyopathy, record quantitative mitral regurgitation measures and treat lower-grade regurgitation as a sign of higher risk.
Preventive PCI was linked to benefit only in lipid-rich plaques
Keep optimal medical therapy as the standard for non-flow-limiting lesions; treat lipid-rich plaque as a research signal, not an indication.
After AV node ablation, start with a higher pacing rate
Set a lower rate of about 80–90 bpm after AV node ablation and book the visit to reduce it at one to two months.
Conduction system pacing was non-inferior to biventricular pacing after AV node ablation
For ablate-and-pace in heart failure with AF, consider left bundle branch area pacing as an alternative to biventricular pacing where operators are experienced.
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