bluuebunny/crossref_metadata_2025 huggingface dataset:
Atrial fibrillation organisation correlates with ventricular response regularity in patients with persistent atrial fibrillation
Authors: Ahsan N , Sau A , Neerahoo R , Qureshi N , Koa-Wing M , Keene D , Malcolme-Lawes L , Lefroy D C , Linton N W F , Lim P B , Varnava A , Whinnett Z I , Kanagaratnam P , Peters N S , Ng F S
Published: November 2023

Background

Atrial fibrillation (AF) is characterised by an irregularly irregular ventricular rhythm. However, the mechanisms by which the regularity of ventricular response is influenced by AF dynamics is yet to be understood. In AF, there is a spectrum of organisation of atrial electrical activity; from organised AF sustained by focal drivers through to disorganised AF sustained by multiple wavelet re-entry. We aimed to investigate whether the ventricular response in AF was associated with the organisation of atrial electrical activity, with the hypothesis that AF organisation correlates with ventricular response regularity.

Methods

We retrospectively reviewed data from 239 patients with persistent AF undergoing pulmonary vein isolation (PVI). In each patient both before and after ablation, AF organisation and measures of ventricular variability and irregularity were evaluated in 50s segments. Shannon entropy (ShEn) and Sample entropy (SampEn) derived from coronary sinus (CS) atrial electrograms were used to assess AF organisation. RR interval (RRI) metrics derived from the surface ECG were used to determine ventricular variability and irregularity. RRI variability was evaluated using the time-domain measures: normalised mean RRI difference, standard deviation of RRIs (SD RRI), normalised SD RRI, root mean square of successive RRI differences (rMSSD) and percentage of successive RR intervals that differ from each other by more than 50ms (pNN50). RRI irregularity was measured using SampEn and normalised SampEn.

Results

A significant decrease in atrial ShEn and SampEn was observed following PVI across all CS channels (e.g. SampEn CS 3-4: pre-ablation=0.907±0.512 vs post-ablation=0.790±0.447, p<0.0001). Both ShEn and SampEn from CS atrial electrograms were significantly correlated with the RRI variability and irregularity measures from surface ECG (pNN50, normalised mean RRI difference, normalised SD RRI and normalised SampEn) both pre- and post-ablation (pNN50: r=0.0771, p=0.00838, Figure 1; normalised mean RRI difference: r=0.144, p<0.0001; normalised SD RRI: r=0.175, p<0.0001; normalised SampEn: r=0.168, p<0.0001; correlations with SampEn CS 3-4 pre-ablation shown).

Conclusion

The reduction in atrial ShEn and SampEn following PVI suggests that an increase in AF organisation occurs with PVI. The significant correlations between atrial entropy and measures of RRI variability and irregularity suggest that AF organisation impacts ventricular response regularity. Therefore, interpretation of the RRI variability and irregularity from the surface ECG may give some insight, non-invasively, into the level of AF organisation.Figure 1
Risk of incident atrial fibrillation and subsequent use of oral anticoagulants in patients with dementia
Authors: Chao T , Kuo L , Lip G Y H , Chen S A
Published: November 2023

Background

Dementia and atrial fibrillation (AF) have many shared risk factors, and the presence of AF is associated with a higher risk of incident dementia. Although patients with dementia have higher risk of adverse cardiovascular events, there are limited data on the risks of incident AF, and the associated AF-related clinical outcomes. Patients with dementia are under-represented in randomised trials, and even if AF is present, oral anticoagulants (OAC) are not prescribed frequently. We aimed to report the incidence of newly-diagnosed AF in dementia patients, and the impact on stroke and bleeding outcomes with vitamin K antagonist (VKA, eg warfarin) and non-VKA OAC (NOACs).

Methods

Nationwide cohort study of 544,074 patients with dementia, compared to 554,074 age- and sex-matched patients without dementia.

Results

Rates of newly-diagnosed AF were higher in patients with dementia compared to those without history of dementia (1.89 per 100 person-years vs 1.78 per 100 person-years, respectively); adjusted risk of incident AF was greater in all types of dementia, pre-senile/senile dementia and vascular dementia (Figure 1). When compared to non-OAC users, warfarin use was associated with higher risk of ischaemic stroke (aHR, 1.290; 95% CI, 1.156 - 1.440), intracranial hemorrhage (ICH) risk (aHR, 1.678; 95% CI, 1.346 - 2.09) and major bleeding (aHR, 1.192; 95% CI, 1.073 - 1.323). NOAC use was associated with lower risk of ischaemic stroke (aHR, 0.42; 95% CI, 0.352 - 0.501) and major bleeding (aHR; 0.504, 95% CI, 0.433 - 0.587), when compared to non-OAC use (Figure 2).

Conclusions

In this large nationwide cohort of dementia patients, the incidence rate of newly-diagnosed or incident AF was higher in patients with dementia compared to patients without dementia. Compared to non-OAC users, NOAC use was associated with a lower risk of ischaemic stroke and major bleeding. Patients with dementia require a holistic approach to their care and management, including the use of NOACs to reduce their risks of clinical events.
Prevalence of atrial fibrillation in patients with atrial septal defect and its impact on in-hospital outcomes
Authors: Htwe K , Baral N , Aung T , Moza A , Munir A
Published: November 2023

Background

Atrial septal defect (ASD) is one of the most common congenital heart diseases in adulthood. ASDs have left-to-right shunt and primarily right-sided volume overload. This leads to electrical remodeling that may predispose patients to atrial fibrillation (AF). There is limited data on the impact of AF on clinical outcomes in patients with ASD.

Purpose

To study the prevalence of AF and its impact on in-hospital outcomes in adult patients with ASD.

