bluuebunny/crossref_metadata_2025 huggingface dataset:
Dubious effect of the high biventricular paced beats percentage itself on the cardiac resynchronization efficacy in patients with atrial fibrillation. The randomized Pilot-CRAfT Study results
Authors: Ciszewski JB , Tajstra M , Kowalik I , Maciag A , Zajac D , Pytkowski M , Gasior M , Sterlinski M
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Cardiology statutory grant

Background

The presence of atrial fibrillation (AF) in cardiac resynchronization therapy (CRT) recipients is common and AF is a marker of poorer CRT response. The negative influence of AF on CRT efficacy is belived to be mediated mainly by the drop of effectively captured biventricular paced beats percentage (BiVp%). According to observational trials, the minimal BiVp associated with better outcomes is 95-98%, however there is lack of randomized trials to confirm this findings.

Purpose

The purpose of the study was to assess the influence of BiVp% itself on the clinical outcomes in the population CRT patients with atrial fibrillation in a prospective, randomized cohort.

Methods

The study included the prospective Pilot-CRAfT study participants that is patients with CRT and permanent or persistent AF lasting for ≥6 months that were randomly assigned to rhythm or rate control strategy. We divided the whole study population according to their BiVp at the 12 month follow-up with two borderline BiVp values (BiVp >98% vs <98% and >95% vs <95%) and analysed the echocardiographic indices, exercise tolerance and quality of life between the prespecified groups.

Results

The study included 43 CRT patients (97,7% males) aged 68,4 (SD: ±8,3) years with mean BiVp% 82,4% ±9,7% at baseline. The mean baseline left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD) and maximal oxygen uptake (VO2max) were: 30 ±8%, 65 ±8 mm, 14 ±5 mL/(kg*min), respectively. In both of the study arms the BiVp% raised significantly reaching 98,1 ±2,3% and 96,3 ±3,9% in the rhythm control and the rate control arms respectively (P=0,093). As a result the were overall 21 patients with BiVp >98% and 29 patients with BiVp >95% at the end of the study. The BiVp groups >98% vs <98% and >95% vs <95% did not differ as to baseline characteristics and we have not observed any differences in the mean LVEF, mean LVEDD, mean VO2max, and quality of life in the prespecified BiVp% groups at the end of the follow up. Moreover no linear correlations between the BiVp% and LVEF, LVEDD, VO2max values were observed. However, in the rate control group patients with AVNA performed had lower LVEDD at the end of the study (57,7 ±3,0 vs 65,4 ±7,0 p=0,007) and significant decrease in the LVEDD after AVNA was observed (-8,6 95%CI [-14,9; -2,3]).

Conclusions

The BiVp >98% or >95% alone does not seem to warrant good response to cardiac resynchronization in patients with persistent atrial fibrillation as assessed in the prospective randomized cohort. However, performing AVNA in this group of patients may be beneficial in terms of LVEDD decrease.
Left atrial anatomical variations correlate with atrial fibrillation sources near the left atrial ridge
Authors: Gagyi R , Szegedi N , Simon J , Wijchers S , Bhagwandien R , Kong M , Ruppersberg P , Szili-Torok T
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Anatomical variations and characteristics of the left atrium (LA) may have a previously undescribed effect on source locations in atrial fibrillation (AF). Electrographic flow (EGF) mapping is a novel method used to estimate cardiac action potential flow in the atria that can detect AF sources in patients with persistent AF. The EGF technology offers a revolutionary mapping possibility for AF, however, it is not commercially available yet.

Purpose

This is the first study aiming to investigate the relationship between anatomical characteristics of the LA and non-PV sources detected by EGF in patients with persistent AF.

Methods

We collected cardiac computed tomography (CT) and EGF data from patients who underwent radiofrequency catheter ablation (CA) for persistent AF. EGF mapping creates a spatial and temporal reconstruction of electric potentials derived from endocardial unipolar electrograms. By analyzing EGF maps obtained during CA procedures, we localized non-PV sources in the LA. Patients with individual stable sources with a source activity above threshold (leading source present in more than > 26% of the time) were classified as having an S-Type EGF signature with source-dependent AF. Patients with no stable active source pattern and no leading source with a source activity above threshold were characterized as having a C-Type EGF signature consistent with source-independent AF. We assessed LA anatomical characteristics including size, LAA length, LAA ostial diameter, trajectory of the left superior pulmonary vein (LSPV) and its relation to the LAA on cardiac CT scans. Abutting LAA-LSPV was defined as cases when the LSPV touched the posterior aspect of LAA, and the maximal distance between the two structures was less than 2 mm. Those cases where the distance between LAA and LSPV was more than 2 mm were defined as non-abutting LAA-LSPV.

Results

Thirty patients were included in this study (mean age 62.4±6.8 years):23 patients had an S-Type EGF signature (77%), and 7 patients had a C-Type EGF signature (23%). We identified 10 patients with AF sources near the LA ridge, while twenty patients had no leading source near the LA ridge. LA anatomical characteristics, LAA length and ostial diameter showed no correlation with the presence of a leading source near the ridge. We described 19 patients with abutting LAA-LSPV, and 11 patients with non-abutting LAA-LSPV. Three out of 19 patients presented with a leading source near ridge in the abutting LAA-LSPV group, while 7 out of 11 patients presented with a leading source near ridge in the non-abutting LAA-LSPV group (p=0.01).

