bluuebunny/crossref_metadata_2025 huggingface dataset:
Left atrial function parameters as predictors of atrial fibrillation recurrence after pulmonary vein isolation
Authors: Kiliszek M , Uzieblo-Zyczkowska B , Krzyzanowski K , Jurek A , Wierzbowski R , Smalc-Stasiak M , Krzesinski P
Published: October 2022

Background

The aim of the study was to test the relationship between left atrial (LA) function parameters and the results of the pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF).

Patients and methods

Consecutive patients undergoing first time PVI in years 2019–2021 were qualified to the study. The patients underwent radiofrequency ablation using contact-force catheters and electroanatomical system. LA pressure was measured directly just after transseptal puncture. Follow-up was based on ambulatory visits/televisits and 7-day holter monitoring (6 and 12 month after ablation). On the day of ablation all the patients underwent transesophageal and transthoracic echocardiography. The primary endpoint was any atrial tachyarrhythmia recurrence during follow-up period.

Results

A total of 210 patients were included in the study. Median of follow-up was 12 months, AF recurrence was observed in 71 patients (33.8%) after mean of 1.03 procedures per patient. In univariate Cox regression analysis several echocardiographic parameters were significant predictors of AF recurrence after catheter ablation: left and right atrial area, LA volume, average e' and average E/e' values, LA reservoir strain, LA conduit strain, LA appendage emptying velocity. AF recurrence was also predicted by mean LA pressure, age, body mass index and calculated eGFR. Interestingly, LA contraction strain and LA emptying fraction were not predictors of results of AF ablation. In multivariate Cox regression analysis (that included all parameters significant in univariate analysis) LA reservoir strain (hazard ratio (HR) 1.076, 95% confidence interval (CI) 1.014–1.141; p=0.014) and LA appendage emptying velocity (HR 0.968, 95% CI 0.947–0.988; p=0.002) were significant predictors of AF ablation results.

Conclusions

LA reservoir strain and LA appendage emptying velocity are predicting factors of AF ablation results. LA contraction strain and LA emptying function were not predictors of effective AF ablation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Statutory Grant of Military Institute of Medicine
Sex differences in terms of recurrent atrial fibrillation after catheter ablation according to the history of heart failure: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry
Authors: Tanaka N , Inoue K , Hirao Y , Koyama Y , Okamura A , Iwakura K , Okada M , Tanaka K , Kobori A , Kaitani K , Morimoto T , Morishima I , Kusano K , Kimura T , Shizuta S
Published: October 2022

Background

There are significant differences in the prevalence and prognosis of cardiovascular diseases between male and female. We previously reported that catheter ablation (CA) of atrial fibrillation (AF) was less effective in female than male, but whether their history of heart failure influence the recurrence after CA of AF remains still unknown.

Purpose

We sought to clarify sex differences in terms of AF recurrence after RFCA of AF according to the history of heart failure.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

Fourteen % of female had a history of heart failure prior to CA, while 12.8% of male had a history of heart failure at baseline (p=0.29). The 3-year cumulative incidence of AF recurrence after a single procedure was 43.3% in female and 39.0% in male (log rank P=0.0046). In patients with the history of heart failure, AF recurrence rates were 42.2% in female and 45.8% in male (log rank P=0.51). On the other hand, in patients without history of heart failure, more females experienced AF recurrence (female vs. male, 43.5% vs. 38.0%, log rank P=0.001).

The rate of AF recurrence after multiple procedures was higher in female (24.2% vs. 19.6%, log rank P<0.0001). AF recurrence rates were similar between sexes in patients with history of heart failure (female vs. male, 26.0% vs. 26.7%, log rank P=0.86), while AF recurrence rates were higher in female without history of heart failure than those in male (females vs. males, 23.9% vs. 18.5%, log rank P<0.0001).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the AF recurrence after CA of AF. Females had higher recurrence rates compared with males in patients without history of heart failure, while recurrence rates were similar between sexes in patients with history of heart failure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.
Comparison of embolism and bleeding risk profile in patients with atrial fibrillation and chronic kidney disease
Authors: Parada Barcia J , Raposeiras Roubin S , Abu Assi E , Dominguez Erquicia P , Lizancos Castro A , Ledo Pineiro A , Noriega V , Iglesias Otero C , Gonzalez Garcia A , Iniguez Romo A
Published: October 2022

Introduction

Clinical decision-making on anticoagulation in chronic kidney disease (CKD) patients with atrial fibrillation (AF) is challenging. Current strategies are based on small observational studies with conflicting results. A better comprehension of patients' risk profiles is therefore needed.

Purpose

The present study explores the impact of glomerular filtration rate (GFR) in the embolic–haemorrhagic balance among a large cohort of AF patients.

Methods

The study cohort included all patients from the health area of Vigo (Galicia, Spain) diagnosed with AF between January 2014 and April 2020. Subjects without data regarding to glomerular filtration rate were excluded. The final population of the study consisted of 15,457 patients. The risk of ischaemic stroke and major bleeding was determined by competing risk regression using the Fine and Gray model, considering death as a competing risk.

Results

During a mean follow-up of 4.29±1.82 years, 3,678 patients died (23.80%), 850 had an ischaemic stroke (5.50%) and 961 had a major bleeding (6.22%). The incidence of stroke and bleeding increased as baseline GFR declined. GFR <30 mL/min/1.73 m2 was associated with increased stroke and major bleeding (Figure 1). Interestingly, below GFR <30 mL/min/1.73 m2, bleeding risk was clearly higher than the embolic risk (Figure 2).