Methods

This is a retrospective cohort analysis of all ASD related hospitalizations between January 1, 2016, and December 31, 2020, from the National Inpatient Sample, the largest publicly available all-payer inpatient care database in the United States. Our study population included adult patients (≥ 18 years) with ASD using ICD-10 diagnostic codes. Patients with a diagnosis of acquired ASD were excluded. ASD patients were divided into two groups: with and without AF. We used Chi square test for categorical variables and t-test for continuous variables to compare group differences between ASD with AF and ASD without AF. Univariate and multivariate logistic regression were used to analyze the clinical outcomes between the two groups.

Results

From 2016 to 2020, we identified 82,574 hospitalizations with primary diagnosis of ASD, of which 23,907 (29%) had coexisting AF. The mean age was 71 years. Among them, 48% were female. Racial distributions were: 81% Whites, 8.8% Blacks, 5.9% Hispanics and 2.1% Asians. Compared to ASD without AF, ASD with AF hospitalizations were older in age (mean age: 71 vs 59, p<0.001), had higher prevalence of chronic heart failure (56% vs 25%, p<0.001), hypertension (71% vs 61%, p<0.001), obstructive sleep apnea (16% vs 9%, p<0.001), and higher Charlson comorbidity index (CCI) of ≥3 (52% vs 46%, p<0.001). ASD patients with AF had higher in-hospital mortality (aOR: 1.25, 95% CI: 1.14, 1.37, p<0.001), longer length of stay (beta coefficient: 0.15, 95% CI 0.13, 0.17, p<0.001), higher odds of acute heart failure (aOR:3, 95% CI: 2.86, 3.15, p<0.001), cardiogenic shock (aOR: 2.68, 95% CI: 2.42, 2.97, p<0.001), acute kidney injury (aOR:1.4, 95% CI: 1.35, 1.46, p<0.001) and requirement of permanent pacemaker (PPM) (aOR: 2.51, 95% CI: 2.16, 2.92, p<0.001) compared to ASD without AF after controlling for age, race, CCI, obesity, COPD and pulmonary hypertension.

Conclusions

Our study showed that a significant percentage of hospitalized patients with ASD had concomitant AF. AF can contribute to higher in-hospital mortality and worse clinical outcomes in patients with ASD. This highlights the importance of optimal management of AF in patients with ASD.
The relationship between changes of antithrombotic drug regimen after ischemic stroke and risks of clinical outcomes in patients with atrial fibrillation
Authors: Chao T , Lip G Y H , Chen S A
Published: November 2023

Background

Stroke prevention is central to the management of patients with atrial fibrillation (AF), but the impact of changes in antithrombotic regime following presentation with an ischaemic stroke on subsequent clinical events is unceratin.

Methods

From 2012 to 2018, 23,165 AF patients who experienced ischemic stroke and survived longer than 90 days after stroke were identified from Taiwan National Health Insurance Research Database. The relationships between post-stroke antithrombotic drug regimen and subsequent clinical outcomes were analyzed.

Results

Compared to NOACs (reference), there was a significant increase in ischaemic stroke in non-anticoagulated and antiplatelet users (both aHR approx 1.8), with no significant differences to warfarin. The same was evident for a higher mortality in non-anticoagulated and antiplatelet users (aHRs 3.441 and 1.483, respectively). Addition of antiplatelets to NOAC or warfarin resulted in non-significant differences in ischaemic stroke or mortality (Figure 1).

Among 769 pateints who received NOACs before and continuously stayed on NOACs after stroke, the shifting to a different NOAC post-stroke was associated with a higher risk of ischaemic stroke (aHR 2.07) as well as the composite outcomes (aHRs between 1.359-1.849), with no difference in major bleeding, mortality or ICH (Figure 2).

Conclusions

Adding antiplatelet agents to NOACs for AF patients after ischemic stroke did not provide additional clinical benefits. For patients under NOACs who experienced ischemic stroke, the change to a different NOAC post-stroke was not associated with a better clinical outcome.
The association between HbA1c variability and strokes in patients receiving anticoagulants
Authors: Huang J , Chandramouli C , Wu M Z , Ren Q W , Tse H F , Lip G Y H , Yiu K H
Published: November 2023

Background

Diabetes, higher glycaemic level, is associated with an increased risk of stroke in patients with atrial fibrillation (AF) and is integrated into the CHA2DS2-VASc score for stroke risk prediction. However, the association between glycaemic variability and stroke risk in AF patients remains unclear.

Objective

To evaluate the association between glycaemic variability and stroke among diabetic and non-diabetic patients with nonvalvular AF receiving anticoagulants.

Methods

Newly diagnosed AF from 2013-2018 (n=8,790) were divided by their diabetes status. Variability in glycaemic, represented by coefficient of variation (CV) on HbA1c (haemoglobin A1c), was assessed by at least three HbA1c measurements following enrollment to the end of the follow-up period. Participants with ischaemic stroke (IS)/systemic embolism (SE), haemorrhagic stroke (HS) or all-cause mortality at baseline or within 1 year of enrollment were excluded. Multivariate Cox regression was performed to evaluate the association between variability in HbA1c and subsequent incident IS/SE, HS and all-cause mortality. Sensitivity analyses included defining HbA1c variability using average successive variability (ASV) and variability independent of the mean (VIM).

Results

Diabetes status significantly modified the relationship between HbA1c variability and risk of IS/SE (Pinteraction = 0.36)and all-mortality (Pinteraction <0.01). Greater incidence rates were observed among individuals with diabetes, compared to those without diabetes (3.74 vs. 2.41 for IS/SE, 0.54 vs. 0.33 for HS and 4.89 vs. 2.42 for all-cause mortality per 100 person years). Among those with diabetes, greater HbA1c variability was significantly associated with increased risk of IS/SE (hazard ratio [HR] = 1.21, 95% confidence interval [CI]: 1.11-1.31), all-cause mortality (HR = 1.13, 95%CI: 1.05-1.20) and HS (HR = 1.10, 95%CI: 1.02-1.23). Similar patterns were found in individuals without diabetes (IS/SE: HR = 1.28, 95%CI: 1.08-1.52; all-cause mortality: HR = 1.50, 95%CI: 1.29-1.75). However, no significant association was observed between glycemia variability and HS among those without diabetes. Results were consistent with alternative measures of HbA1c variability.