Conclusion

Our data suggests that non-abutting LAA-LSPV is associated with the presence of AF sources near the LA ridge.
Impact of mapping technology on procedural characteristics during radiofrequency or cryoballoon pulmonary vein isolation for atrial fibrillation
Authors: Martel J , Addo K , Kim Y , Hamdan F , Demo H , Bonavita G , Li J , Ahmad S , Shah S , Delurgio D , Bailey C , Shim J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cryoballoon ablation (CBA) is often associated with shorter procedure times along with tradeoffs such as increased fluoroscopy use compared to radiofrequency (RF) ablation of atrial fibrillation (AF), however the impact of mapping technology on these characteristics is not fully understood.

Purpose

To assess the effect of mapping technology on trends in fluoroscopy use and procedure times in AF pulmonary vein isolation (PVI) procedures with an RF or CBA catheter.

Methods

Acute procedure data from 210 de novo AF cases using a 3D mapping system was prospectively collected from 48 centers in eight countries. Choice of technology was left to physician discretion; a PVI only ablation strategy was utilized in all cases. Procedure data such as total procedure and fluoroscopy times from cases using either an RF or CBA catheter with either a grid-style mapping catheter (HD Grid) or circular mapping catheter (CMC) were compared.

Results

Of the 210 cases, RF ablation was used in 103 (49%), and CBA used in 107 (51%). In RF cases, a relatively even split between CMC and HD Grid use was observed (n=46, 45% vs. n=57, 55%), while a CMC was used in 100% of CBA cases (Figure 1). Across all cases, fluoroscopy and procedure times were significantly shorter when HD Grid was used (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (20.4±17.6 minutes; 133.7±62.7) (p<0.001; p=0.003). A similar trend was also observed in RF cases using HD Grid (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (17.9±12.3 minutes; 175.1±50.5) (p=0.01; p<0.001). Fluoroscopy times in RF cases with HD Grid (7.4±26.7 minutes) were significantly shorter compared to CBA cases with a CMC (21.5±19.4 minutes) (p<0.001), while procedure times were similar (108.2±46.3 minutes; 116.0±59.2 minutes, p=0.20).

Conclusion(s)

Use of HD Grid resulted in significantly shorter procedure and fluoroscopy times compared to a CMC across all cases, including those using RF ablation. Fluoroscopy times were also significantly shorter in RF cases using HD Grid compared to CBA cases using a CMC, with similar procedure times. These observations suggest that use of HD Grid may better enable safer and more efficient PVI, specifically when employing RF ablation, in addition to safer and equally efficient RF PVI compared to CBA with a CMC. Further study in in a larger, randomized cohort may be necessary.
The triangle correlation among the impact on serum S100B protein release, incidence of the silent cerebral ischemic phenomena and pulsed field ablation for patients with atrial fibrillation
Authors: Tohoku S , Schmidt B , Bordignon S , Chen S , Pansera F , Chun KRJ
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Backgrounds: Pulsed field ablation (PFA) represents a cardiac specific energy source for atrial fibrillation (AF) ablation. The correlation among this remarkable technique, the incidence of silent cerebral ischemic phenomena (SCIP), and the clinical impact on serum S100B release, a well-known neural injury relevant biomarker concomitant to denervation of the intrinsic cardiac autonomic nervous system during AF ablation, has been unclear.

Aims

This study thought to reveal the "triangle correlation" by investigating the serum S100B increase, incidence of SCIP on cerebral magnetic resonance imaging (MRI), and its interactive correlation in PFA using the FARAPULSE system.

Methods and Results

Pre- and postprocedural serum S100B was analyzed in a total of 85 patients who underwent AF ablation using the FARAPULSE PFA device. Cerebral MRI was performed subsequently 24-48 hours after procedure. All PVs (332 PVs) were successfully isolated solely with PFA. No additional left atrial mapping using other catheters was performed.

The median overall serum S100B increase from the preprocedural value was 0.01μg/l (-0.02 – 0.04μg/l). Asymptomatic SCIP were detected on MRI in 10/53 patients (18.9 %). Of those, the patients with SCIP demonstrated a significantly higher S100B release (0.04, 0.02 – 0.16μg/l vs. without SCIP:0.01, -0.04 – 0.03μg/l, p = 0.0038). Receiver operating characteristic curve revealed a predictive cut-off point for SCIP of 0.04 μg/l (sensitivity:0.7, specificity: 0.49).

Conclusions

We revealed no clear detectable impact of PFA on S100B release, highlighting the cardioselectivity with limited concomitant denervation. SCIP was detected approximately in a one-fifth after procedures and was a potential confounder of the higher S100B increase.
Procedural and outcome impact of obesity in cryoballoon versus radiofrequency pulmonary vein isolation in atrial fibrillation patients
Authors: Scheurlen C , Van Den Bruck JH , Dittrich S , Erlhoefer S , Filipovic K , Lueker J , Woermann J , Steven D , Sultan A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon-(CB)- and radiofrequency-(RF)-ablation are the most common techniques for pulmonary vein isolation (PVI) in patients (pts) with symptomatic atrial fibrillation (AF). An increasing number of pts undergoing PVI are obese.