As glomerular filtration rate decreased, anticoagulation was associated with an increased bleeding risk (sHR 1.72, 95% CI 1.15–2.56; P=0.01 for patients with GFR 30–59 mL/min/1.73 m2 and 2.05, 95% CI 0.80–5.28; P=0.13 for subjects with <30 mL/min/1.73 m2 in comparison with those with GFR >60 mL/min/1.73 m2, respectively), but it was not associated with a reduction in embolic risk in patients with GFR <30 mL/min/1.73 m2 (sHR 1.91, 95% CI 0.73–5.04; P=0.19)

Conclusions

In advanced chronic kidney disease (GFR <30 mL/min/1.73 m2), the increase of major bleeding risk was higher than the increase of ischaemic stroke risk, with a negative anticoagulation balance (greater increase in bleeding than reduction in embolism).

In this setting, left atrial appendage occlusion appears to be an alternative to consider.

Funding Acknowledgement

Type of funding sources: None.
Screening for atrial fibrillation to prevent stroke in elderly individuals with or without preexisting cardiovascular disease
Authors: Xing L Y , Diederichsen S Z , Hojberg S , Krieger D W , Graff C , Olesen M S , Brandes A , Kober L , Haugan K J , Svendsen J H
Published: October 2022

Background

Previous research has showed that various cardiovascular diseases (CVD) are associated with increased risks of atrial fibrillation (AF) and stroke. However, data on the interaction between CVD and AF screening efficacy are lacking.

Purpose

To evaluate the influence of preexisting CVD on the effects of AF screening with long-term continuous monitoring.

Methods

The LOOP Study (Atrial Fibrillation detected by Continuous ECG Monitoring using Implantable Loop Recorder to prevent Stroke in High-risk Individuals) randomized AF-naïve individuals aged ≥70 years and with additional stroke risk factors to either long-term screening with implantable loop recorder (ILR) and subsequent anticoagulation initiation upon detection of AF episodes ≥6 minutes, or usual care (the control group). In the current study, all participants from the LOOP Study were divided into two risk groups according to the presence of CVD (defined as ischemic heart disease, heart failure, previous stroke, valvular heart disease, or peripheral artery disease). The relative risks of outcomes in groupwise comparisons, as indicated by hazard ratio (HR), were assessed in the cause-specific Cox proportional-hazards model with death as competing risk.

Results

Of 6004 participants included, 1997 (33.3%) had ≥1 CVD at baseline. Compared with no CVD, the presence of CVD was associated with increased risks of AF diagnosis in the ILR group (adjusted HR 1.32 [1.09–1.59]) and of stroke or systemic arterial embolism in the entire study cohort (adjusted HR 1.34 [1.06–1.69]). For ILR screening versus usual care, there was no decrease in stroke or systemic arterial embolism among participants with preexisting CVD (adjusted HR 1.13 [0.76–1.68]), whereas a significant risk reduction was obtained by screening among those without CVD (adjusted HR 0.64 [0.44–0.93]). The interaction was significant (adjusted p-value for interaction 0.041).

Conclusions

In an elderly, high-risk population, ILR screening did not prevent stroke significantly in individuals with preexisting CVD, but it was associated with an approximately 40% risk reduction among those without CVD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The LOOP Study was funded by Innovation Fund Denmark [grant number 12-1352259], The Research Foundation for the Capital Region of Denmark, The Danish Heart Foundation [grant number 11-04-R83-A3363-22625], Aalborg University Talent Management Program, Arvid Nilssons Fond, Skibsreder Per Henriksen, R og Hustrus Fond, the European Union's Horizon 2020 program [grant number 847770], Læge Sophus Carl Emil Friis og hustru Olga Doris Friis' Legat, and an unrestricted grant from Medtronic.
Management of atrial fibrillation by different medical specialties in the UK: AF-GEN-UK study
Authors: Shantsila A , Lip G Y H , Lane D A
Published: October 2022

Background

The AF-GEN-UK study is an extension of the EURObservational Research Programme (EORP) Long-term Registry on patients with atrial fibrillation (AF) in the UK (AF-GEN). The study aimed to establish a registry of the contemporary management of patients with AF by cardiologists, general practitioners, stroke, acute and emergency medicine physicians at baseline and 1-year of follow-up, to allow comparison between medical specialties.

Methods

Data on patients with AF diagnosed within the previous 12-months were collected using electronic case records from 101 sites, to permit comparison of patient characteristics and treatments between medical specialties. The impact of guideline-adherent oral anticoagulation (OAC) use on outcomes was assessed using Cox regression analysis.

