bluuebunny/crossref_metadata_2025 huggingface dataset:
Relationship of particular matter and temperature on the risk of adverse events in atrial fibrillation patients
Authors: Rivera-Caravaca J.M , Roldan V , Vicente V , Lip G.Y.H , Marin F
Published: November 2020

Background

Ambient particulate matter (PM), is a principal component of air pollutant and the main culprit of the adverse effects of air pollution on humans' health. In particular, PM with aerodynamic diameter <10 μm (PM10) has been shown to be associated with worse clinical outcomes. Similarly, cardiovascular risk increases during colder temperatures/seasons. Thus, both, air pollution and temperature fluctuations are examples confirming how the climate change is affecting our health. However, our knowledge about the impact of air pollution and temperature in anticoagulated atrial fibrillation (AF) patients is scarce.

Purpose

Herein, we investigated if PM10 and temperature are associated with an increased risk of adverse clinical outcomes in patients with AF taking vitamin K antagonists (VKAs).

Methods

We included AF patients who were stable on VKAs (INR 2.0–3.0) for 6 months in a tertiary hospital (Murcia, South-east Spain). During a median follow-up of 6.5 (IQR 4.3–7.9) years, ischemic strokes, major bleeds, adverse cardiovascular events, and mortality were recorded. From 2007–2016, data on average temperature and PM10 (PM with aerodynamic diameter <10 μm) were obtained and related to clinical outcomes.

Results

1361 patients (48.7% male; median age 76, IQR 71–81 years) were included. High PM10 and low temperatures were associated with higher risk of major bleeding (adjusted Hazard Ratio, aHR 1.44, 95% CI 1.22–1.70 and aHR 1.03, 95% CI 1.01–1.05) and mortality (aHR 1.50, 95% CI 1.34–1.69 and aHR 1.04, 95% CI 1.02–1.06) (Table 1). PM10 was also significantly associated with ischemic stroke and temperature with cardiovascular events. The relative risk for cardiovascular events and mortality increased in months in the lower quartile (Q1) of temperature (<12.74°C) (RR 1.12, 95% CI 1.04–1.21 and RR 1.41, 95% CI 1.15–1.74; respectively). Comparing seasons, there were higher risks of cardiovascular events in spring, autumn, and winter than in summer, whereas the risk of mortality increased only in winter.

Conclusions

In AF patients taking VKAs highPM10 and low temperature were associated with an increased the risk of ischemic stroke and cardiovascular events, respectively. Both factors increased major bleeding and mortality risks, which were higher during colder months and seasons.

Table 1. Univariate and Multivariate Cox

Funding Acknowledgement

Type of funding source: None
Prediction of mortality and mode of death by clinical risk score systems in 2.6 million patients with atrial fibrillation: a nationwide analysis
Authors: Fauchier L , Bisson A , Bodin A , Herbert J , Clementy N , Pierre B , Angoulvant D , Hanon O , Babuty D , Lip G
Published: November 2020

Atrial fibrillation (AF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict mortality and the different modes of death in AF.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all AF patients treated between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. CHA2DS2VASc score, CCI and CFI were calculated for each patient.

Results

Among 2,641,626 patients with AF, 670,541 patients died during a follow-up of 2.0±2.3 years (median 1.1) (yearly rate 12.6%, 30.3% cardiovascular and 69.7% non-cardiovascular deaths). Death occurred more often in patients with higher CHA2DS2VASc, CCI and CFI scores. CCI was a better predictor of total mortality than CFI and CHA2DS2VASc score (see C-statistics in table); however, the CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI. By contrast, CCI was a better predictor of non-cardiovascular mortality than CFI and CHA2DS2VASc score. The optimal predictive performances were better for non-cardiovascular death than for cardiovascular death.

Conclusion

Multimorbidity assessed with CCI demonstrated better performances in predicting total mortality and non-cardiovascular mortality than CHA2DS2VASc score and Frailty assessed with CFI in AF patients. By contrast, CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI in these patients.

Funding Acknowledgement

Type of funding source: None
Screening for atrial fibrillation in subjects aged 65 using a long-term continuous ECG telemonitoring vest: the NOninvasive Monitoring for early detection of atrial fibrillation (NOMED-AF) study
Authors: Sredniawa B , Mitrega K , Stokwiszewski J , Sokal A , Boidol J , Wierucki L , Zieleniewicz P , Rajca A , Bandosz P , Zdrojewski T , Opolski G , Kazmierczak J , Grodzicki T , Lip G.Y.H , Kalarus Z
Published: November 2020

Background

Atrial fibrillation (AF) confers a high healthcare burden from stroke, heart failure, dementia and hospitalisation, and one challenge is. Early detection of this arrhythmia in the community, given that it is often asymptomatic.

Aim

To perform population screening for atrial fibrillation and flutter (AF/AFl) using a mobile long-term continuous ECG telemonitoring vest in a representative Polish and European population aged ≥65 years (age range 65–100 years).

Methods

The NOMED-AF study is a cross-sectional study based on a representative sample of adults aged ≥65 years (n=3014; mean age 77.5±7.9 years; 49.1% female). All study participants were equipped with a mobile long-term continuous ECG telemonitoring vest. National and European estimations were calculated on weighted data.