Conclusion

Variability in HbA1c was independently associated with the risk of IS/SE and all-cause mortality among patients with AF, regardless of diabetes status.
Neurofilament light chain (NFL) - a neuron-specific plasma biomarker for evaluating risk of ischemic cerebral events in atrial fibrillation
Authors: Aulin J , Sjolin K , Lindback J , Benz A P , Connolly S J , Eikelboom J W , Hijazi Z , Oldgren J , Wallentin L , Burman J
Published: November 2023

Background

A history of ischemic stroke is one of the strongest risk factors for future stroke in patients with atrial fibrillation (AF). Circulating biomarkers specific for the brain may be used to detect overt and covert cerebral ischemia. Neurofilament light chain (NFL) is a neuron-specific cytoskeleton protein that is released into blood at increased levels when the brain is injured and may be a complement to already established risk factors of AF.

Purpose

We hypothesized that NFL measured in plasma (pNFL) is an independent and incremental risk indicator of ischemic stroke in patients with AF.

Methods

pNFL was measured in venous blood samples from 1,056 patients with AF randomised to aspirin in the ACTIVE A trial. Samples were collected at randomisation and the median follow-up duration was 3.6 years. pNFL was analysed with a single molecule array. Associations between pNFL and subsequent clinical outcomes were evaluated by Cox-regression models adjusted for fifteen clinical characteristics and NT-proBNP levels.

Results

The median concentration of pNFL was 17.3 (interquartile range 10.9-28.3) ng/L. The variables most strongly associated with higher pNFL levels were advanced age, renal dysfunction, lower body mass index, prior stroke/transient ischemic attack and female sex. In multivariable analyses, pNFL was a stronger risk indicator for ischemic stroke than any clinical factor, including previous stroke (Figure 2), and of similar prognostic importance as NT-proBNP. pNFL was independently associated with ischemic stroke (per doubling of pNFL, hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01-1.50, p=0.038), all-cause death (HR 1.30, 95% CI 1.12-1.51, p<0.001) and heart failure (HR 1.30, 95% CI 1.09-1.54, p=0.003) when adjusting for both clinical characteristics and other biomarkers including NT-proBNP. pNFL improved the discriminatory value (c-index) for ischemic stroke from 0.676 to 0.686 (p=0.038) when added to a fully adjusted model including NT-proBNP.

Conclusions

In patients with AF, pNFL was associated with an increased risk of ischemic stroke, independent of clinical characteristics and NT-proBNP. pNFL was a stronger risk factor for ischemic stroke than previous stroke and of similar prognostic importance as NT-proBNP. pNFL may be a novel plasma biomarker improving the evaluation of the risk of ischemic cerebral events in patients with AF.Stroke risk by pNFL quartile groupVariable importance for ischemic stroke
Left atrial appendage morphology and mitral annular plane systolic excursion predict stroke in patients with atrial fibrillation and high thromboembolic risk
Authors: Sarb A , Lazar R D , Zehan I G , Schiop-Tentea C P , Coseriu G , Apetrei C A , Moldovan M , Mocanu L , Jelnean M , Sarb O F , Gusetu G , Serban A , Chiorescu R , Pop S , Blendea D
Published: November 2023

Background

Previous research has revealed a relationship between the morphology and function of the left atrial appendage (LAA) and the rate of thromboembolic events in patients with atrial fibrillation (AF). There is limited data on the impact of the left ventricular (LV) function on LAA thrombus formation. Emptying of the LAA depends on the active contraction of this structure as well as on the passive motion due to external compression from the LV base during ventricular diastole.

Purpose

Given these considerations the goal of this study was to investigate by transesophageal and transthoracic echocardiography the morphology and function of the LAA in relationship with the LV function and to assess the impact on incidence of stroke in a group of patients with AF with high thromboembolic risk who underwent TEE-guided direct current cardioversion.

Methods

We included 148 patients (age 65 ±11 yrs, 79men, median CHA2DS2-VASc score 4 (IQR 2-6), left ventricular ejection fraction 48±11%), who underwent transesophageal echocardiography before cardioversion. During a median follow-up period of 23 months (range 1-107) 34 patients developed stroke or TIA.

Results

The distribution of the four LAA morphologies (Figure 1) was: Cactus [47 (32%)], Cauliflower [30 (20%)], Windsock [38(26%)], and Chicken Wing [33 (22%)].

During the follow-up period stroke/TIA occurred significantly more frequently in patients with cactus or cauliflower LAA morphology vs. patients with windsock or chicken wing morphology (25 (35%) vs 9 (11%); p value=0.001). Patients who developed stroke or TIA had significantly lower MAPSE vs patients with event free survival (8±3 vs 12±3mm; p value=0.001).

Kaplan-Meier survival curves for different categories of MAPSE and LAA morphology are shown in Figure 2. The significant relationship between MAPSE and stroke-free survival was retained in Cox multivariable analysis that included LAA morphology, CHA2DS2-VASc score and AF types. This association was present whether MAPSE was entered into the multivariable model as a continuous or dichotomized variable.

Conclusions

In patients with high thromboembolic risk, MAPSE predicts the occurrence of stroke independent of LAA morphology and CHA2DS2-VASc score. This phenomenon could be related to the impact LV diastole on LAA emptying.
The prognostic value of atrial fibrillation in patients with cardiac sarcoidosis
Authors: Fujimoto Y , Matsue Y , Maeda D , Dotare T , Sunayama T , Akama Y , Yoshioka K , Kitai T , Naruse Y , Taniguchi T , Tanaka H , Okumura T , Baba Y , Nabeta T , Minamino T
Published: November 2023

Background/Introduction

The prognostic value of the presence of atrial fibrillation (AF) at the time of diagnosis in patients with cardiac sarcoidosis (CS) is unknown.