Results

1595 patients (mean (SD) age 70.5 (11.2) years; 60.1% male; 97.4% white) with ECG-documented AF were included (recruited between June 2017 and June 2018) and followed-up for 1-year. Overall OAC prescription rates were 84.2% at baseline and 87.1% at 1-year follow-up, with NOACs predominating (74.9% at baseline and 79.2% at 1-year) Figure, mainly apixaban. Prescription of VKA was significantly higher in primary care, with NOAC prescription higher among stroke physicians. Guideline-adherent OAC (CHA2DS2-VASc ≥2) at baseline significantly reduced risk of composite endpoint of death and stroke at 1-year (adjusted hazard ratio 0.42; 95% confidence intervals 0.25–0.70). Rhythm control was evident in approximately one-quarter, with only 1.6% receiving catheter ablation. Most patients (56.6%) reported AF symptoms, but these were severe in only 17.9%. Symptomatic patients were mainly managed by cardiologists or acute/emergency medicine; among patients managed by stroke physicians, 81.5% were asymptomatic. Quality of life did not appear significantly impaired however there was a slight but significant improvement at follow-up (70.3% vs. 71.5%; p=0.044). Symptomatic patients reported poorer quality of life related to usual activities, mental health and overall quality of life.

Conclusion

Overall OAC use was high (>80%) with NOAC prescription predominating but rates varied by specialty, with VKA prescription significantly higher in primary care. Guideline-adherent OAC therapy at baseline was associated with significant reduction in composite outcome of death and stroke at 1-year, regardless of specialty. Rhythm control management was only evident in around one-quarter despite AF symptoms being reported in 56.6%. This registry extends the knowledge of contemporary management of AF outside of cardiology by including other specialties and demonstrates good implementation of clinical guidelines for the management of AF, particularly in relation to stroke prevention.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This project was supported by the BMS/Pfizer European Thrombosis Investigator Initiated Research Program
Factors associated with prescription of oral anticoagulation for atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018
Authors: Ritchie L , Harrison S L , Penson P E , Akbari A , Torabi F , Hollinghurst J , Harris D , Oke O B , Akpan A , Halcox J P , Rodgers S E , Lip G Y H , Lane D A
Published: October 2022

Background

Prescription of oral anticoagulants (OAC) is paramount for stroke prevention in people with atrial fibrillation (AF), but treatment decisions in older care home residents are complicated by frailty, multi-morbidity and heightened stroke and bleeding risk. There is a paucity of data on factors influencing the decision to prescribe OAC in this high-risk population who are under-represented in research studies.

Purpose

To explore the factors associated with OAC prescription for care home residents aged ≥65 years with AF.

Methods

Nationwide retrospective cohort study of people aged ≥65 years entering a care home in Wales between 1 January 2003 and 31 December 2018, using anonymised individual-level electronic health record and administrative data sources available within the Secure Anonymised Information Linkage Databank. Unadjusted and adjusted logistic regression models were used to explore the association between resident characteristics and OAC prescription or non-prescription.

Results

Between 2003 and 2018, 14,493 people with AF aged ≥65 years became new residents in care homes in Wales and 7,057 (48.7%) were prescribed OAC (32.7% in 2003 compared to 72.7% in 2018), Figure 1. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per one year age increase [95% confidence interval, 0.95 to 0.96] and aOR 0.91 [0.84 to 0.98], respectively). Conversely, prior venous thromboembolism (aOR 4.06 [3.17 to 5.20]), advancing frailty (mild: aOR 4.61 [3.95 to 5.38]; moderate: aOR 6.69 [5.74 to 7.80]; severe: aOR 8.42 [7.16 to 9.90]) and year of care home entry in the post-non-vitamin K antagonist oral anticoagulant (NOAC) era from 2011 onwards (aOR 1.91 [1.76 to 2.06]) were associated with higher odds of OAC prescription, Figure 2.

Conclusions

The proportion of care home residents prescribed OAC therapy has increased over time with the introduction of NOACs in 2011, but OAC prescription rates are still sub-optimal. Although there is an expected rise in OAC prescribing for increasingly frail people, further work is needed to investigate the interaction with deprivation and other socio-economic and demographic factors to assess potential inequalities in prescribing across these groups. Targeted educational tools for clinicians are needed to address barriers to OAC prescription for AF, such as older age and separate indications for antiplatelet therapy.

Funding Acknowledgement

Type of funding sources: None.
The association between dyslipidaemia treatment and the risk of clinical events in edoxaban-treated patients with atrial fibrillation: insights from the 2-year follow-up of ETNA-AF-Europe
Authors: De Vries T A C , Pecen L , Komen J J , De Groot J R , Kirchhof P , De Caterina R
Published: October 2022

Background/Introduction

Dyslipidaemia is a major risk factor for cardiovascular (CV) events. This increased risk can be attenuated with lipid-lowering therapies (LLT), such as statins, which are associated with a relative risk reduction of CV events of 22% for each 1 mmol/L reduction in low-density lipoprotein cholesterol.

Purpose

To explore the association between use of LLT and clinical outcomes in routine practice patients with atrial fibrillation (AF) receiving edoxaban.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational cohort study conducted in 825 centres, enrolling routine practice patients with AF treated with edoxaban in 10 European countries. This registry is still ongoing and patients are to be followed-up annually for 4 years after enrollment. In the current sub-study, on the now available first 2 years of follow-up, patients were categorised by use of LLT at baseline. We used Cox proportional hazards models to determine the associations between LLT use and adverse clinical events, including the composite of any stroke and systemic embolic events (SEE), major bleeding, and death, after adjusting for confounding factors at baseline.

Results

Of 13,133 patients with AF, 36.3% (n=4761) used LLT at baseline. Among those receiving LLT, 90.7% received statins only and 3.6% received combination therapy with a statin. Most patients in both treatment groups were 65 years or older and had one or more CV-risk factors aside from a history of AF. Patients receiving LLT were older and had a higher prevalence of CV co-morbidities (including diabetes, hypertension, peripheral artery disease and coronary heart disease) than those who did not receive LLT (Table 1).