Objective

To address the paucity of procedural differences and outcome data of CB- vs. RF-based PVI in relation to body mass index (BMI) of AF patients.

Methods

All pts undergoing de novo PVI between 01/2018-08/2019 at our university hospital were included in this retrospective analysis. Pts of each group (CB-PVI vs. RF-PVI) were subdivided based on their BMI: normal weight BMI <25kg/m², pre-obesity 25-30kg/m², obesity stage I 30-35kg/m² and severe obesity stage II ≥35kg/m². Hereafter, procedural characteristics and AF recurrence rate during follow-up were compared with regard the different BMI groups.

Results

A total of 526 pts (62% male, 65.3±11.2 years) underwent successful de novo PVI (320 CB and 206 RF). Especially in obese patients, differences in procedural characteristics were noted: A significantly increased contrast medium volume in CB group (all: CB 50 [40-80] vs. RF 20 [20-30], p<0.001; BMI≥35: CB 70 [54.5-102.5] ml vs. RF 20 [15-30] ml, p<0.001). In line with previous studies, the overall procedure time was significantly shorter with CB-PVI (CB 75 [60-100] vs. RF 120 [110-180], p<0.001). Also, as expected, lower fluoroscopy dose was detected in RF group (all: CB 392.4 [197.9-995.9] vs. RF 282.5 [139.8-507.2], p<0.001). The complication rate was equal throughout all BMI groups.

A 12-month follow up was available in 480 of 526 (91%) pts. Freedom from any arrhythmia was comparable between CB-PVI and RF-PVI (CB 77% vs. RF 75%, p=0.63). However, for obese pts a trend towards higher AF recurrence rate after RF- compared to CB-PVI was observed (BMI≥35: CB 24% vs. RF 50%, p=0.099).

Conclusion

For obese pts CB-PVI is similarly safe and effective as RF-PVI. The significantly shorter procedure time for CB-PVI may minimize potential obesity-related complications. However, the lower contrast medium quantity and fluoroscopy dose in RF-PVI must be considered. AF recurrence rates were comparable between CB-PVI und RF-PVI. Randomised trials are needed to evaluate the long-term freedom of AF recurrence in pts with higher BMI comparing CB- vs. RF-based PVI and possible obesity related complication.
The impact of RF wattage level on local impedance and procedural parameters in AF ablation cases
Authors: Meynet I , Stabile G , Mantica M , Ferraro A , D’ammando M , Scaglione M , Di Cori A , Schillaci V , Ottaviano L , Mantovan R , Ferrari F , Bianchi S , Solimene F , Malacrida M , De Sanctis V
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Local impedance (LI) measurement can provide information on catheter tip contact, but also changes in LI during ablation can inform the extent and effectiveness of RF energy delivery. To date the relationship between highly LI measurements and contact force (CF) during atrial fibrillation (AF) ablation at different levels of energy delivery is still lacking.

Purpose

We aimed to evaluate the impact of power setting on LI and key procedural parameters in AF ablation cases.

Methods

A novel CF ablation catheter equipped with dedicated algorithm was used to measure LI at the distal electrode of this catheter. Radiofrequency (RF) catheter applications ≥45 watts were categorized as high power (HP) and applications <45w as standard power (SP). Ablations were also grouped according to different levels of CF (<5g, 5-14g, 15-24g and ≥25g). Data are reported as mean±SD.

Results

Sixty-two consecutive pts undergoing RF catheter ablation of AF from the CHARISMA registry were included A total of 4619 ablation spots performed around PVs were analyzed (58% paroxysmal, 84% de novo, RF deliveries per pt=76±27, RF delivery time=9.1±5s, CF=12.3±8g). The majority of these were HP applications (n=4192, 91%). The mean LI was 158±17Ω prior to ablation and 138±14Ω after ablation (p<0.0001, absolute LI drop of 21.9±8Ω) with a LI drop rate equal to 4.4±3Ω/s. HP ablations had significantly shorter RF delivery times, 8.8±4s vs 12±7s (p<0.0001), larger LI drops (22.2±8Ω vs 19.3±9Ω, p<0.0001) and higher LI drop rates (4.5±3Ω/s vs 3.6±2Ω/s, p<0.0001) than SP, respectively. For both HP and SP settings, the magnitude of LI drop increased and RF delivery time decreased with increasing amounts of CF. The largest differences between HP and SP were found when CF was <15g (RF delivery time: 9±5s at HP vs 12.9±7s at SP, percentage of difference 26.3%, p<0.0001; LI drop: 21.2±8Ω at HP vs 18.6±9Ω, percentage of difference -14.3%, p<0.0001). No major complications occurred during the procedures. All PVs were successfully isolated.

Conclusions

This preliminary experience suggests that, HP ablation is effective and safe and resulting in shorter RF delivery times and larger LI drops than SP ablation.
The impact of atrial fibrillation burden early post cryoballoon pulmonary vein isolation on long-term freedom from recurrent atrial fibrillation
Authors: Musat D , Milstein N , Saberito M , Bhatt A , Habibi M , Preminger M , Sichrovsky T , Shaw R , Mittal S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. A three-month blanking period (BP) is commonly used in clinical trials and practice. Early recurrence of AF portends worse ablation long-term outcome; however, the utility of using AF burden (AFB) early post cryoballoon (CB) PVI to predict long-term outcome is unknown.