Purpose

The aim of this study is to investigate the association between the presence of AF at the time of diagnosis of CS and prognosis.

Methods

This study is a post-hoc analysis of ILLUMINATE-CS (Illustration of the Management and Prognosis of Japanese Patients With Cardiac Sarcoidosis), a multicenter, retrospective, and observational study that evaluated the clinical characteristics and prognosis of cardiac sarcoidosis. The primary endpoint was the combined endpoint of all-cause death and heart failure hospitalization.

Results

After excluding 32 patients with missing data about the presence of AF, 480 patients with CS (61.6±11.4 years, 36% men) diagnosed according to current guidelines were analyzed, and 86 primary endpoints were observed during a median follow-up period of 3.3 (interquartile range, 1.8-6.0) years. Patients with AF were associated with older age, higher levels of brain natriuretic peptide (BNP), and the prevalence of heart failure admission compared to those without AF. Kaplan-Meier curve analysis indicated that AF was significantly associated with a high incidence of primary endpoints (log-rank P=0.002), and this association was retained even after adjusting for known risk factors including log-transformed BNP and left ventiricular ejection fraction (LVEF) (hazard ratio, 2.10 [95% CI, 1.16-3.82]; P=0.015).

Conclusion

The presence of atrial fibrillation at the time of diagnosis in patients with cardiac sarcoidosis is independently associated with adverse events.
Bleeding risk profile and heart failure hospitalizations in patients with atrial fibrillation according to FIB-4 index
Authors: Parada Barcia J , Abu-Assi E , Raposeiras Roubin S , Barreiro Perez M , Melendo Viu M , Dobarro Perez D , Iglesias Otero C , Gonzalez Fernandez D , Gonzalez Garcia A , Noriega Caro V , Prado Prado H , Dominguez Erquicia P , Lizancos Castro A , Dominguez Rodriguez L , Iniguez Romo A
Published: November 2023

Introduction

Fibrosis-4 index (FIB-4 index), calculated by age, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet count, is a simple marker to evaluate liver fibrosis. The FIB-4 index is associated with higher all-cause mortality in patients with heart failure (HF). However, the relationship between liver stiffness and atrial fibrillation remains unclear.

Purpose

The present study explores the impact of the FIB-4 index in the bleeding risk and heart failure hospitalizations among a large cohort of AF patients.

Methods

The Fibrosis-4 index (FIB-4) was applied to 10,530 patients diagnosed with AF from our health area between January 2014 and April 2020. Patients were analyzed in three regions of the Fib-4index based on the cutoff points (Group 1 F0<1.30, group 2 F1-F2:1.30–2.67 and group 3 F3-F4: >2.67). The outcome was a composite of major bleeding events and hospitalization for heart failure. The risk of the combined end-point was determined by competing risk regression.

Results

4471 patients (42.5 %) were included in Group 1, 5139 (48.8 %) in Group 2 and 920 (7.4%) in Group 3.

During a mean follow-up of 3.78±2.05 years, 1,834 patients died (17.49%), 2,359 had a heart failure hospitalization (22,42%) and 772 had a major bleeding (7.36%).

The incidence of major bleeding and heart failure hospitalizations was significantly higher amongst group 3. In the univariate analysis, group 2 and group 3 were associated with increased risk of the combined outcome (Figure 1).

Multivariate adjustment was developed including all those variables with clinical significance and those that had been associated in the univariate analysis. Group 3 was associated with higher increased risk of major bleeding and heart failure hospitalizations (sHR 1.21, 95% CI 1.05-1.39; P=0.007), whilst Group 2 not (1.06, 95% CI 0.97-1.16; P=0.169) in comparison with Group 1.

Conclusions

FIB4 index >2.67 was associated with higher risk of major bleeding and heart failure hospitalizations. FIB-4 index may reflect venous congestion and it could be an useful tool for predicting HF and major bleeding events in patients with AF.Figure 1
Impact of cardiorenal syndrome on clinical outcomes of atrial fibrillation patients undergoing catheter ablation
Authors: Matsuura H , Itonaga J , Hara A , Kisanuki H , Sada M , Okabe K , Okahara A , Kawai S , Tokutome M , Matsukawa R , Mukai Y
Published: November 2023

Background

Heart failure (HF) coexists with both atrial fibrillation (AF) and chronic kidney disease (CKD) and exacerbate each other. All of them are increasing in the aging society all over the world. Little is known regarding the impact of cardiorenal syndrome (CRS) on clinical outcomes of patients with AF undergoing catheter ablation (AFCA) in the real-world setting.

Purpose

In the present study, we investigated clinical outcomes of CRS patients with de novo AFCA. Method: Consecutive 494 patients (68.1±11.1 yrs, male 68.0%) undergoing de novo AF catheter ablation in our hospital from April 2019 to March 2021 were enrolled. CRS was defined as having both HF and CKD. HF was defined as having a history of HF admission and/or BNP≥100 pg/mL. CKD was defined as eGFR< 60 ml/min/1.73m2. The primary outcome was composite outcomes of; all-cause death, redo ablation, thromboembolisms, atherosclerotic cardiovascular disease (ASCVD) events, major bleeding, HF admission, and dialysis initiation.

Result

The incidence of primary outcome in CRS patients during median follow-up periods of 739.5 days was significantly higher than the non-CRS patients (54.9% in CRS vs. 30.3% in non-CRS; P<0.01, Figure 1). In CRS patients, all-cause death, ASCVD events, and HF admission were significantly worse (7.7% in CRS vs. 0.3% in non-CRS; P<0.01, 10.3% in CRS vs. 1.8% in non-CRS; P<0.01, 11.5% in CRS vs. 0.9% in non-CRS; P<0.01, respectively, Table), however redo ablation, thromboembolism, major bleeding and dialysis initiation were similar compared with non-CRS patients (10.3% in CRS vs. 14.5% in non-CRS; P=0.25, 1.3% in CRS vs. 0.6% in non-CRS; P=0.59, 5.1% in CRS vs. 2.1% in non-CRS; P=0.09, 1.3% in CRS vs. 0.3% in non-CRS; P=0.24, respectively, Table). The incidence of primary outcome in CRS patients was similar in those with ejection fraction (EF)≤40% and in those with EF>40% (47.6% in EF≤40% vs. 54.7% in EF>40%; P=0.48, Figure 2), however it was significantly higher in those with eGFR<45 compared with those with eGFR≥45 (74.8% in eGFR<45 vs. 26.2% in eGFR≥45+ P<0.01, Figure 3).