Results

In 680 subjects AF/AFl (including 279 with SAF; 9.3%) was confirmed. In the NOMED-AF population, the prevalence of AF/AFl was 22.6%, estimated to be 19.2% for Poland [1,251,100 (95% CI: 1,158,300–1,344,000) and 480,100 (95% CI: 426,60–533,700) subjects with AF/AFl and SAF, respectively] and 20.4% for Europe [20,300,000 (95% CI 18.8–21.9 M), including 8,000,000 (95% CI: 6.9–9.3 M) subjects with AF/AFl and SAF, respectively]. The prevalence of AF/AFl was 2.56-fold higher in men than in women and the incidence of silent AF (SAF) was 4.73-fold higher in men than in women. Although the risk of either AF/AFl or SAF increased with age, the odds ratio was significantly higher in women of a particular age group than in men of the corresponding age. Based on our survey, the total number of subjects with AF/AFl in Europe is estimated to be roughly 20.3 million (95% CI 18.8–21.9M), including 8.0 million (95% CI: 6.9–9.3M) subjects with silent AF/AFl (Figure).

Conclusions

Approximately 1 in 5 subjects aged ≥65 years suffers from AF/AFl. The risk for AF/AFl and SAF is higher in men than that in women, but when correlated to a particular age group, the risk increases significantly in women. Continuous ECG telemonitoring allows for more credible AF/AFl and SAF detection.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The research has received funding from the National Centre for Research and Development under grant agreement (STRATEGMED2/269343/18/NCBR/2016
The prognostic impact of catheter ablation for atrial fibrillation after heart failure hospitalization on long-term mortality – Propensity-score matching analysis
Authors: Iwanami Y , Jujo K , Higuchi S , Abe T , Shoda M , Ejima K , Hagiwara N
Published: November 2020

Background

In the last two decades, catheter ablation (CA) for atrial fibrillation (AF) including pulmonary vein isolation (PVI) has been developed as a standard and effective treatment for atrial fibrillation (AF). In patients with chronic heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF), PVI CA for AF dramatically improves LVEF, resulting in better clinical prognoses. On the contrary, there still has been no data that PVI CA for AF improves the prognosis in heart failure patients with preserved LVEF (HFpEF).

Purpose

The aim of this study was to evaluate the prognostic impact of PVI CA for AF after the hospitalization due to decompensation of heart failureHF, focusing on LVEF.

Methods

From the database including 1,793 consecutive patients who were hospitalized due to congestive HF, we ultimately analyzed 624 AF patients who were discharged alive. They were assigned into two groups due that PVI CA for AF procedure done after the index hospitalization for HF; the PVI CA group (n=62) and Non-PVI CA group (n=562). For the two groups, we performed propensity-score (PS) matching using variables as follows: age, sex, LVEF, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) and estimated glomerular filtration rate (eGFR) at discharge. Further analysis was performed separately in HFrEF (LVEF <50%) and HFpEF (LVEF >50%). The primary endpoint of this study was death from any cause.

Results

In unmatched patients, Kaplan-Meier analysis showed that patients in the PVI CA group had a significantly lower all-cause mortality than those in the Non-PVI CA group during 678 median follow-up period (Log-rank test: P=0.003, Figure A). In 96 PS-matched patients, patients in the PVI CA group still had lower mortality rate than those in the Non-PVI CA group (hazard ratio 0.28, 95% confidence interval 0.09–0.86, p=0.018, Figure B). When the whole study population was classified into HFrEF and HFpEF, HFrEF patients who received PVI showed a significantly lower mortality than those who did not (p=0.007); whereas, in HFpEF patients, PVI CA for AF did not make statistical difference in all-cause mortality (p=0.061).

Conclusions

In this observational study, PVI CA for AF may improve the mortality in HF patients with reduced LVEF. However, the prognostic impact of PVI CA for AF was not observed in HF patients with preserved LVEF.

Funding Acknowledgement

Type of funding source: None
Geographical region differences in the Cabana trials
Authors: Cappato R , Silverstein A.P , Bahnson T.D , Monahan K.A , Poole J.E , Al-Khalidi H.A , Mark D.B , Packer D.L
Published: November 2020

Background

Unexpected variations in treatment benefits by geographic region raise questions about the generalizability of findings from international clinical trials.

Purpose

Investigate the outcome of catheter ablation vs drug therapy in CABANA patients with AF treated at North American (NA) compared with non-NA sites, a pre-specified comparison.

Methods

CABANA randomized 2204 symptomatic patients with atrial fibrillation (AF) to ablation vs drug therapy at 126 centers in 10 countries. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest.

Results

There were 1285 patients enrolled at 85 NA sites, and 919 at 45 non-NA sites. At baseline, NA and non-NA patients differed significantly with regard to age, sex, BMI, CCS, CHA2DS2-VASc score, family history of AF, prior AF hospitalization, history of A Flutter, diabetes, NYHA class, and proportion with sleep apnea, heart disease, CAD, CHF, or EF >35%. Four-year Kaplan-Meier event rates showed considerable differences in treatment effects between NA and non-NA patients (see Table). Ablation was associated with a 50% reduction in the primary endpoint in non-NA (HR 0.50, 95% CI 0.24 to 1.03) vs a 5% reduction in NA (HR 0.95, 95% CI 0.69 to 1.30) enrollees despite higher event rates in NA patients. The trend of favorable outcome with ablation at non-NA sites was maintained after adjustment for baseline covariates that differed between the non-NA (HR 0.51, 95% CI 0.24 to 1.04) and NA populations (HR 0.93, 95% CI 0.68 to 1.20).