Purpose

To determine, using ECG data acquired by an implantable loop recorder (ILR), the relationship between post-ablation AFB and long-term freedom from AF.

Methods

We enrolled consecutive patients with AF who had CB PVI and an ILR. We determined the monthly AFB for the first 3 months post CB PVI and assessed the relationship between AFB and 1-year freedom from AF. We defined 4 distinct AFB groups: (1) 0%, (2) > 0-0.1%, (3) > 0.1-0.5%, and (4) > 0.5%.

Results

There were 210 patients (66 ± 9 years; 138 [66%] male; 116 [55%] paroxysmal AF; CHA2DS2-VASc 2.5 ± 1.6). Following a 3-month BP, 101 (48%) patients had a recurrence of AF at 160 ± 86 days post-ablation. An AFB of > 0% over the first 3 months predicted AF recurrence (p < 0.0001, Figure 1). Patients with > 0.5% AF burden after 1st month and any AF after 2nd month post CB PVI have a very high long-term AF recurrence rate (Figure 2).

Conclusion

The best long term outcome post CB PVI is seen in pts who have no AF in the first 3 months post ablation. An AFB >0.5% after the first month and any AF after the second month portend ablation failure. These data define a clinical utility of using AFB to risk stratify patients post CB PVI.
Single-center outcome after ablation of atrial fibrillation using very high-power short duration pulmonary vein isolation
Authors: Manninger M , Rohrer U , Eberl AS , Pratl B , Loibnegger S , Andrecs L , Zirlik A , Scherr D
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation of atrial fibrillation is (AF) an established second line therapy for patients with symptomatic paroxysmal (PAF) and persistent AF (persAF). Novel ablation catheters with integrated thermocouples allow fast application of radiofrequency lesions with powers up to 90W.

We aimed to describe primary and secondary outcomes after very high-power short duration (vHPSD) ablation.

Methods

126 consecutive patients (78 PAF, 43 persAF, 5 longstanding persistent AF) underwent pulmonary vein isolation (PVI) using the QDOT Micro Catheter (Biosense Webster) with the ablation mode QMODE+ (90W, 4s, interlesion distance ≤4mm anterior, ≤6mm posterior).

Results

Mean age was 62±9 years, 33% were female, median CHA2DS2-VASc Score was 2 (0, 7). Median follow up duration was 204 (14, 461) days. 30% of patients had additional ablation of typical right atrial flutter.

Primary success rate to achieve pulmonary vein isolation was achieved in all patients, no catheter-related complications (e.g., charring, steam pop) occurred. First pass isolation of all 4 PVs was achieved in 48% of patients, re-ablations were necessary in the carina regions (right: 37% of cases, left: 29%) and ridge (14%). Median procedure for PVI only were 102 (45-210) minutes.

Arrhythmia-free survival was 79,6% (see Figure 1). Eight patients underwent re-do procedures during follow-up showing most commonly showing gaps in the right inferior PV (63%) and ridge (50%).

Conclusion

Very high-power short duration ablation allows safe and quick pulmonary vein isolation. However, first pass isolation rate is low due to gaps in the carina regions. Arrhythmia-free survival is comparable to other pulmonary vein isolation techniques.

Figure 1: Left panel: Sample image of a vHPSD-PVI, posterior view of the left atrium. Right panel: Single procedure arrhythmia-free survival after vHPSD-PVI.
Conduction velocity mapping in Bachmann Bundle using Omnipolar Technology
Authors: Volpato G , Casella M , Compagnucci P , Valeri Y , Parisi Q , Cipolletta L , Carboni L , Bondavalli B , La Piscopia V , Messano L , Ricciotti J , Guerra F , Dello Russo A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Bachmann’s bundle is emerging as a critical component of atrial fibrillation (AF) catheter ablation (CA). The introduction of Omnipolar Technology (OT) in the new Ensite X Cardiac Mapping system, provides three-dimensional information on conduction velocity, activation direction and voltage of endocardial potentials, independently of catheter orientation. OT can create a wave speed map: a color map type coded by numeric value of conduction velocity.

Objective

To assess the feasibility and reliability of left atrium wave speed maps in Bachmann’s bundle identification and conduction velocity characterization.

Methods

We included 10 patients, (60% male, 40% female, mean age 56±8.7 years) undergoing CA for paroxysmal AF at our institution with new Ensite X Cardiac Mapping System; the left atrium (LA) was mapped with the Advisor HD Grid catheter. A sinus rhythm voltage map and wave speed map were obtained and analyzed to identify high conduction velocity areas throughout the Bachmann’s bundle location (septum, roof and left atrium appendage (LAA)).

Results

Wave speed mapping allowed the identification, at the septum, roof and LAA, of a myocardial bundle with greater speed values (2.5±0.3 m/s) with respect to mean atrial value (1±0.1). Pulmonary vein antra conduction velocity mean value was 1.2±0.4 m/s. Standard voltage map (low-voltage areas defined as any LA region with voltage values < 0.5 mV) was compared with wave speed map. Standard voltage map (Figure 1) did not discriminate Bachmann’s bundle, while wave speed map did (Figure 2).