Conclusion

CRS patients with AFCA had significantly worse outcomes with more all-cause death, ASCVD events and HF admission compared with non-CRS patients. In the CRS patients undergoing AFCA, worse kidney function, rather than the cardiac systolic function, had a significant prognostic impact on the over-all clinical outcomes.
Temporal association between atrial fibrillation burden in cardiac implantable electronic devices and the risk of heart failure hospitalization
Authors: Ahluwalia N , Schilling R J , Koehler J , Majumder S , Landman S , Sarkar S
Published: November 2023

Background

high daily atrial fibrillation (AF) burden measured in cardiac implantable electronic devices (CIEDs) has been shown to be temporally associated with increased stroke risk.1

Purpose

We investigated whether AF burden is temporally associated with an increased risk of heart failure (HF) events in a large real-world cohort of patients with CIED devices.

Methods

We linked a de-identified database of aggregated electronic health records from 2007-2021 to a manufacturer’s device data warehouse with device based continuous diagnostic monitoring data. Patients with dual or triple chamber CIED implants with capability to measure daily AF burden and having HF events with 120 days of AF burden data prior to the HF event were included in this study. HF event was defined as an inpatient admission, emergency department presentation, or observation unit stay in a hospital with primary diagnosis of HF with intravenous diuretics administration. AF burden of ≥5.5 hours (as defined in earlier studies) on any given day was compared during days 1-30 before (case period) and days 91-120 days (control period) before the first HF event in each patient in this case-crossover study.2

Results

A total of 7257 earliest HF events with AF burden available in the case and control period were included. The average age of patients was 72 ±12years, with 74% being males, and following co-morbidities diagnosed prior to the HF event: 83% hypertension, 48% diabetes, 74% coronary artery disease, 31% stroke/TIA, 45% CKD, and 27% vascular disease. Comparison of occurrence of AF above threshold (≥5.5 hours on any given day) on days 1-30 versus 91-120 pre-HF event is shown in table to illustrate the effect of temporally proximate AF on risk of HF event. A total of 957 (13%) had discordant arrhythmic state between case and control period, with 763 (11%) having AF ≥5.5 hours on a day in case period versus 194 (2%) in the control period (OR: 3.93; 95% CI: 3.36-6.60). Higher odds of HF event was observed closer the day with AF ≥5.5 hours is to the HF event (table 1).

Conclusions

In a large real-world population of patients with CIED devices, AF burden of ≥5.5 hours or more on a given day increases risk of worsening HF.Table 1:odds ratio of HF eventFigure 1:Temporal association
Pulmonary vein isolation durability after very high-power short-duration ablation utilizing a very-close protocol
Authors: Heeger C H , Subin B S , Feher M F , Popescu S S P , Hatahet S H , Eitel C E , Vogler J , Kuck K H K , Tilz R R T
Published: November 2023

Background

Very high-power short-duration (vHP-SD) radiofrequency (RF) ablation of atrial fibrillation (AF) treatment by pulmonary vein isolation (PVI) aims for safer, more effective and faster procedures. The lesion formation of vHP-SD ablation creates wider but shallower lesions. Utilizing an individualized "very close-protocol" of 3-4mm inter-lesion distance (ILD) at the anterior and 5-6mm at the posterior aspect of the left atrium using vHP-SD only the close-protocol was adapted. Although acute efficacy for PVI was recently shown no data on chronic PVI durability has been assessed up to date. Here chronic PVI durability was evaluated during repeat electrophysiological procedures in patients after initial vHP-SD based PVI and recurrence of AF, atrial tachycardia or left atrial appendage closure.

Methods and Results

A total of 25 consecutive patients with repeat left atrial procedures after initial vHP-SD based PVI were included in this study. The median time to the repeat procedure was 5 (IQR 2, 10) months. The patients received a repeat procedure and verification of PVI due to recurrence of AF (n=8), atrial tachycardia (n=12), typical flutter (n=1) or left atrial appendage closure (n=4). During repeat procedures 3D electroanatomical mapping of the left atrium was conducted. Verified PVI durability of all PVs was found in 16/25 (64%) patients. In 1/25 (4%) patient PVI reconduction was found in 1 PV, in 6/25 (24%) patients PVI reconduction was found in 2 PVs and in 1/25 (4%) patient PVI reconduction was found in 3 PVs. A total of 81/100 PVs (81%) were found to be chronically isolated. For right sided PVs 42/50 PVs (84%) were isolated while for left sided PVs 39/50 PVs (78%) were isolated. All PVs were reisolated utilizing radiofrequency energy.

Conclusions

PVI solely utilizing vHP-SD via a very close-protocol provides high rates of chronically isolated pulmonary veins.
Amiodarone is associated with increased mortality compared with other antiarrhythmic drugs in female patients with atrial fibrillation
Authors: Choi J I , Kim Y G , Kim H S , Kim M N , Jeong J H , Lee H S , Choi Y Y , Shim J , Kim Y H
Published: November 2023

Objective

Antiarrhythmic drug (AAD) is the first-line therapy in patients with atrial fibrillation (AF) to maintain sinus rhythm. Amiodarone is one of the commonly used AAD that is known to lead to cardiac and extra-cardiac toxicities including pulmonary fibrosis and thyroid function abnormalities. However, the effect of amiodarone as compared with other-AADs (mainly Ic sodium channel blockers) on all-cause mortality is not fully evaluated.