Conclusion

We observed substantial geographic variation in clinical outcomes and treatment effects in the CABANA trial that suggests an important disconnection between overall event rates and treatment benefit from ablation in AF.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NIH
Catheter ablation for atrial fibrillation in patients with reduced systolic function: a national perspective
Authors: Munir M , Khan M.Z , Agrawal P , Benjamin M.M , Syed M , Farjo P , Patel K , Ghaffar Y.A , Khan M.U , Khan S , Balla S
Published: November 2020

Background

Randomized trials have shown improvement in hard clinical end points when catheter ablation (CA) was employed as a management strategy for certain atrial fibrillation (AF) patients with heart failure and reduced ejection fraction (HFrEF). We sought to determine real world data on mortality and complications after utilization of CA in such patients.

Methods and results

Data were derived from National Inpatient Sample from January 2008 to August 2015. Patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Baseline characteristics and outcomes were compared among AF and HFrEF patients undergoing CA or not. Propensity matching was done to mitigate selection bias and balance confounding variables. Various CA related complications were assessed. Logistic regression was done to determine predictors of mortality in our study cohort. A total of 2,569,919 patients were enrolled and out of these approximately 7773 patients underwent CA. Mortality was significantly better in CA group in both unmatched (1.2% vs. 4.9%, p<0.01) and propensity matched cohorts (1.2% vs. 3.6%, p<0.01). Overall complication rate was 10.2% in CA cohort and were primarily cardiac and neurological in origin. In regression analysis, CA remains a strong predictor of reduced mortality (OR 0.301, 95% CI 0.184–0.494).

Conclusion

CA is associated with improved mortality in admitted AF patients with concomitant HFrEF. Overall complication rate after CA was modest at 10.2%.

Funding Acknowledgement

Type of funding source: None
Not only power and energy but also balloon size is correlated with lesion formation in laser ablation model in vitro study
Authors: Matsunaga Y , Egami Y , Yano M , Yamato M , Shutta R , Nishino M , Tanouchi J
Published: November 2020

Background

Power and total energy were known to correlate with lesion formation during laser balloon ablation for atrial fibrillation. However, it is unclear whether balloon size can influence lesion formation. The aim of this study was to evaluate the impact of balloon size on lesion formation during laser balloon procedure in vitro model.

Methods

Laser energy was applied to chicken muscles using first generation laser balloon. Laser ablation was performed with different 2 balloon size (18mm and 32mm) using 2 different power settings (12W/20sec and 8.5W/20sec). Forty lesions were evaluated for each setting. We compared maximum lesion width, maximum lesion depth, depth at maximum width and endocardial lesion width between 18mm and 32mm balloon groups at 12W/20sec and 8.5W/20sec, respectively.

Results

At 8.5W/20sec, inadequate lesion formation to assess lesion size was observed in 1/40 lesion of 18mm balloon group and in 5/40 lesions of 32mm balloon group. Thus, at 8.5W/20sec 18 mm balloon group consisted of 39 lesions and 32 mm balloon group consisted of 35 lesions. At 12W/20sec 18 mm balloon group consisted of 40 lesions and 32 mm balloon group consisted of 40 lesions. At both power settings, maximum lesion depth was larger in 18mm balloon than in 32mm balloon group. At 12W/20sec setting, maximum lesion width and endocardial width were larger in 32mm balloon group than in 18mm balloon group. At 12W/20sec setting, depth at maximum width was smaller in 32mm balloon group than in 18mm balloon group. Lesion morphologies were summarized in a figure.

Conclusion

Balloon size could affect lesion formation during laser balloon ablation in addition to laser power and energy. Laser ablation lesion were wider but shallower in 32mm balloon group compared with in 18mm balloon group.

Funding Acknowledgement

Type of funding source: None
Prevalence of LAA thrombus in patients undergoing percutaneous ablation of atrial fibrillation
Authors: Silva C , Freitas P.N , Ferreira A.M , Albuquerque F , Guerreiro S , Abecasis J.M , Rodrigues G , Carmo J , Saraiva C , Goncalves M , Carmo P , Cavaco D , Morgado F , Adragao P , Mendes M
Published: November 2020

Introduction

Computed tomography (CT) is often performed before atrial fibrillation (AF) ablation to assess the anatomy of the pulmonary veins and exclude left atrial (LA) and left atrial appendage (LAA) thrombus. With the growing use of new oral anticoagulants (NOACs), a reassessment of the need for systematic thrombus exclusion in this context seems warranted.

Objective

To evaluate the prevalence of thrombus in LA/LAA in pre-ablation CT in a contemporary cohort of patients predominantly anticoagulated with NOACs.

Methods

We evaluated 789 consecutive patients (mean age 61±12 years; 38% female; 84% with paroxysmal AF) who underwent pre-ablation CT between Oct/2015 and Oct/2019. ECG-gated CT-angiography was performed using a dual-source 64-slice CT after iodinated contrast injection. Whenever necessary, a second dedicated acquisition was made 60 seconds after the first set of images. Presence of thrombus was defined as a persistent opacification defect. For each patient, thromboembolic risk was assessed with the CHA2DS2-VASc score.