Conclusion

Wave speed mapping introduced by OT is a promising new map type, allowing characterization and identification of Bachmann’s bundle. Further studies are needed to assess the impact of this new technology on procedural workflow and clinical outcome.
Relationship between electrical activity and left atrial volume during atrial fibrillation
Authors: Adragao P , Nascimento Matos D , Costa FM , Galvao Santos P , Rodrigues G , Carmo J , Salome Carvalho M , Carmo P , Cavaco D , Morgado F , Mendes M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulmonary veins (PV) ostia were previously identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Currently, atrial fibrillation (AF) cycle length mapping (CLM) is possible due to a special tool of the Carto® electroanatomical mapping, which identifies areas in the left atria with shortest refractory period, during AF.

Purpose

Using this new EAM feature, our study aimed to assess the relationship between short refractory period LA areas and left atrial volume and AF type, known predictors of AF relapse.

Methods

Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI AF ablation with Carto® EAM. CLM was performed. CL maps were created with a high-density mapping Pentaray® catheter before and after PVI. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV).

Results

A total of 35 patients (21 men, median age 62 IQR 53-71 years) were included. Most patients presented with persistent AF (n=23, 66%), and 8 patients (23%) had a previous PVI. The mean shortest measured cycle length in AF was 134ms (SD ± 23ms). There was a negative correlation between LA volume and SCL areas after PVI (Spearman Correlation coefficient [ρ] = - 0.47, P = 0.037). There was no correlation between LA volume and SCL areas before the PVI procedure (ρ = -0.06, P = 0.776), nor between AF type and SCL (ρ = -0.118, P = 0.620). All patients presented areas of SCL located in the PVs or their insertion, 76% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) and 76% in the anterior region of the wall adjacent to the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (16%). SCL were related to low-voltage areas in 93% and were adjacent to CFAE in 84% of the cases. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL.

Conclusion

Our study shows that LA volume, not AF type, is correlated with remaining SCL areas after a pulmonary vein isolation procedure. This finding suggests a possible causal link between increased LA volume and AF relapse post-PVI. More studies are needed to assess the role of the SCL areas as a potential ablation target and their impact on AF ablation outcomes.
Thawing plateau time indicating the duration of phase transition from ice to water is the strongest predictor for long-term durable pulmonary vein isolation after cryoablation for atrial fibrillation
Authors: Shi LB , Chu SY , Wang YC , Solheim E , Schuster P , Chen J
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Helse Vest, Norway (LBS), and the Research Council of Norway (SYC).

Background

Cryoballoon ablation is an important method for pulmonary vein (PV) isolation in treatment of atrial fibrillation (AF). Previous studies have shown that thawing time, but not freezing time or temperature, impacts PV reconnection during long-term follow-up. However, it is unknown whether the entire or only part of the thawing stage plays a critical role.

Purposes

This study aimed to clarify the relationship between the durability of PV isolation and the time of phase transition from ice to water indicated by thawing plateau (TP) time during a cryoballoon ablation.

Methods

In this retrospective study, 241 PVs from 71 patients who underwent a repeat AF ablation 526 (IQR: 412, 675) days after a cryoballoon ablation were analyzed. The predictive value of procedural parameters for the durability of PV isolation were evaluated. Definitions of different phases of the temperature-time curve are shown in Figure 1. TP Time is defined as the time from 0 to 10°C inside the balloon in the thawing period (the plateau on the curve).

Results

Reconnection was observed in 101 (41.9%) PVs of 53 patients (74.6%). Durable PV isolation was associated with significantly longer TP Time compared with PV reconnection (26.0 vs. 11.0 s, P<0.001). The proportion of durable PV isolations increased with TP Time in a dose-proportional manner (Figure 2). The cut point for PV reconnection was TP Time <15 s with a positive predictive value of 82.1% (sensitivity=63.4%, specificity=90.0%) while for durable PV isolation the cut point was TP Time >25 s with a positive predictive value of 84.6% (sensitivity=55.0%, specificity=86.1%). After the analysis of multivariable logistic regression, location of PV (P<0.01), and TP Time (P<0.05) were shown as independent predictors for durable PV isolation. None of nadir temperature, initial cooling time, effective freezing time, initial thawing time, or late warming time was independent predictor. Accumulated TP Time for all PVs showed a positive linear correlation with the plasma level of troponin T (ρ=0.624, P<0.01).

Conclusions

TP Time is an independent predictor for the durability of PV isolation, and it presents in a dose-proportional manner. TP Time <15 s predicts long-term reconnection while TP Time >25 s predicts durable PV isolation.
Impact of sleep apnea treatment with CPAP on recurrence of atrial fibrillation after catheter ablation
Authors: Antunes Coelho R , Parreira L , Farinha J , Esteves A , Pinheiro A , Ferreira J , Quintal J , Amador P , Marinheiro R , Mesquita D , Caria R
Published: May 2022

Funding Acknowledgements

Type of funding sources: None. Main funding source(s): None

Background

Sleep apnea, as well as other risk factors such as obesity and high blood pressure, increase the risk of recurrence of atrial fibrillation after catheter ablation. But the true impact of sleep apnea treatment on recurrence of atrial fibrillation is less well defined.