After correction for confounders, treatment with LLT was associated with a significantly lower rate of any stroke or SEE (HR: 0.61; 95% CI: 0.42–0.88), ischaemic stroke (HR: 0.54; 95% CI: 0.35–0.83), all-cause death (HR: 0.73; 95% CI: 0.63–0.85) and CV-death (HR: 0.73; 95% CI: 0.60–0.90), but not with bleeding events or myocardial infarction (Figure 1).

Conclusion

These findings suggest a protective effect of LLT on the risk of stroke in anticoagulated patients with AF, although an overall better CV risk management in these patients probably contributed to this reduced risk. Notably, both mono- and combination-LLT were seemingly underused in our cohort, highlighting the potential for further reductions of CV risks in the AF patients seen in our clinics.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This research was funded by Daiichi Sankyo Europe.
Bleeding risk prediction in a large cohort of patients with atrial fibrillation and cancer: a nationwide cohort study
Authors: Pastori D , Marang A , Bisson A , Herbert J , Cuzol F , Lip G Y H , Fauchier L
Published: October 2022

Introduction

The association between cancer types and specific bleeding events in atrial fibrillation (AF) patients has been scarcely investigated. Also, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear.

Purpose

We investigated the rate of intracranial haemorrhage (ICH), major (MB) and gastrointestinal bleeding (GB) according to cancer types in AF patients. We also tested the predictive value of HAS-BLED, ATRIA and ORBIT bleeding risk scores.

Methods

Observational retrospective cohort study including 399,344 AF patients with cancer (mean age 77.9±10.2 years; 63.2% men). MB was defined according to Bleeding Academic Research Consortium (BARC) definitions.

Results

The highest ICH rates were found in leukaemia (1.89%/year), myeloma (1.52%/year), lymphoma and liver (1.45%/year) and pancreas cancer (1.41%/year). GBs were highest in liver (7.54%/year), pancreas (7.42%/year) and gastric (5.51%/year). Receiver operating characteristic (ROC) analysis showed that an ORBIT score ≥4 had the highest predictivity for MBs (AUC 0.805) followed by HAS-BLED and ATRIA (AUC 0.716 and 0.700, respectively). HAS-BLED and ORBIT performed best for ICH (AUC 0.744 and 0.742, respectively), better than ATRIA (AUC 0.635). For GB, ORBIT ≥4 had the highest predictivity (AUC 0.756), followed by the HAS-BLED (AUC 0.702) and ATRIA (AUC 0.662).

Conclusions

Some cancer types carry a greater bleeding risk in AF patients. The identification and management of modifiable bleeding risk factors is crucial in these patients, as well as to flag up high bleeding risk patients for early review and follow-up

Conclusions

Some cancer types carry a greater bleeding risk in AF patients. The identification and management of modifiable bleeding risk factors is crucial in these patients, as well as to flag up high bleeding risk patients for early review and follow-up.

Funding Acknowledgement

Type of funding sources: None.
Sex-differences in oral anticoagulation therapy in patients hospitalised with atrial fibrillation: a nationwide cohort study
Authors: Lee K , Doudesis D , Bing R , Astengo F , Perez J , Anand A , McIntyre S , Bloor N , Sandler B , Lister S , Pollock K , Qureshi A , McAllister D , Shah A , Mills N
Published: October 2022

Background

Important disparities in the treatment and outcomes of women and men with atrial fibrillation are well recognized. Whether introduction of direct oral anticoagulants has reduced disparities in treatment is uncertain.

Methods

All patients who had an incident hospitalization from 2010 to 2019 with non-valvular atrial fibrillation in Scotland were included in this cohort study. Community drug dispensing data were used to determine prescribed oral anticoagulation therapy and comorbidity status. Logistic regression modelling was used to evaluate patient factors associated with treatment with vitamin K antagonists and direct oral anticoagulants.

Results

A total of 172,989 patients (48% women [82,833/172,989]) had an incident hospitalization with non-valvular atrial fibrillation in Scotland between 2010 and 2019. The proportion of patients with thromboembolic risk factors (CHA2DS2VASc score >0 in men and >1 in women) treated with oral anticoagulation therapy increased from 36.8% to 66.3% over this 10-year period. By 2019, factor Xa inhibitors accounted for 83.6% of all oral anticoagulants prescribed, while treatment with vitamin K antagonists and direct thrombin inhibitors declined to 15.9% and 0.6%, respectively. Women were less likely to be prescribed any oral anticoagulation therapy compared to men (adjusted odds ratio, aOR 0.68 [95% CI, CI 0.67–0.70]). This disparity was mainly attributed to vitamin K antagonists (aOR 0.68 [95% CI 0.66–0.70]), whilst there was less disparity in use of factor Xa inhibitors between women and men (aOR 0.92 [95% CI 0.90–0.95]). At 1 year following hospitalization with atrial fibrillation, patients not prescribed oral anticoagulation therapy were more likely to have subsequent major adverse cardiovascular events compared to those prescribed with oral anticoagulation therapy (38.8% [15,380/39,608] versus 17.0% [6,761/39,671] in women and 35.2% [12,977/36,868] versus 16.4% [7,395/45,093] in men).