Methods

This study used nationwide healthcare insurance system data. Patients with new-onset AF between 2013 and 2019 were enrolled. Use of AADs were confirmed if the patient were prescribed with AAD for more than six months during first year of AF diagnosis (medication possession ratio > 0.5). Clinical follow-up duration was three years from the moment AAD prescription after AF diagnosis. All-cause mortality was compared between amiodarone vs. other-AAD users.

Results

A total of 770,977 new-onset AF cases were detected. Among these people, 15,142 and 38,707 were identified as amiodarone and other-AAD users, respectively. Significant differences were observed in mean age and prevalence of heart failure, myocardial infarction, chronic kidney disease, diabetes mellitus, and dyslipidemia. After propensity score matching, 9,672 amiodarone users were compared with other-AAD users with same sample size and baseline characteristics were well matched. In multivariate adjusted analysis, amiodarone was associated with 2.5-fold increase in all-cause mortality (hazard ratio=2.520; 95% confidence interval=2.202 – 2.883; p< 0.001). Amiodarone did not show any significant interactions with age, thyroid disease, chronic kidney disease, heart failure, myocardial infarction, diabetes mellitus, dyslipidemia, and hypertension. However, the association between amiodarone and increased mortality was more pronounced in women compared with men (HR=3.124 vs. 2.231; p for interaction=0.022).

Conclusion

This study showed that all-cause mortality was significantly higher in amiodarone users than other-AAD users due to the toxicities, not by underlying diseases, which was more profound in female. This findings suggests that avoiding amiodarone as a first-line therapy should be considered in AF patients who have no compelling indications such as significant coronary artery disease or heart failure.All-cause mortality
The omnipolar voltages as an ablation indicator for pulmonary vein isolation in patients with atrial fibrillation
Authors: Mine T , Sugitani M , Kogame T , Fukuhara E , Ishihara M
Published: November 2023

Background

Lesion Index (LSI) without considering myocardial voltage is well-known to guide pulmonary vein isolation (PVI) ablation using the TactiCath™ Ablation Catheter in paroxysmal atrial fibrillation (PAF) patients. However, some patients show gaps after LSI-guided PVI ablation. Meanwhile, the omnipolar voltages detected using EnSite™ Omnipolar Technology (OT) have been reported to improve the underestimation of voltage.

Purpose

We aimed to clarify their differences by comparing the omnipolar voltages with conventional bipolar voltages and to verify whether it could be an additional indicator of LSI.

Methods

[Study1] We retrospectively studied 48 PAF patients (32 male, 69±8yrs) who received catheter ablation (CA). The left atrial voltage mapping was performed with Advisor™ HD Grid Mapping Catheter under right atrial pacing. The voltages within a 1cm diameter circle were measured at each site (Roof, Anterior, Posterior, Septal, Lateral; 238 sites) and evaluated the omnipolar and conventional bipolar voltages. [Study2] Twelve patients (8 males, 71±9yrs) with PAF who underwent CA were prospectively studied. The left atrial voltage mapping was performed before PVI ablation. The pre-ablation omnipolar voltages / bipolar voltages and LSI on each ablation site (558 points) of the PVI line were measured and compared in gapped and non-gapped regions. The gapped areas were defined as sites that required additional ablation after the first-round ablation of PVI.

Results

[Study1] The omnipolar voltages were higher than the bipolar voltages (total 238 sites, 2.84±2.05 vs. 2.67±1.81 mV, P<0.0001) in the entire left atrium. There was no feature in the difference between the omnipolar voltage and the bipolar voltage, according to the site and the voltage height (Figure). [Study2] Five gaps (14 ablation points) were confirmed after the first round of LSI-guided PVI (LSI 4.5±0.4, minimum 3.8 - maximum 5.8) in 4 of 12 patients. The omnipolar voltage in the gapped areas was higher than the non-gapped areas (544 ablation points) (5.64±1.93 vs. 3.73±2.82mV, P=0.0118, cut-off value 3.56mV, the area under the curve 0.74678). Meanwhile, there was no difference between the gapped and non-gapped areas in LSI and the conventional bipolar voltage.

Conclusion

Although the omnipolar voltage obtained by OT is detected only slightly higher than the bipolar potential, the higher omnipolar voltage could be an indicator of additional ablation to the LSI.
The application of 4S atrial fibrillation scheme in predicting atrial arrhythmia recurrence after catheter ablation
Authors: Kuo L , Chao T F , Chang S L , Lin Y J , Chung F P , Lo L W , Hu Y F , Duan T C , Liao J N , Chang T Y , Lin C Y , Liu C M , Liu S H , Wu C I , Chen S A
Published: November 2023

Background

Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia. Recently, there is a new scoring system - 4S (Stroke Risk; Symptoms; Severity of Burden; Substrate), proposed in 2020 European Society of Cardiology AF guideline to identify the characteristics of AF patients in details and provide precise guidance for the AF management.

Purpose

We aimed to report the disease severity of AF patients who received first time catheter ablation (CA) using 4S-AF scoring system, and further discover the value of 4S-AF scheme in the prediction of atrial arrhythmia recurrence after CA.

Methods

We conducted a retrospective study of 350 AF patients between 2015 and 2017 referred for first time CA. The components of 4S-AF scheme including the following: (1) ischemic stroke risk (score 0 or 1), (2) symptoms (score 0 to 2), (3) severity of AF burden (score 0 to 2), (4) substrate (cardiovascular risk factors-score 0 to 2; left atrial enlargement-score 0 to 2). The 4S-AF score ranges from 0 to 9, and the study population was stratified into three groups as mild (score 0 to 2), moderate (score 3 to 4) and severe (score 5 to 9) disease. The 3-year risk of recurrence of atrial arrhythmias was studied using the Cox regression analysis. Atrial arrhythmias at follow-up were reported with a time-to-event analysis, and survival curves were created utilizing the Kaplan–Meier method with differences between groups compared with the log-rank test.