Purpose

Assess the impact of untreated sleep apnea and treatment with CPAP (continuous positive airway pressure) on the risk of atrial fibrillation recurrence in patients undergoing catheter ablation.

Methods

We performed a retrospective analysis of 160 patients undergoing catheter ablation of paroxysmal or persistent atrial fibrillation in our institution, in a period between November of 2015 and November of 2021. We compared two groups: with atrial fibrillation recurrence and without atrial fibrillation recurrence, in a follow-up period of eighteen months. We analysed the clinical characteristics, diagnosis of sleep apnea, treatment with CPAP, echocardiographic findings (indexed volume of left atrium and left ventricular ejection fraction), cardiovascular risk factors and other comorbidities (table 1). Survival analysis of atrial fibrillation recurrence was performed using a Cox Regression analysis (figure 1).

Results

During a mean follow-up time of 22,8 ± 19,9 months, 46 patients (28,8%) had atrial fibrillation recurrence and none died. The recurrence was associated with hypertension, alcohol habits and untreated sleep apnea. Untreated sleep apnea was associated with a 4-fold increased risk of atrial fibrillation recurrence (HR 3,74; 95% CI 1,89-7,42; p <0,001). In patients with sleep apnea (n = 41), CPAP treatment was associated with a 74% decreased risk of recurrence (HR 0,26; 95% CI 0,10-0,72; p = 0,009).

Conclusions

Treatment with CPAP was associated with lower risk of recurrence of atrial fibrillation after catheter ablation in patients with sleep apnea.
P-wave duration and atrial fibrillation recurrence after catheter ablation, a systematic review and meta-analysis
Authors: Koutalas E , Intzes S , Zagoridis K , Symeonidou M , Spanoudakis E , Arya A , Dinov B , Dagres N , Hindricks G , Bollmann A , Kanoupakis E , Kochiadakis G , Nedios S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is a global health problem with high morbidity and mortality. Catheter ablation (CA) can reduce AF burden and symptoms, but AF recurrence (AFr) remains an issue. Simple AFr predictors like P-wave duration (PWD) could help improve AF therapy.

Purpose

This updated meta-analysis reviews the increasing evidence for the association of AFr with PWD and offers practical implications.

Methods

Publication databases were systematically searched and cohort studies reporting PWD and/or morphology at baseline and AFr after CA were included. Complete interatrial block (cIAB) was defined as PWD≥120 ms and biphasic morphology in inferior leads. Random-effects analysis was performed using the Review Manager 5.3 and R programs after study selection, quality assessment and data extraction, to report odds ratio (OR) and confidence intervals (CI).

Results

Among 4175 patients in 22 studies, 1138 (27%) experienced AFr. Patients with AFr had longer PWD with a mean pooled difference of 7.8 ms (19 studies, p<0.001)(Figure 1). Pooled OR was 2.04 (1.16-3.58) for PWD>120 ms (13 studies, p=0.01), 2.42 (1.12-5.21) for PWD>140 ms (2 studies, p=0.02), 3.97 (1.79-8.85) for cIAB (6 studies, p<0.001) and 10.89 (4.53-26.15) for PWD>150 ms (2 studies, p<0.001)(Figure 2). There was significant heterogeneity but no publication bias detected.

Conclusion

PWD is an independent predictor for AF recurrence after LA ablation. The AFr risk is increasing exponentially with PWD prolongation. This could facilitate risk-stratification by identifying high-risk patients (cIAB, PWD>150 ms) and adjusting follow-up or interventions.
Prevalence and clinical impact of major incidental findings detected on routine cardiovascular resonance imaging prior to catheter ablation of atrial fibrillation
Authors: Richter S , Ebert M , Karrengarn R , Oebel S , Doering M , Kircher S , Jahnke C , Hindricks G , Paetsch I
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Preprocedural contrast-enhanced cardiovascular magnetic resonance (CMR) or computed tomography (CT) imaging of the left atrium (LA) and pulmonary veins (PVs) is usually employed to facilitate catheter mapping and ablation of atrial fibrillation (AF). Incidental findings (IFs) are common on cardiac imaging prior to AF catheter ablation (AFCA). However, previous studies were of small size and have mainly focused on radiological extracardiac IFs detected on preprocedural CT scan.

Purpose

To assess the prevalence of major cardiac and extracardiac IFs on routine preprocedural CMR in a large cohort of consecutive patients scheduled for first-time AFCA, and to report its impact on clinical decision-making and management.

Methods

All consecutive patients who underwent routine preprocedural CMR prior to first-time AFCA between April 2015 and March 2019 were considered for analysis. Main exclusion criteria were referral for repeat AFCA; prior cardiac CT or CMR imaging; and general contraindication to CMR or AFCA. All CMR examinations consisted of survey images with full thoracic coverage, cardiac cine and late-gadolinium enhancement imaging, and three-dimensional contrast-enhanced CMR angiography of the LA/PVs. An IF was defined as major when any newly detected finding either resulted in cancellation of the AFCA procedure or intentional deviation from the standard AFCA protocol. In patients with accessory or anomalous PVs the ablation strategy was individually tailored aiming at isolation of all PVs.