Conclusions

Women with non-valvular atrial fibrillation were significantly less likely to be prescribed vitamin K antagonists compared to men. Most patients admitted to hospital in Scotland with incident non-valvular atrial fibrillation are now treated with factor Xa inhibitors and this is associated with less treatment disparities between women and men.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by the British Heart Foundation through a Clinical Research Training Fellowship (FS/18/25/33454), Intermediate Clinical Research Fellowship (FS/19/17/34172), Senior Clinical Research Fellowship (FS/16/14/32023) and a Research Excellence Award (RE/18/5/34216), and a research grant to NHS Lothian from Bristol Myers Squibb Pharmaceuticals Ltd and Pfizer UK Ltd.
Causes of death in patients with atrial fibrillation and a recent acute coronary syndrome or percutaneous coronary intervention: insights from the AUGUSTUS trial
Authors: Guimaraes P , Wojdyla D M , Alexander J H , Goodman S G , Aronson R , Windecker S , Mehran R , Granger C B , Lopes R D
Published: October 2022

Background

Patients with atrial fibrillation (AF) and concomitant coronary artery disease are at increased risk for poor outcomes. Less is known about specific causes of death in this population.

Methods

We describe specific causes of death among patients with AF and acute coronary syndrome and/or percutaneous coronary intervention included in the AUGUSTUS trial and followed for 6 months. An independent clinical events committee, blinded to treatment assignment, adjudicated cause of death according to pre-defined criteria. The association between baseline factors and all-cause death was evaluated using Cox proportional hazards modeling.

Results

A total of 151 deaths occurred in 4614 patients and were adjudicated as follows: 111 (73.5%) deaths due to cardiovascular (CV) causes and 40 (26.5%) due to non-CV causes. The most common cause of CV death was sudden death (n=39 [35.1%]), followed by myocardial infarction (n=29 [26.1%]) and heart failure (n=24 [21.6%]). The most common causes of non-CV death were infection (n=11 [27.5%]), bleeding (n=8 [20.0%]), and malignancy (n=5 [12.5%]). Increasing age, African American race, history of heart failure, treatment with diuretics, and lower body weight were associated with an increased risk of all-cause death (Table).

Conclusions

Among patients with AF and coronary artery disease, cardiovascular causes were responsible for the majority of deaths within 6 months. Our findings provide relevant information to inform the design of future studies in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AUGUTUS was funded by Bristol Myers Squibb and Pfizer.
Decreased device related thrombus and enhanced neo-endocardial tissue maturation with a new generation left atrial appendage closure (LAAC) device. An anticoagulation and antiplatelet free canin study
Authors: Saliba W , Wazni O , Kanj M , Shah M , Herbst T , Peelukhana S , Suttom B , Kopesky E , Jaber W
Published: October 2022

Introduction

Device related thrombus (DRT) has been reported in up to 7% of patients post LAAC even while on anticoagulation. Clinical predictors of DRT are poorly understood and may be related to patient, procedural and device factors. A next generation WATCHMAN LAAC device (NG) is identical in shape and geometry to the current WATCHMAN FLX device (CW) but has a device coating designed to make it hemocompatible and less thrombogenic.

Objective

To evaluate the incidence and burden of WM surface thrombus formation as detected longitudinally by TEE and at necropsy in a canine model implanted with the NG device.

Methods

The study included 12 canine (6 implanted with CW and 6 implanted with NG) that underwent serial TEE follow up at 14, 28 and 45 days to evaluate surface thrombus on WM face. This was a challenged canine model designed to induce thrombus with no anticoagulation or antiplatelet use throughout the study. D-dimer levels were measured at 7 days and 45 days and compared to baseline measurements.

Results

All devices were successfully implanted. TEE follow up at 14 days showed noticeably reduced thrombus burden on the NG device compared to CW (fig.1) with even further diminution by 28 days in the NG (6/6) as compared to only in 1/6 in the CW group (fig.2). After 45 days in-life, the post-fixation trim en-face images show a smooth, glistening neoendocardial covering (absence of acute thrombus material) in all (6/6) NG compared to only 2/6 in the CW (fig.3). The CW had 3/6 devices with exuberant, bulging calcified thrombus mass one of which was considered to be a mobile DRT. D Dimer levels at 7 and 45 days were significantly lower relative to baseline in the NG compared to CW.

Conclusion

The NG device compared to the CW device was associated with markedly less thrombus formation at 14 days and no thrombus formation at 28 days post implant on no anticoagulant and no antiplatelet therapy along with a more mature uniform tissue coverage at 45 days. The WATCHMAN FLX Pro device coating is a promising step to reduce DRT even without the use of anticoagulation and antiplatelets and merits further investigation in human studies.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boston Scientific
Increased risk of incident atrial fibrillation in young adults with mental health disorders: a nationwide population-based study
Authors: Ahn H , Lee S , Choi E , Bae N , Ahn H , Kwon S , Lee S , Han K , Oh S , Lip G
Published: October 2022

Background

Mental health disorders and cardiovascular diseases are closely associated. The impact of mental health disorders on cardiovascular disease risk could be related to associated smoking, high blood pressure, and high cholesterol. Despite shared risk factors, there remains a paucity of information on incident atrial fibrillation (AF) incidence in patients with mental health disorders.

Purpose

To assess the association between mental health disorders and the risk of AF, especially amongst young adults aged 20 to 39 years.