Results

The mean age of patients was 56 ± 11 years, 260 (74%) were men, and 82 (23%) had non-paroxysmal AF. Over the 3-year follow-up, 168 (47%) patients experienced recurrence. The recurrence rates were 32%, 47% and 62% for mild, moderate, and severe disease groups, respectively (Figure A). Non-paroxysmal AF (hazard ratios [HR]: 2.1, 95% confidence interval [CI]:1.5-2.9, p<0.001), larger left atrial dimensions (HR: 1.0, 95% CI:1.0-1.1, p=0.03) and a higher 4S-AF score (HR: 1.2, 95% CI:1.1-1.3, p=0.001) were significantly associated with a higher risk of recurrence of atrial arrhythmia. After the multivariate adjustment, a higher 4S-AF score (HR: 1.1, 95% CI:1.0-1.2, p=0.006) remained as the independent predictor of recurrence. The recurrence-free survival curves after CA are shown in Figure B. The severe disease group was associated with a 1.9-fold higher risk of atrial arrhythmia recurrence compared to mild disease group (HR 1.9, 95% CI:1.3-2.9, p =0.002).

Conclusions

The disease severity of AF patients characterized using 4S-AF scheme could predict the risk of atrial arrhythmia recurrence after CA.
Atrial fibrillation catheter ablation: electroporation against high-power short duration radiofrequency
Authors: Reis Santos R , Matos D , Gomes D , Paiva M S , Rodrigues G , Carmo J , Costa F M , Santos P G , Carmo P , Morgado F , Cavaco D , Mendes M , Adragao P
Published: November 2023

Background

Pulmonary vein isolation (PVI) is one of the cornerstones of rhythm-control therapy for symptomatic atrial fibrillation (AF) patients. The new ablation technologies of pulse field ablation (PFA) and high-power short-duration radiofrequency ablation (HPSD) with the new QDOT® catheter have been recently introduced in the EP lab.

Aims

To evaluate and compare the efficacy, and safety of single-shot PFA and HPSDRA for PVI in AF symptomatic patients.

Methods

Single centre, retrospective study of consecutive patients undergoing PVI with PFA or HPSD between May-December 2022. Data on demographic, procedural and clinical/ electrocardiographic recurrence (assessed after a 3-months blanking period) were analysed. Comparative analysis between both techniques was performed.

Results

One hundred and ten consecutive patients were included (63 ± 11 years, 75% men), with a mean CHA2DS2-VASc score of 2±1 points, median LVEF of 61% [IQR 57-62%] and a median left atrial volume index (by CT scan) of 56 mL/m2 [IQR 51-67 mL/m2]. 55% patients presented paroxysmal-AF and 19 patients (17%) performed a redo ablation. 47% (n=52) patients performed HPSD and 53% (n=58) PFA (all with CARTO®3D system v.7 and high-density mapping). In the HPSD: median RF ablation time was 792 sec [IQR 614-919sec], while in PFA was 90 sec [IQR 30-138 sec]. Median time of catheter inside the LA for PFA was 18 min [IQR 2-33 min]. Comparing HPSD and PFA (Fig 1): median procedure time was similar (91 min [IQR 71-107 min] vs 89 min [IQR 66-111 min], p=0.261), while median fluoroscopy time was lower with HPSD (5.4 min [IQR 3.1-6.8 min] vs 13.2 min [IQR 10.3-15.6 min], p<0.001); posterior wall isolation (PWI) was performed in 5 (10%) HPSD vs 21 (37%) PFA patients (p<0.001). All PFA patients undergoing PWI had first pass isolation, while only 40% of HPSD had first pass isolation. When performed PVI only, PFA presents a lower median procedure time than HPSD (76 min [IQR 62-93 min] vs 97 min [IQR 69-135 min], p=0.048). There was only one major complication, a cardiac tamponade with PFA, treated with pericardiocentesis. At 3 months of follow-up, 17% (n=10) patients had clinical or electrocardiographic AF recurrence: 7 PFA patients and 3 HPSD patients (p=0.127).

Conclusions

PFA and HPSD were both feasible and safe. When undergoing PVI-only, procedure time was lower with PFA. In patients undergoing PWI, PFA achieved higher first pass isolation. Although still in its early real-world evaluation, both techniques seem to be efficient, providing low AF recurrence during follow-up.
Conduction time around the mitral valve annulus could predict the incidence of peri-mitral atrial tachycardia
Authors: Hara S , Miwa N , Hirano H , Nakata T , Doi J , Sato Y , Kusa S , Hachiya H
Published: November 2023

Background

Empirical ablation for mitral isthmus (MI) for AF patient is sometimes challenging for its complex anatomy and wall thickness. It would be helpful in determining the ablation strategies if it could be predicted in advance that peri-mitral atrial tachycardia (PMAT) would occur. Using 3D mapping, a method to confirm MI block has been reported using E-PMCT (estimated peri-mitral conduction time: the doubling the time between coronary sinus (CS) pacing and the wave-front collision at the opposite side of the mitral annulus).

Purpose

We investigated whether E-PMCT correlated with cycle length of PMAT and was involved in the establishment of PMAT.

Methods

We retrospectively investigated the AF patients who were created the LA map during CS pacing with multipolar mapping catheter which could measure E-PMCT after pulmonary vein isolation. Amon these cases, 1) PMAT was observed spontaneously or induced (PMAT group, N=25, 68.6±10.9 years old, male 15) and none of the AT occurred by the provocation test and during follow up (no-AT group, N=53, 65.2 years old , male 38) were analyzed. In these group, we evaluated the relationships between E-PMCT and tachycardia circuit of PMAT.