Results

The median interval between CT and AF ablation was 1 day (IQR 1 – 2 days). The median CHA2DS2-VASc was 2 points (IQR 0 – 3 points), with 590 patients (75%) having CHA2DS2-VASc ≥1. Among the 199 patients (25%) with CHA2DS2-VASc = 0, 118 (59,3%) were anticoagulated with a NOAC and 14 (7%) with a vitamin K antagonist; 67 (34%) were not anticoagulated. Conversely, amongst the 590 patients with CHA2DS2-VASc ≥1, 84% were anticoagulated with a NOAC (n=494), 11% used vitamin K antagonists (n=62), and 34 patients were not anticoagulated (23 with CHA2DS2-VASc = 1). On cardiac CT, 521 (66%) patients were in sinus rhythm. Overall, only one LAA thrombus was found (0.12% [1/789]; 95% CI: 0.0–0.7%) – in a patient with CHA2DS2-VASc = 0, anticoagulated with a NOAC. The median effective radiation dose was 3.2 mSv (IQR 2.1–4.8 mSv). There were 5 minor allergic reactions to iodinated contrast. No strokes were documented within the first 24 hours after ablation.

Conclusion

In this contemporary cohort of patients with predominantly paroxysmal AF and anticoagulated with NOAC, the prevalence of intracavitary thrombus was extremely low (0.12%). While these findings do not compromise the multipurpose role of pre-ablation CT, they should nevertheless inform future discussions on the risk/benefit and cost/benefit of performing systematic exclusion of LA/LAA thrombi prior to AF ablation.

Funding Acknowledgement

Type of funding source: None
Three-dimensional transesophageal echocardiography versus magnetic resonance imaging for pulmonary vein imaging prior to catheter ablation of atrial fibrillation: extended long-term follow-up
Authors: Kettering K
Published: November 2020

Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI).

Methods

In 150 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 65 patients, persistent AF: 85 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system.

Results

A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 144/150 patients (96.0%). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.8 (cryo group), 4.0 (radiofrequency catheter ablation group)). At 48-month follow-up, 69.3% of all patients were free from an arrhythmia recurrence (cryo group: 75.4%, Carto group: 64.7%). There were no major complications.

Conclusions

AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients.

Funding Acknowledgement

Type of funding source: None
Atrial fibrillation ablation in athletes: 5-years experience of a single italian third-level center
Authors: Pizzamiglio F , Riva S.I , Dessanai M.A , Bonomi A , Fassini G , Casella M , Moltrasio M , Tundo F , Zeppilli P , Tondo C
Published: November 2020

Background

The number of master athletes is increasing and treatment of AF is mandatory for sports continuation. However, few data exist about the effectiveness of catheter ablation (CA) in athletes and the feasibility of resuming vigorous exercise afterwards.

Objectives

Aim of our study was to analyze the efficacy and safety of AF CA in athletes and to evaluate the feasibility of resuming vigorous exercise.

Methods

We report a retrospective registry of athletes referred to our center for AF CA in the last five years. All athletes were previously declared non-eligible to competitive sport because of recurrences of AF or evidence of persistent asymptomatic AF. CA was performed as per practice and recurrences were defined as recrudescence of symptoms and/or any documentation of AF lasting more than 30 sec. At the end of the follow-up all pts were asked about resuming sport.

Results

We ablated 40 athletes (38 males, 95%) with a mean age of 48±13 years. Mean left atrium volume was 36±11 ml/m2 and mean ejection fraction was 61±5%. Distribution between AF characteristics was: 31 (78%) paroxysmal AF, 8 (20%) early-persistent AF, 1 (2%) long-persistent AF.

After a median follow-up of 787 days, 62,5% of athletes were free from recurrences after one CA procedure and mostly without antiarrhythmic drugs (87%). 7 athletes underwent a redo procedure and all of them were then free of recurrences with an overall freedom from recurrences of 84%. No major complication was observed. Athletes practicing endurance sports showed a negative trend in terms of recurrences (p = ns).

Most (72%) of the athletes resumed vigorous exercise after at least 3 months from the CA as per Italian sport protocols.

Conclusions

CA is safe and efficient in treating AF also in athletes. Resuming high intensity sports is often possible after 3 months from CA.

Funding Acknowledgement

Type of funding source: None
Real world experience from 1000 patients. Preprocedural DOAC interruption impacts detectable DOAC serum levels but not adverse events after catheter ablation of atrial fibrillation
Authors: Konstantinou A , Bordignon S , Tohoku T , Chen S , Bologna F , Tsianakas N , Urbanek L , Trolesse L , Lindhoff-Last E , Schmidt B , Chun K.R.J
Published: November 2020

Introduction

Direct oral anticoagulation (DOAC) therapy represents the standard of care in patients with atrial fibrillation (AF) and increased stroke risk. In a real world setting withholding DOAC medication before elective AF ablation is considered to reduce procedural bleeding risks. The aim of this study was to determine the individual DOAC level prior to the ablation procedure, to identify predisposing factors affecting traceable DOAC levels and to screen for associated severe adverse events.

Methods

Between September 2016 and March 2019 blood samples were obtained from patients on DOAC before an elective AF ablation. Per institutional standard all patients have been instructed to pause DOAC medication prior ablation for one or two doses depending on the patient profile and type of medication. The time interval between ablation and last DOAC intake was calculated in hours. Patient characteristics, procedural data and in-hospital complications were noted from all patients.