Methods

Using the Korean National Health Insurance database between 2009 and 2012, we identified young adults aged 20 to 39 years without a history of AF and who have been diagnosed with mental diseases. Mental health disorders were defined as having one of the following diagnoses: schizophrenia (ICM-10 code F20), bipolar disorder (ICM-10 codes F30, F31), depression disorder (ICM-10 codes F32, F33), insomnia (ICM-10 codes G470, F510), and anxiety disorder (ICM-10 codes F40, F41). The primary outcome was new-onset AF during follow-up. We compared the risk of AF between those with mental health disorders and those without.

Results

A total of 6,576,582 people between the ages of 20–39 years old (mean age, 30.9±5.0 years; male, 59.6%) were included in this study. Among the total population, 668,683 patients (10.2%; mean age, 31.4±5.0 years; female, 53.9%) were diagnosed with mental health disorders: schizophrenia 7,575 (1.1%), bipolar disorder 10,956 (1.6%), depression disorder 184,061 (27.5%), insomnia 173,365 (25.9%), and anxiety disorder 413,914 (61.9%). During a 7.4±1.1 year of median follow-up, 8,932 AF events occurred (1,235 in those with mental health disorders and 7,697 in those without). Patients with mental health disorders showed a higher AF incidence than those without (25.4/100,000 PY vs. 17.7/100,000 PY). After adjusting with multivariate variables, patients with mental health disorders still showed a significantly higher risk of AF (Hazard ratio (HR) 1.507, 95% confidence interval (CI) 1.418–1.601). When analyzed according to each mental health disorder, patients with bipolar disorder or schizophrenia had 2 times higher risk of AF (HR 2.105, 95% CI 1.461–3.031; and HR 2.006, 95% CI 1.307–3.079, respectively), and those with depression, insomnia and anxiety showed an approximately 50% higher risk of AF compared to those without mental health disorders (HR 1.553, 95% CI 1.397–1.727; HR 1.635, 95% CI 1.47–1.818; and HR 1.478, 95% CI 1.372–1.592, respectively). Subgroup analyses were generally consistent with the main result.

Conclusions

Young adults diagnosed with mental health disorders, ie. depression, insomnia, anxiety, bipolar disorder, or schizophrenia are associated with a higher risk of incident AF. Awareness and screening for AF in these high-risk populations should be considered.

Funding Acknowledgement

Type of funding sources: None.
Bleeding and thrombotic events in patients with atrial fibrillation and cancer: a systematic review and meta-regression analysis
Authors: Pastori D , Menichelli D , Di Rocco A , Farcomeni A , Sciacqua A , Pignatelli P , Fauchier L , Lip G Y H
Published: October 2022

Background

Atrial fibrillation (AF) and cancer are frequently coexisting in elderly patients. Pooled metanalytic data on the impact of cancer on outcomes in AF patients are lacking.

Purpose

We want to investigate the impact of cancer in patients with AF, particularly in relation to the incidence of bleeding and ischemic events

Methods

Systematic review and meta-regression analysis of clinical studies retrieved from Medline (PubMed) and Cochrane (CENTRAL) databases according to PRISMA guidelines. Safety endpoints included any, major, gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH). Efficacy endpoints included myocardial infarction (MI), ischemic stroke/systemic embolism (IS/SE), cardiovascular (CV) and all-cause death.

Results

15 studies were included in the metanalysis: 4 prospective, 3 randomized clinical trials and 8 retrospective studies with 2,868,010 AF patients, of whom 479,571 (16.7%) had cancer. The pooled HR for cancer was 1.43 (95% CI 1.42–1.44) for any bleeding, 1.27 (95% CI 1.26–1.29) for major bleeding, 1.17 (95% CI 1.14–1.19) for GI bleeding, and 1.07 (95% CI 1.04–1.11) for ICH. The risk of major bleeding increased with the proportion of breast cancer. Cancer increased the risk of all-cause death (HR 2.00, 95% CI 1.99–2.02) whereas no association with MI (HR 0.97, 95% CI 0.94–1.01) and CV death (HR 1.01, 95% CI 0.99–1.03) was found. Patients with AF and cancer were less likely to suffer from IS/SE (HR 0.91, 95% CI 0.89–0.94).

Conclusion

The presence of cancer modifies the clinical history of AF patients, mainly increasing the risk of bleeding. Further analyses according to the type and stage of cancer is necessary to better stratify bleeding risk in these patients.

Funding Acknowledgement

Type of funding sources: None.
Higher risk of adverse outcomes and need for pacemaker among patients undergoing radiofrequency ablation due to ectopic atrial tachycardia – a nationwide registry-based Danish study
Authors: Middelfart C , Toennesen J T , Zoerner C Z , Gislason G G , Pallisgaard J P , Ruwald M R , Hansen M L H
Published: October 2022

Introduction

Atrioventricular nodal reentry tachycardia (AVNRT), Wolf-Parkinson-White syndrome (WPW), and Ectopic atrial tachycardia (EAT) are common arrhythmias and associated with lower quality of life. The use of radiofrequency ablation (RFA) treatment has increased over time, however long-term risk of adverse outcomes after RFA in patients with AVNRT, WPW, or EAT is unknown.

Purpose

To examine the long-term risk of adverse outcomes and need for pacemaker after RFA in AVNRT-, WPW-, and EAT-patients.