Results

Two thousand consecutive patients (62±10 years; 59% male) with paroxysmal (48%) or persistent (52%) AF were included. Among the entire study cohort 172 patients (8.6%) had a total of 184 cardiac (75%) and extracardiac (25%) major IFs (Fig. A+B). Preprocedural detection of a major IF resulted in cancellation of the scheduled AFCA procedure in 88 patients (4.4%). Forty-two patients (2.1%) have thereupon never been ablated, 46 patients (2.3%) underwent postponed AFCA after a median time from CMR imaging of 83 (32-213) days. The remaining 84 patients with major IF (4.2%) underwent an individualized approach to AFCA (Fig. A). The most common major IFs were accessory or anomalous PVs in 76 (3.8%), extracardiac abnormalities suspicious of malignancy in 29 (1.5%), and positive stress perfusion imaging in 19 (1.0% overall; 7.2% of 261 tested) patients. In 19 patients (1.0%) preprocedural CMR detected a previously unknown intracardiac thrombus or structural cardiac disease.

Conclusion

Unexpected major IFs on routine preprocedural CMR affected clinical decision-making and therapeutic management in 8.6% of patients scheduled for first-time AFCA at our institution. Whether preprocedural CMR imaging may improve safety and outcome of AFCA needs to be addressed in future research.
Optimization of a care pathway before atrial fibrillation ablation with the integration of translational research into routine clinical care
Authors: Verhaert D , Linz D , Wassink GW , Weijs B , Philippens S , Luermans JGLM , Westra SW , Schotten U , Vernooy K , Den Uijl DW
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

The diagnostic work-up for atrial fibrillation (AF) catheter ablation is often complex and expensive. Improving the organization of this work-up may help to streamline patient journeys and to reduce administrative burden and costs. Additionally, reorganizing the existing work-up provides the opportunity to integrate (translational) research into routine clinical care, hereby contributing to improved patient selection and improved care for future patients.

Purpose

The aim of this project was to optimize a care pathway for patients considered for AF ablation, with the goals to improve the patient journey and simultaneously integrate research into the clinical process.

Methods

The Lean Six Sigma approach was used to map the pre-existing process, identify constraints in the process and formulate countermeasures. The impact of this pathway optimization was evaluated using four outcome measures: (1) efficient use of medical resources, defined as the percentage of patients receiving the pre-ablation work-up and eventually undergoing AF ablation, (2) number of hospital visits and consultations with a cardiologist, (3) pathway compliance, defined as the percentage of patients that completed the work-up with a maximum of 2 outpatient hospital visits, a maximum of 1 cardiologist consultation, laboratory results available, and a complete echocardiogram available, and (4) completeness of scientific data, defined as the availability of a predefined set of relevant variables (clinical indicators, medication, laboratory results and echocardiography derived data).

Results

Five root causes for constraints in the pre-existing work-up were identified and corresponding countermeasures were formulated (Figure 1). The impact of the countermeasures was studied for 33 patients before and 26 patients after pathway optimization. After optimization, efficient use of resources increased from 44% to 95% (p<0.01). The project resulted in fewer hospital visits per patient (3.2 ±1.2 versus 2.3 ±0.8, p=0.01) and fewer cardiologist consultations (1.8 ±0.7 versus 1.0 ±0.3, p<0.01). Pathway compliance increased significantly (3% versus 73%, p<0.01), an increase that was reflected in all separate components of overall pathway compliance (Figure 2, panel A). The percentage of available data for scientific research increased from 80% to 94% (p<0.01), resulting in a complete dataset in 73% of patients after, compared to only 15% of patients prior to the optimization project (p<0.01, Figure 2, panel B).

Conclusions

This optimization project resulted in a more efficient care pathway for patients considered for AF ablation. The structural integration of research into the care pathway may lay the foundations for further improvements of AF care in the future.
The impact on renal function after long-term use of anticoagulants in atrial fibrillation patients
Authors: Lee WC
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): This study was supported by the research program of the Chang Gung Memorial Hospital.

Objective

Long-term oral anticoagulant should be considered or recommended in patients with atrial fibrillation (AF) and CHA2DS2VASc score ≥1 for stroke prevention. Warfarin and different direct oral anticoagulants (DOACs) are metabolized differently by the kidney. The impact on renal function after long-term use of anticoagulants in the patients with AF remains unclear. This study aimed to compare DOACs and warfarin’s impact on the decline in renal function from a large cohort with AF.

Methods

This study included patients with nonvalvular AF from 2000 to 2018, mainly through the medical history (ICD code) of the Chang Gung Research Database. Baseline estimated glomerular filtration rate (eGFR), follow-up eGFR and the change in eGFR between 2-year eGFR and baseline eGFR were compared between different DOACs and warfarin after propensity score matching. The primary study endpoint was acute kidney injury (AKI).

Results

3657 patients were enrolled in this study and the mean observation time was 3.3 ± 0.9 years. During the observation period, there was a significantly higher incidence of AKI during follow-up in the warfarin group than in the different DOAC groups before and after propensity score matching (before: warfarin vs. DOAC: 9.2% vs. 5.2%, p<0.001; after: warfarin vs. DOAC: 8.9% vs. 4.4%, p<0.001). There was no difference in the incidence of AKI between dabigatran group and anti-factor Xa inhibitor group after propensity score matching. The incidence of AKI was similar among rivaroxaban, apixaban and edoxaban groups after propensity score matching. The change in eGFR between 2-year eGFR and baseline eGFR did not differ between the warfarin and DOAC groups after propensity score matching (warfarin vs. DOAC: -1.27 ± 20.32 vs. -1.94 ± 17.24 mL/min/1.73 m2, p=0.461).