Results

A total of 1000 patients (60% male, age: 68y, GFR 83.25: BMI: 28, CHADSVASC score 3) undergoing AF ablation were included. Two groups were defined. Group A (n=416, 41.6%): patients treated with “single pill” DOAC (Rivaroxaban (n=288, 28.8%) and Edoxaban (n=128, 12.8%)). Group B (n=584, 58.4%): patients treated with twice a day DOAC (Apixaban (n=505, 50.5%) and Dabigatran (n=79, 7.9%)). The only difference in patient characteristics was an increased prior bleeding history in group B. The DOAC pause was significantly longer in group A (mean 40h) compared to group B (mean 32h), p=0.026. In a total of 217 patients (21.7%) DOAC levels where traceable prior to AF ablation. Traceable DOAC levels were significantly more common in group B (n=144/584, 24.7%) compared to group A (n=73/416, 17.5%). Adverse events occurred in 5.7% of patients (0.4% stroke, 0.3% tamponade, 2.5% hematoma, 1.9% AV-fistel, 0.7% pseudoaneurysma). T-Test analysis showed no significant difference in the occurrence of adverse events between both groups.

Conclusion

Despite of interrupting DOACs before an elective AF ablation therapeutic substance levels can be detected in >20% of patients. The rate of adverse events was not different between “single pill” vs. twice a day DOAC intake.

Funding Acknowledgement

Type of funding source: None
Positive clinical benefit on patient care, quality of life and symptoms after radiofrequency ablation with contact force in persistent atrial fibrillation: analyses from PRECEPT
Authors: Natale A , Calkins H , Osorio J , Pollack S.J , Melby D , Marchlinski F.E , Athill C.A , Delaughter C , Patel A , Gentlesk P.J , Deville B , Macle L , Ellenbogen K.A , Dukkipati S , Mansour M
Published: November 2020

Background

The management of persistent (PsAF) aims to prevent AF recurrence and associated disabilities while reducing side effects from treatment. Contact force (CF)-guided RF catheters have proven efficacious and safe for pulmonary vein isolation (PVI) to treat paroxysmal AF; however, there is limited evidence on clinical benefits with ablation of PsAF.

Purpose

To assess long-term clinical effects on patients care, symptoms and QOL after CF-guided RF ablation in PsAF.

Methods

PRECEPT was a multicenter study evaluating the safety and efficacy of CF RF catheters in the treatment of symptomatic PsAF (NCT02817776). PVI was performed with or without substrate modification. Patients were followed at 6, 9, 12 and 15 mos to collect the following data: Atrial Fibrillation Effect on Quality-of-Life (AFEQT) score, Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) score, Class I/III AAD use, and incidence of cardioversion and cardiovascular hospitalization.

Results

A total of 333 enrolled patients (65.4±8.8 yrs, 71.2% male, CHA2DS2-VASC score 2.3±1.5) underwent PVI. Compared to baseline, 1) improvements in the AFEQT composite and subscores were seen from 6–15 mos, exceeding Clinical Important Difference (±5 points) in majority of subjects (Figure), 2) proportion of CCS-SAF Class 0 patients (asymptomatic with respect to AF) rose from 0.7% to 81.0%, 3) class I/III AAD use was reduced from 97.0% to 24.7%, and 4) incidence of cardioversion decreased from 62.0% to 10.7%. Moreover, the 1-yr Kaplan-Meier estimate of freedom from hospitalization was 84.2% [95% CI: 80.2%, 88.2%].

Conclusion

CF-guided RF ablation in PsAF patients led to a clinically meaningful improvement in QOL, as well as a reduction in AAD use, cardioversion, and hospitalization.

Figure 1. Mean AFEQT composite and subscore

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This study was funded by Biosense Webster, Inc.
Risk factors for progression of paroxysmal to persistent atrial fibrillation following successful PV isolation
Authors: Mohanty S , Trivedi C , Della Rocca D.G , Gianni C , Salwan A , Macdonald B , Mayedo A , Bassiouny M , Gallinghouse G.J , Burkhardt J.D , Horton R , Al-Ahmad A , Di Biase L.D , Natale A
Published: November 2020

Background

Progression from paroxysmal (PAF) to persistent atrial fibrillation (PerAF) following effective PV isolation (PVI) has important clinical implications, as it is relevant for subsequent management of the arrhythmia.

Objective

We evaluated risk factors responsible for progression of PAF to PerAF following successful PVI.

Methods

Consecutive AF patients that received their first catheter ablation as well as the first redo at our center were identified (n=1352). Patients were included in group 1 if the diagnosis was PAF at both first and redo procedure (PAF to PAF) and group 2 if PAF at index progressed to PerAF at redo. All patients received PVI plus isolation of LA posterior wall and SVC at the first procedure.

Results

A total of 822 patients remained as PAF at redo, whereas 530 (39%) progressed from PAF to PerAF. Clinical characteristics of the study population are presented in table 1. In multivariate analysis, BMI (OR 1.02, 1.01–1.04, p=0.04), hypertension (1.4, 1.08–1.8, p=0.01), heart failure (1.67, 1.03–2.69, p=0.03), LA size (2.75, 2.29–3.31, p<0.001) were independent predictors of progression of PAF to PerAF. Data on serum-transthyretin level was available for 37 and 48 patients in group 1 and 2 respectively. It was <18 mg/dL (normal) in 33 (68.7%) patients in group 2 vs 6 (16.2%) in group 1 (p<0.001).

Conclusion

In our patients, after successful PVI, progression of PAF to PerAF was mediated by independent risk factors such as high BMI, heart failure, hypertension, larger LA size and lower LVEF.