Methods

Using Danish nationwide registries, patients of 18 years or older who underwent RFA for AVNRT, WPW, or EAT between January 1st 2001 and January 1st 2019 were included. Comorbidities and use of antiarrhythmic drugs were analyzed.

The cumulative incidences of pacemaker implantation and a combined endpoint of death, thromboembolism (TE), ischemic heart disease (IHD), and heart failure (HF) were estimated at 5-year follow-up using the Aalen-Johansen estimator, taking death as competing risk into account.

Results

A total of 10.439 patients were enrolled in the study. 6187 patients were treated for AVNRT. The median age was 55 [42, 65] and 40% were male. The WPW group consisted of 2872 patients. The median age was 42 [29, 55] and 61% were male. The EAT group consisted of 1380 patients. The median age was 57 [44, 67] and 47% were male.

The comorbidity burden was generelly higher in EAT patients especially regarding heart failure and hypertension. Use of antiarrhythmic drugs was higher in EAT patients compared to patients with AVNRT and WPW.

Figure 1 shows the cumulative incidence of a composite endpoint of death, TE, IHD, and HF 5 years after RFA treatment and depicts that the cumulative incidence was 22.1%, 13.9% and 8.2% for EAT-, AVNRT- and WPW-patients respectively. Figure 2 shows the 5-year cumulative incidence of pacemaker implantations which was 9.0%, 4.4% and 3.1% for EAT-, AVNRT- and WPW-patients respectively.

Conclusion

At long-term follow-up patients with RFA for EAT have a higher risk of death, TE, IHD and HF compared to patients treated for AVNRT and WPW. EAT patients also have the highest risk of pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None.
Catheter ablation of atrial arrhythmias by using a multipolar grid-patterned high density mapping catheter in patients with congenital heart disease: a single-center experience
Authors: Kerst G , Gulgun M , Ozcan S , Ostenmayer S , Hartmann L , Hanten J , Vazquez-Jimenez J
Published: October 2022

Objective

Catheter ablation of arrhythmias in patients with congenital heart disease (CHD) remains challenging and time-consuming. A novel diagnostic catheter with a multipolar grid-patterned electrode configuration for high density mapping may reduce mapping time and enhance ablation success. Here we describe our experience of catheter ablation by using a multipolar grid-patterned mapping catheter in patients with CHD suffered from atrial tachycardia.

Methods

All patients with CHD underwent catheter ablation for atrial tachycardia by using multipolar grid-patterned high density mapping catheter between 04/2018 and 12/2021 were enrolled. Primary success was defined as non-inducibility of atrial tachycardia. Only the first catheter ablation was included in the study.

Results

A total of 37 consecutive patients (median age 34.2±33.0 years (range 7–65), female n=20) underwent 37 ablation procedures with initial high density mapping. The underlying heart defects were s/p ASD-closure (n=2), ASD-closure and corrected partial anomalous pulmonary venous return (n=2), corrected unroofed coronary sinus (n=1), pulmonary valve commissurotomy (n=2), repaired Tetralogy of Fallot (n=2), tricuspid and pulmonary valve replacement in PA/IVS (n=1), mitral valve replacement (n=1), Hypoplastic right heart syndrome (n=1), atrial switch procedure for dTGA (n=7), TA with Glenn shunt (n=1), Ross operation (n=1), Fontan palliation (tricuspid atresia n=6, DILV n=5, HLHS n=1, DORV n=1, dTGA n=1, criss-cross heart n=1, single ventricle n=1). A history of previous ablation was positive in 8 patients. During mapping of the cardiac chambers, the mean value of total collected points and used points were 32657.8±46171 and 3851.6±3295.5 respectively. Mean mapping and fluoroscopy time were 62.1±40.7 minute (range 3–178) and 11.4±8.5 minutes (range 0–32.2), respectively. There were 69 atrial tachycardia substrates in the 37 patients (median 2, range 1–4 per patient). All tachycardia substrates were completely ablated in 33/37 (89.2%) patients and partially in 4/37 (11.8%) patients. Acute success was achieved with successful ablation of 65 of 69 (94.2%) atrial substrates. During a median follow-up time of 20 months (range 5–49), recurrence rate was 5/65 (7.7%) atrial substrates in 5/37 (13.5%) patients. Comparison of 16 patients with Fontan palliation to the 23 patients without Fontan operation showed higher partially success rate in the patients with Fontan palliation (4/16 vs. 0/21, p=0.028).

Conclusion

In this series, high density mapping allowed elucidation of the tachycardia mechanism in all patients with a high primary ablation success, a limited radiation exposure and a low rate of arrhythmia recurrence.

Funding Acknowledgement

Type of funding sources: None.
Utility of open window mapping using high-density mapping approach in accessory pathways ablation
Authors: Martinez Sande J L , Gonzalez-Melchor L , Garcia-Seara J , Minguito-Carazo C , Rodriguez-Manero M , Otero-Garcia O , Fernandez-Lopez J A , Gonzalez-Ferrero T , Gonzalez-Juanatey J R
Published: October 2022

Introduction and purpose

We sought to described a new protocol of open window mapping (OW) utilizing high-density mapping in accessory pathways (AP) in CARTO® 3 system. This protocol automatically map conventional electrophysiology criteria for AP location, as shorter local EGM AV interval (extended early meets late tool), earliest local activation time (LAT)and annotation at unipolar signal (wavefront annotation).