Conclusions

During the mean observation time of 3.3 ± 0.9 years, warfarin was associated with a higher incidence of AKI compared with DOACs. The decline in renal function did not differ among warfarin and different DOAC groups.
Patients’ perspective on a pill-in-the-pocket oral anticoagulation as an alternative stroke prevention strategy in atrial fibrillation
Authors: Briosa E Gala A , Pope MTB , Leo M , Lobban T , Betts TR
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Oral anticoagulation (OAC) decisions are binary: if atrial fibrillation (AF) is detected and additional risk factors are presented, lifelong continuous OAC is recommended regardless of AF burden or temporal patterns. AF-related stroke risk appears to be lower in patients with paroxysmal AF and, therefore, indefinite OAC may have limited benefit whilst exposing patients to a significant bleeding risk. ‘Pill-in-the-pocket’ OAC during and shortly after AF challenges this dichotomous approach to OAC and is being explored in several pilot studies as an alternative AF-related stroke prevention strategy.

Purpose

This patient questionnaire sought to examine patients’ perspective of ‘pill-in-the pocket’ OAC strategy.

Methods

An 8-question interactive survey was developed in collaboration with AF Association (UK based charity) and included a short description of implantable cardiac monitors main features, implant procedure and associated risks. The survey was available online on the AF Association website from 30/09/2020 to 2/11/2020.

Results

Overall, 321 participants with an underlying diagnosis of AF replied to the online survey over the course of four and half weeks. The majority (82%) were taking direct oral anticoagulants. Just over two thirds of patients had concerns regarding bleeding side-effects from taking OAC and, approximately, a quarter had experienced a bleeding event (1.5% major bleeding and 24.2% minor bleeding). When asked if it was shown to be safe to monitor their heart rhythm continuously and take anticoagulants only during an episode of AF and for a small number of days afterwards (i.e. ‘pill-in-the-pocket’), 53.7% of participants would use guided by an implantable cardiac monitored. Slightly lower number of patients (48%) would take pill-in-the-pocket oral anticoagulation guided by a wearable device. In the comments the main reasons not to pursue ‘pill-in-the-pocket’ were permanent AF, previous thromboembolic events and concerns regarding reliability of monitoring technologies. In contrast, those who were receptive to this alternative approach had previous bleeding episodes, had very infrequent AF episodes and wanted to reduce their medication burden.

Conclusion

Approximately half of patients with choose a ‘pill-in-the-pocket’ OAC guided by daily rhythm monitoring with an ICM if proven to be safe and effective at reducing thromboembolism.
Single versus dual antiplatelet therapy following transcatheter left atrial appendage closure
Authors: Massalha E , Beinart R , Leshem E , Nof E , Guetta V , Barbash I , Sabbag A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial appendage occlusion (LAAO) had emerged as an alternative to anticoagulation in patients with non-valvular atrial fibrillation and a contraindication to long-term oral anticoagulants (OAC). LAAO implantation aims to reduce the risk of both systemic thromboembolism and the bleeding events associated with prolonged OAC. Post-procedural antithrombotic regimen varies among patients and may include antiaggregant (dual or single agents) or anticoagulation therapy in minority patients. The current study aims to compare the effectiveness and safety of post-procedural antithrombotic treatment with either dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT) in a real-world cohort.

Methods

The cohort consisted of 205 consecutive patients who had undergone LAAO at Sheba medical center between the years 2010-2020. We prospectively evaluated baseline characteristics and periprocedural clinical, laboratory, and imaging data. All patients were followed by scheduled in-clinic visits. After excluding patients prescribed OAC following the procedure or deceased in the index procedure, the study cohort was divided into two groups according to the antithrombotic regimen following the LAAO: SAPT (35 patients) versus DAPT (151 patients). A propensity analysis via the stabilized inverse-probability-of-treatment weighting (IPTW) was applied.

Results

The leading etiologies for transcatheter LAAO were previous gastrointestinal bleeding (41%) and previous intracranial bleeding (32%). The median CHADSVASC score is 5 [IQR:4-6]. Patients discharged with SAPT following LAAO were older (78±8 yrs vs.75±8 yrs), accompanied by an evident trend over the years of discharging more patients with SAPT instead of DAPT (Figure 1). No statistically significant differences were observed in other baseline characteristics, including gender, hypertension, diabetes mellitus, malignancy, chronic renal or heart failure. During two years of clinical follow-up, no differences in major adverse cardiovascular events were observed between the two groups (20% vs.19% for SAPT and DAPT, respectively). After applying an IPTW propensity analysis adjusting for several clinical and procedural relevant parameters, a K-M survival curve demonstrates no survival benefits of dual over single antiplatelet therapy (Figure 2).

Conclusions

Among patients undergoing LAAO, post-procedural DAPT provides no survival benefits over single antiplatelet therapy.