Funding Acknowledgement

Type of funding source: None
Empirical superior vena cava isolation in patients undergoing redo- catheter ablation procedure after recurrence of atrial fibrillation
Authors: Spies F , Madaffari A , Voellmin G , Krisai P , Schaerli N , Reichlin T , Osswald S , Sticherling C , Kuhne M , Knecht S
Published: November 2020

Background/Introduction

Extra pulmonary vein (PV) foci may trigger AF recurrence after an initially successful PVI. Superior vena cava (SVC) catheter ablation (CA) may therefore offer a treatment target in order to improve success rates.

Purpose

The purpose of this study was to evaluate the potential benefit of empirical SVC isolation in addition to PVI in patients undergoing a second CA after index PVI.

Methods

We retrospectively analyzed consecutive patients scheduled for a second CA because of a recurrence of symptomatic AF. Redo-CA was performed with a 3D electroanatomic mapping system and point-by-point ablation using RF energy in the range between 25 W and 30 W. In case of persistent isolation of all PVs, only SVCI was performed. In case of reconnection of vein(s), a wider antral re-isolation was performed. Redo-PVI (PVI-group) or Redo-PVI plus SVC isolation (SVCI) (PVIplusSVCI-group) were performed at the discretion of the operator. No additional targets were allowed. The endpoint of all procedures was elimination of the PV signals confirmed by a circular mapping catheter at the level of the PV ostium and elimination of all signals in the SVC in case of SVCI. Recurrence of AF during a follow-up of 12 months is presented.

Results

We analyzed 191 patients (age 61±10 years, 30% female, BMI 27±5 kg/m2, LVEF 56±9%, PLAX 41±7 mm, paroxysmal 61%). Whereas 148 (78%) patients underwent Redo-PVI only, 31 patients (16%) underwent PVI plus SVCI, and in 12 patients (6%) SVCI only was performed. Baseline characteristics did not differ significantly between the two groups. In the PVI-group, 79% were recurrence-free compared to 65% (see Kaplan-Meier curve: log rank p=0.011) in the PVIplusSVCI-group. The RF time of the PVI group focusing on the wide antral re-isolation of vein(s) was significantly higher than for the PVIplusSVCI-group (819±494 s versus 458±444 s; p<0.001).

Conclusion

Additional empirical SVCI at redo-PVI in patients with symptomatic AF recurrence does not lead to an increase in freedom from AF recurrence. Focusing on an additional “wider antral” re-isolation may be more effective.

Kaplan-Meier Survival Curves for Recurre

Funding Acknowledgement

Type of funding source: None
Long-term follow-up of thoracoscopic ablation for long-standing persistent atrial fibrillation
Authors: Harlaar N , Oudeman M.A.P , Trines S.A , De Ruiter G.S , Khan M , Zeppenfeld K , Tjon A , Braun J , Van Brakel T.J
Published: November 2020

Background

Catheter ablation in patients with long-standing persistent AF (LSPAF) remains challenging and often requires repeated procedures with variable results. We report long-term outcomes of a bipolar thoracoscopic pulmonary vein and left atrial posterior wall ablation for LSPAF, and compare continuous and interval rhythm monitoring.

Methods

Seventy-seven LSPAF patients who underwent thoracoscopic pulmonary vein and box isolation between 2009–2017 in two Dutch centers were included. Follow-up consisted of continuous rhythm monitoring using an implanted loop recorder or 24-h Holter at 3/6/12/24/60 months.

Results

Mean age was 59±8 years with a median AF duration of 3.8 [1.2–6.3] years. In the total cohort, at 2-year follow-up, 86.0% of patients were in sinus rhythm, 12.3% were in paroxysmal AF and 1.6% in persistent AF. At 5 years, 62.9% of patients were in sinus rhythm, 20.0% in paroxysmal AF, 14.3% in persistent AF and 2.9% was experiencing atrial flutter. Continuous rhythm monitoring was performed in 46% of patients. Comparing continuous and interval rhythm monitoring, freedom from any atrial arrhythmia episode at 2- and 5 years was 60.0% and 49.9% in the continuous group and 93.8% and 51.9% in the interval monitoring group, respectively (p=0.02, Breslow-Wilcoxon test). In patients with continuous rhythm monitoring the mean atrial arrhythmia burden was reduced from 99.1% preoperatively to 0.1% at the end of the blanking period and 7.3% at 2-year follow-up.

Conclusions

Thoracoscopic box ablation is highly effective in restoring sinus rhythm at medium term follow-up. However, it is not a curative treatment as demonstrated by the 50% arrhythmia-free survival at long-term follow-up. Whether this is due to the progressive nature of AF needs further investigation. Continuous rhythm monitoring shows earlier recurrence detection with a potential early treatment adaptation.

Funding Acknowledgement

Type of funding source: None
16-month outcomes following hybrid ablation for long-standing persistent atrial fibrillation in patients with dilated atria
Authors: Kaba R.A , Ashry A , Elbadri A , Gukop P , Li A , Sohal M , Bajpay A , Saba M , Sharma R.A , Gallagher M , Chandrasekaran V , Momin A
Published: November 2020

Introduction

Although catheter ablation therapy is a well-established treatment for cardiac dysrhythmias, the success rates for longstanding, persistent AF with dilated atria remain unsatisfactory. The minimally invasive hybrid technology is a novel form of therapy.