Methods

This was a single center, prospective and observational trial of 21 consecutive patients who underwent an AP catheter ablation.

Results

We included 16 men and 5 women, with a mean age of 32.6±17.9 years. The characteristics of AP, including mapping and ablation were described in Table 1. Twelve AP were of left location and 9 in right location. Mapping was performed in anterograde conduction in 17 patients (80.9%), retrograde in 9 patients (42.9%) and orthodromic tachycardia in 7 patients (33.3%). Mean mapping points were 3205±2034, with 29.2 min±12.5 min of mapping. All 21 patients had a successful ablation after OW mapping and mean radiofrequency time until complete AP elimination was 2.76 s.

We present an example of a Left lateral AP OW mapping in antegrade and retrograde conduction in Figure 1, which shows EEML mapping tool, targeting shorter interval EGM AV or VA and color adjust to determine earliest LAT in chamber of exit.

Conclusions

In our experience, automatically mapping of conventional electrophysiology criteria for AP diagnostic is feasible to localize AP insertion, suggesting an increasing in effectiveness of procedure, and reducing mapping time, ablation time and X-ray exposure time. More studies should be performed to corroborate these conclusions.

Funding Acknowledgement

Type of funding sources: None.
A novel scoring system to predict cardiac device implantation in patients presenting with syncope
Authors: Khan A A , Shah N , Raison K , Khan T , Esmail M , Watkin R , Basavarajaiah S
Published: October 2022

Background

Cardiac syncope occurs when the heart fails to maintain cardiac output to match cerebral need and can occur due to either mechanical/structural defect of the heart or secondary to an arrhythmia. It has a raised 1-year mortality with some figures estimating this as high as 30%. Implantable loop recorders (ILR) are a useful diagnostic tool in patients presenting with syncope or pre-syncope to ascertain a cardiac cause. A higher number of patients are presenting with advancing age and undergoing ILR implantation. Subsequently, they end up requiring a cardiac implantable electronic device (CIED) implantation, adding to additional costs, exposure to procedural complications and frequent hospitalisations.

Purpose

To investigate the number of patients undergoing CIED implantation following implantation of ILRs for syncope and identify predictors of CIED implantation in patients presenting with syncope.

Methods

A retrospective analysis of 736 patients who underwent ILR implantation at our teaching hospital trust between November 2012 to October 2020. Data on demographics, clinical characteristics, pathology results, ECGs, holter findings and CIED implanted was collected using the local electronic patient record system. The data was analysed using SPSS software. Univariable and multivariable regression analysis and ROC curve analysis was carried out to determine prediction model for CIED implantation.

Results

The mean age of patients who underwent an ILR implantation was 65±19 years. 22% of patients required CIED implantation, 68% of patients did not require a cardiac device and were safely discharged and 10% of patients died during follow up. Age (p<0.001), male sex (p=0.006), impaired left ventricular function (p=0.04) and presence of hypertension (p=0.04) were found to be independent predictors of CIED implantation on univariable and multivariable regression analysis (see Table 1).

Conclusions

Old age, presence of coronary artery disease, impaired left ventricular function and presence of hypertension are inter-linked and in our study were found to be key predictors of poor prognosis and thus requiring CIED implantation. We propose a scoring system based on age >75, male sex, presence of ischaemic heart disease, heart failure and hypertension as key markers of conduction abnormalities requiring CIED implantation (see fi−ure 1).

Funding Acknowledgement

Type of funding sources: None.
Effects of electromagnetic interference produced by smartphones on patients with permanent pacemakers (EMS-PPM study)
Authors: Wisaratapong T , Pechaksorn N
Published: October 2022

Background

Since the 1990s, the electromagnetic field generated by mobile phones using 2G/3G communication networks has been shown to affect pacemaker functions. Over the past two decades, improvements in pacemaker technology, such as feed-through filters, combined with mobile 4G networks have significantly reduced the incidence of adverse effects. However, the safety of newer-generation mobile phones using 5G networks in patients with modern-generation pacemakers has not yet been studied.

Methods

We enrolled 489 patients with pacemakers from three different manufacturers. The pacemaker mode was programmed for overdrive pacing and sensing mode when an intrinsic rhythm was present. A smartphone (Samsung S21+5G) was placed directly over the pulse generator and right ear. The phone was tested under four conditions: standby mode, 5G internet connection, incoming and outgoing calls for each location. Real-time ECG monitoring and patient symptoms were recorded to determine the occurrence of electromagnetic interference. The possibility of electromagnetic interference with the interrogation telemetry was also investigated.

Results

A total of 4824 tests were performed on 489 patients. Most pacemakers were dual-chamber (82%) and MRI-compatible systems (83%). The average implantation duration is 4.3±3.5 years, 4.8±3.9 years, and 5.5±4.4 years for the pulse generator, right atrial lead, and right ventricular lead, respectively. No electromagnetic interference was detected either pulse generator or right ear location. Interference to telemetry was demonstrated in 11.5% of the patients. Almost (98.2%) occurred mainly during incoming calls. Single-chamber pacemakers, non-MRI compatible systems, older pulse generators, older leads, and unipolar settings were significantly related to the higher incidence of interference to interrogation telemetry.

Conclusion

The risk of electromagnetic interference between modern smartphones with 5G networks and pacemakers is negligible. Nevertheless, interference to interrogation telemetry may still occur.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Faculty of Medicine, Prince of Songkla University