Results

E-PMCT was significantly longer in PMAT group than non-AT group(216.5±30ms vs 166.7ms, p<0.005). Strong positive correlation was observed between cycle length of PMAT and E-PMCT (Person’s r=0.85, p<0.001). PMAT was non induced in patients with E-PMCT less than 176ms. According to the ROC curve, AUC for the detection of the non-AT group was 0.908 (95% CI 0.843-0.974, sensitivity 91.7%, specificity 81.1%) with the cut off value E-PMCT less than 180ms. The slow conduction during CS pacing were consistent with slow conduction during PMAT in this study. Although left atrial diameter, ejection faction, type of AF(paroxysmal or not), low voltage area in the left atrium and mitral annulus size in 3D mapping system was also different between PMAT group and non-AT group in the univariate analysis, E-PMAT was strongest predicter of occurrence of PMAT in multivariate analysis.

Conclusion

E-PMCT obtained after PVI could predict the non-inducibility of PMAT and was helpful to decision making for ablation strategy.
A novel designed atrial septum linear ablation method (Icho line) for non-pulmonary vein triggers originating from atrial postero-septum and crista terminalis
Authors: Kawai S , Okahara A , Tokutome M , Matsuura H , Itonaga J , Ikuta K , Kisanuki H , Hara A , Sada M , Okabe K , Nakano M , Matsukawa R , Mukai Y
Published: November 2023

Background

Therapeutic strategy for non-pulmonary vein (PV) trigger of atrial fibrillation (AF) has not been well established although they are the major cause of AF recurrence after PV isolation. The atrial postero-septum or right atrial crista terminalis (CT) are the common non-PV trigger sites of AF. For them, a focal ablation is often insufficient due to a regional arrhythmogenicity. We devised an original linear ablation method, named "Icho Line". Icho means ginkgo in Japanese.

Methods

Eight hundred and thirty-two AF ablation patients were retrospectively studied. An AF induction test was conducted after each PV isolation procedure. Non-PV triggers from the postero-septum or CT that initiate AF were analyzed. Premature atrial contractions that did not initiate AF were excluded. A linear ablation was designed horizontally from the anterior right PV isolation line to fossa ovalis in the left atrium. In the right atrium, the opposite side of the left atrial ablation and CT were continuously ablated like the shape of a ginkgo leaf (Figure 1).

Results

A hundred and fifteen non-PV triggers were detected in 104 patients (12.5%), among which Icho line ablation was performed in 39 patients (37.5%) with documented triggers from the postero-septum or CT (Figure 1). Atrial tachyarrhythmia recurrence free rate in the Icho line group and other non-PV ablation patients were 61.8% and 45.4%, respectively (P=0.54, Figure 2).

Conclusions

A novel designed Icho line is a feasible and effective ablation strategy covering non-PV triggers from the atrial septum and CT.Icho Line Figure 1Icho Line Figure 2
Biomarkers of myocardial injury during cellular electroporation by means of pulsed-field ablation and radiofrequency of atrial fibrillation
Authors: Casella M , Gaggiotti G , Valeri Y , Cipolletta L , Compagnucci P , Volpato G , Parisi Q , Carboni L , Iovinella A , Messano L , Centanni M , Masci F , Malacrida M , Natale A , Dello Russo A
Published: November 2023

Background

Several authors implemented different biomarkers to evaluate and quantify the size of effective atrial fibrillation (AF) ablation lesions after pulmonary veins isolation (PVI) with thermal energy source. However, limited data have been reported on the effects of a new form of non-thermal energy such as electroporation obtained by means of a pulsed-field ablation (PFA, Farapulse) system.

Purpose

Our analysis aims to compare acute myocardial injury through different biomarkers variation after PVI performed with different technologies (PFA vs radiofrequency, RF).

Methods

All consecutive patients (pts) undergoing AF ablation with PFA at our center were included. A PFA protocol-directed PVI was applied using 2kV with 8 applications per vein. RF deliveries were deployed according to a wide antral lesion set around the PVs at 50W. Pre- and post-procedure samples of cardiac troponin I (hs-TnI, ng/l), creatinine kinase-MB (CK-MB, ng/dl), fibrinogen (FB, mg/dl), myoglobin (Myo, ng/ml), N-terminal (NT)-pro hormone B-type natriuretic peptide (NT-ProBNP, pg/ml) and C-reactive protein (CRP, mg/dl) values were collected before PVI and at 24h after ablation. Ablation endpoint was PVI.

Results

Fourty-nine pts were included (62±12 years, 63% male, 84% with paroxysmal AF). PFA cases were 35 (71.4%) whereas RF cases were 14 (28.6%). Evaluating the kinetic of each cardiac biomarker, no differences were found between baseline and 24h for both FB (363±93 at baseline vs 387±112 at 24h, p=0.4513) and NT-ProBNP (137[61-462] at baseline vs 227[157-423] at 24h, p=0.0544). On the contrary kinetics of remaining biomarkers differed and significantly increased from baseline to 24h: 61±22 to 112±101 for Myo level, p=0.0017; 0.38±0.2 to 1.45±2.2 for CRP values, p<0.0001; 1.5±0.7 to 19.4±14 for CK-MB level, p<0.0001 and 11.2±20 to 6177±5765 for hs-TnI level, p<0.0001. By looking at the effect of the ablation strategy on cardiac biomarkers, hs-TnI level, CRP level and CK-MB were significantly different between groups at 24h after PFA/RF (hs-TnI: 7556±6025 for PFA vs 2038±1257 for RF, p<0.0001; CRP: 1.6±2.3 for PFA vs 0.9±1.2 for RF, p=0.0297; CK-MB: 23.7±12 for PFA vs 6.3±9.6 for RF, p<0.0001). PVI was achieved in all patients (100%) using only RF or PFA. No major procedure-related adverse events were reported.

Conclusion

Our preliminary results showed that cardiac troponin I enzyme level, C-reactive protein and creatinine kinase-MB increased after PVI by means of both radiofrequency and pulsed-field ablation and were higher after cellular electroporation by PFA than RF.