Methods

A prospective, single-center UK study to evaluate the hybrid ablation technique for patients with longstanding (>1 year) persistent AF and dilated atria. Stage 1 was a minimally invasive epicardial approach for ablation of the posterior wall of left atrium (LA) and pulmonary veins (PVs). Stage 2 was a transcatheter approach via the femoral veins to isolate the endocardial aspect of the PVs +/− posterior wall. Occasionally, the sequence of the stages was reversed.

Results

Forty-one patients were enrolled for the study with a mean follow-up for 16±9 months. Mean age was 65±9 years and the mean BMI was 32±7. Males constituted 75% of the study cohort. Mean LA size was 48±7 mm and mean left ventricular ejection fraction (LVEF) was 51.9%, although 51.6% of patients had impaired LVSF (LVEF below 55%). 87.8% CI (0.7–0.9) of patients remained in sinus rhythm (SR) without repeat ablation, whereas only 12.2% CI (0.04–0.02) had redeveloped persistent AF. Although numerically different, there was no statistically significant difference in maintaining SR between patients with severely dilated LA (>50 mm) and those without (70% vs. 90%, respectively; z=−1.39, p=0.165). Major perioperative complications during stage 1 ablation were low, with IVC injury in 1 patient and a mild stroke in 1 patient. Median LOS was 1 day (1–4 days) and there was no 30-day mortality after stage 1.

Conclusions

The hybrid ablation therapy has a conversion rate from longstanding persistent AF to SR of 87.8% at a mean follow-up of 16±9 months, without repeat ablation. LOS was short, with very few complications and no peri-operative mortality. The hybrid approach appears to be very encouraging for a condition with otherwise low success rates by conventional endocardial techniques alone.

Funding Acknowledgement

Type of funding source: None
Safety and efficacy of antithrombotic therapy according to stroke and bleeding risk in patients with atrial fibrillation and acute coronary syndrome or PCI: insights from AUGUSTUS
Authors: Harskamp R , Lopes R.D , Li Z , Wojdyla D , Goodman S.G , Aronson R , Windecker S , Mehran R , Granger C.B , Alexander J.H
Published: November 2020

Background

The AUGUSTUS trial showed that patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and/or PCI treated with a P2Y12 inhibitor and apixaban resulted in less bleeding and comparable ischemic events compared with regimens that included a vitamin K antagonist (VKA), aspirin, or both. We assessed the effect of apixaban versus VKA and aspirin versus placebo according to patients' baseline risk of stroke and bleeding.

Methods

AUGUSTUS randomized 4614 patients in a two-by-two factorial design to open label apixaban or VKA and blinded aspirin or placebo. The primary endpoint was major or clinically relevant nonmajor (CRNM) bleeding over 6 months of follow-up. The effects were assessed stratified by baseline CHA2DS2-VASc and HAS-BLED score using Cox proportional hazards models.

Results

4386 patients were included for this analysis. The median age was 71 (64–77) years, 29.4% were female, 81.7% had a CHA2DS2-VASc score≥3, and 66.8% a HAS-BLED score≥3. As shown in the table, rates of bleeding were lower with apixaban (vs VKA) irrespective of baseline bleeding risk (p-value interaction: 0.23). Aspirin (vs placebo) was associated with increased bleeding irrespective of baseline risk (p-value interaction: 0.88). Apixaban use was associated with a lower risk of death or hospitalization without a significant interaction with stroke risk (p-value of interaction=0.53). No differences were found for ischemic outcomes.

Conclusion

An antithrombotic regimen including a P2Y12 inhibitor and apixaban is associated with less bleeding and hospitalization compared to a regimen with VKA, aspirin, or both with results consistent across CHA2DS2-VASc, and HAS-BLED scores. Our findings support the use of apixaban and a P2Y12 inhibitor without aspirin during the first 6 months for most patients with AF and ACS and/or PCI, regardless of stroke and bleeding risk.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Augustus trial was sponsored by Bristol-Myers Squibb and Pfizer, Inc
Uninterrupted twice-daily direct oral anticoagulants are safer than once-daily ones for atrial fibrillation catheter ablation
Authors: Oshima T , Fujiu K , Yoshida Y , Matsunaga H , Matsuda J , Matsubara T , Saga A , Shimizu Y , Oguri G , Kojima T , Hasumi E , Komuro I
Published: November 2020

Background

In patients undergoing AF catheter ablation (CA), uninterpreted DOACs reduced bleeding events without increasing ischemic events compared with vitamin K antagonist, and the continuation of anticoagulants is recommended for AF ablation. However, in the past studies, patients received once-daily DOACs in the evening, not in the morning of the procedure day. Moreover, there has been no study comparing uninterrupted 4 DOACs; therefore, the safety and effect of uninterpreted DOACs taken just in the morning of AF ablation is unknown.

Objective

The purpose of this study was to compare bleeding complications and thromboembolism events between 4 DOACs in patients undergoing AF ablation.

Method

This study was the retrospective single-center cohort study of consecutive patients who underwent AF ablation between April 2014 to July 2019. All patients continued DOAC uninterruptedly including just in the morning of the procedure. The primary endpoint included major bleeding events within the first 30 days after CA. The secondary endpoints included the composite events of ischemic stroke, systemic embolism, myocardial infarction, and vascular death.

Result

A total of 713 patients (mean age 64±12 years, 72% male) were included in this analysis; enrolled patients were 88, 238, 218, and 169 respectively in dabigatran, rivaroxaban, apixaban and edoxaban group. At the baseline, the ratio of age ≥75 years and CHADS2 score was higher in apixaban group, though all other baseline variables were similar between them.

The primary endpoint was observed 0%, 2.1%, 0.45%, and 4.7% respectively in dabigatran, rivaroxaban, apixaban, and edoxaban group (P=0.013) without significant difference about secondary endpoint between them (P=0.3).

Comparing twice-daily vs once-daily DOACs, the primary endpoint was observed significantly lower in the twice-daily group than in once-daily group (0.32% and 3.2% respectively, P=0.0054), without any significant difference about secondary endpoint (0% and 0.73% respectively, P=0.26).

Conclusion

Taking DOACs also in the morning of AF ablation, uninterrupted twice-daily DOACs are safer than once-daily DOACs without increasing ischemic event, although twice-daily DOACs, especially apixaban, were used in higher aged patients.

Figure 1

Funding Acknowledgement

Type of funding source: None
Data for 3D left atrial printing acquired using open source and free software, with the aim to determine the proper size of left atrial appendage occlured
Authors: Hecko J , Jiravsky O , Chovancik J , Hudec M , Sramko M , Sknouril L
Published: November 2020

Background

The occlusion of the left atrial appendage is the treatment of choice in patients with high both thrombembolic and bleeding risks. The optimal method for size selection and occluder placement is still evolving. Based on published data, the ability to print a 3D atrial model might be helpful in these processes. Minimizing the cost of this approach may contribute to a massive extension of the methodology.

Aim

To present a process of data acquisition for 3D left atrial printing without the need of using a premium software.

Method

Patients indicated for percutaneous left atrial appendage closure are prepared according to standard recommendations. Afterwards, DICOM CT scans were used for our purpose. This data was transfered to the segmentation software. With the help of 3D Slicer 4.10 (slicer.org), the cardiac chambers were segmented from the contrast CT (DS CorCTA 1.0 B26f BestDiast 72%). The “Paint” function was specifically used for segmentation, marking each chambe. “GrowFromSeeds” utility was then used to automatically initialize chambers with the option of manual correction. Segments were subsequently transfered to the 3D model format (STL, 3MF). The difficulty was, that from the aforementioned contrast CT, we were only able to acquire the left atrial “cavity”, not reflecting the true dimensions of the walls. Therefore, we subtracted this shape from a cuboid. Then, using function “Hollow” in 3D Builder, we gradually removed the outer part of the cuboid around the subtracted cavity, resulting in a true left atrial wall. This enabled a valid sizing of the appendage. Since this procedure was part of a blinded study, a small cuboid marker (10x10x3mm) was added to the cast for patient identification and correct 3D printing.

For the printing itself, a flexible material with 30–35D hardness was used to simulate compliant cardiac tissue.

Conclusion

The segmentation of the left atrium using open source and free 3D software enables to minimize printing costs which may lead to extension of this method to everyday clinical practice.

Figure 1. Sequention of work

Funding Acknowledgement

Type of funding source: None
Impact of liver disease on oral anticoagulant prescription and major adverse events in patients with atrial fibrillation: analysis from a population-based cohort study
Authors: Proietti M , Marzona I , Vannini T , Colacioppo P , Tettamanti M , Foresta A , Fortino I , Merlino L , Lip G.Y.H , Roncaglioni M.C
Published: November 2020

Aims

Data on the impact of liver disease (LD) in patients with atrial fibrillation (AF) and the role of oral anticoagulant (OAC) drugs for stroke prevention, are limited. We analysed the impact of LD and OAC treatment in determining stroke, major bleeding, all-cause death and secondary bleeding outcomes.

Methods

A retrospective observational population-based cohort study. The study cohort is derived from the administrative health databases of Lombardy region (>10 million inhabitants), Italy. All AF patients ≥40 years admitted to hospital from 2000 to 2018 were considered. AF and LD diagnosis were established using ICD9-CM codes. Use of OAC was determined with Anatomical Therapeutic Chemical (ATC) codes. Primary study outcomes were stroke, major bleeding and all-cause death.

Results

Among 393,507 AF patients, 16,168 (4.1%) had concomitant LD. LD AF patients were significantly less treated with OAC independent of associated clinical characteristics (OR: 0.96, 95% CI: 0.92–0.98). Concomitant LD was found associated with an increased risk in all the study outcomes (HR: 1.18, 95% CI: 1.11–1.25 for stroke; HR: 1.57, 95% CI: 1.47–1.66 for major bleeding; HR: 1.41, 95% CI: 1.39–1.44 for all-cause death. Use of OAC in patients with AF and LD resulted in a reduction in stroke (HR: 0.80, 95% CI: 0.70–0.92), major bleeding (HR: 0.86, 95% CI: 0.74–0.99) and all-cause death (HR: 0.85, 95% CI: 0.80–0.90), with similar results according to several clinically relevant subgroups. A net clinical benefit (NCB) analysis suggested a positive benefit/risk ratio in using OAC in AF patients with LD (NCB: 0.408, 95% CI: 0.375–0.472).

Conclusions

In AF patients, concomitant LD carries a significantly higher risk for all clinical outcomes. Use of OAC in AF patients with LD was associated with a significant benefit/risk ratio, even in high-risk patient subgroups.

Funding Acknowledgement

Type of funding source: None